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Figure 4. Approach to the investigation of a thyroid nodule. (Adapted from Gharib H. Thyroid Today 1997; 201:1.)

the mortality rate from thyroid cancers has remained stable, a reflection of improved therapies. Women are affected about three times more often than men. Unlike medullary carcinomas, which may be sporadic or occur in families, the follicular-derived neoplasms are said to occur mainly sporadically. Nonetheless, familial groupings of papillary cancer do occur with greater than chance frequency. There is a familial predisposition to thyroid cancer in Gardner's syndrome (multiple colonic and rectal polyposis) and in Cowden's disease (multiple hamartoma syndrome).

The only environmental factor known to increase the incidence of thyroid cancers is exposure to ionizing radiation. In the early part of the 20th century, x-rays were used to treat facial and neck hemangiomas of infants and lymphoid hyperplasia (tonsils, adenoids and thymus) of young children. In the following decades there was an increased number of thyroid cancers in these patients, which began to appear about a decade after the exposure, reached a peak incidence at about 25 years and continued to appear at greater than the sporadic population incidence throughout the lives of these people. In the post WWII years, the state of Israel used x-irradiation to treat immigrant children for scalp ringworm. These children developed an excess number of thyroid cancers in adult life. The experience of radioactive fallout, with a

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