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Iodine deficiency is a possible carcinogenic factor, acting through chronic TSH stimulation. It has been argued that differentiated cancers occurring in iodine-deficient regions behave more aggressively.

Pre-existing nodules and goitre have been identified with an increased incidence of cancer but the significance of this is difficult to ascertain. The relationship may reflect only an ascertainment bias secondary to increased observation of these patients.

The diagnostic algorithm of suspected thyroid cancer is that of the suspicious nodule. Aspiration needle biopsy is the primary diagnostic tool. Ultrasound imaging may be required to define those nodules that are difficult to palpate and ultrasound-guided biopsy may be necessary to ensure satisfactory sampling. Suspicion of malignancy on fine needle aspiration biopsy should direct the patient to surgery for a near-total thyroidectomy. A good quality biopsy with a benign diagnosis should direct the patient to long term follow up and ultrasound is also useful to follow these nodules. In current practice, radionuclide imaging should be reserved for evaluation of nodules with a non-diagnostic biopsy and cold nodules thus identified should be surgically removed. This protocol has been shown to maximize the yield of malignancies while reducing the number of operations. Post-surgical imaging and follow-up of thyroid cancer is covered in Chapter 14.

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