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The Thyroid Incidentaloma. Dimyati Achmad Department of Surgery Faculty of Medicine Padjadjaran University/ Hasan Sadikin Hospital Bandung Indonesia.

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the thyroid incidentaloma

The Thyroid Incidentaloma


Department of Surgery Faculty of Medicine Padjadjaran University/ HasanSadikin Hospital Bandung Indonesia


Female, 70 years old after cancer resection 6 months ago due to anal cancer, undergo positron emission tomography to determine distant metastases.

  • There is no sign and symptom thyroid gland disorder on physical examination.
  • PET Exam. revealed: No sign of distant metastases, but there is a focal uptake in the thyroid gland.

Thyroid Incidentaloma (T.I.)

Is a thyroid lesions detected during

Imaging investigation unrelated to

examination of thyroid gland


Prevalency of T.I. increased as the extent of use Ultrasonography (USG), Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and especially Positron Emission Tomography (PET).


CurrentlyPET scans with 18F flourodeoxyglucose(FDG-PET) are widely used in the management of patients with malignant conditions of various organ systems, especially to determine the extent of the primary tumor, regional nodal metastases and distant metastases.


Until today the management of T.I.

is still dilemmatic

whether put on further investigationor not.


This problems has actually been there before

but again brought attention

due to development imaging technology

such as PET scans.


There are some clinical features of T.I. suspicious malignant

Gender : Male

Age : < 20 years or > 60 years

Prior head and neck irradiation

Family history of thyroid carcinoma

Lateral neck lymphadenophaty

usg examination
USG Examination

Prevalence of T.I. : 9,4 % - 27 %

Characteristics of suspicious malignant :

1. Microcalcification

2. Irreguler margin

3. Incomplete halo.

ct mri examination
CT / MRI Examination

Prevalence of T.I. :

CT : + 11.3%

MRI : + 13%

CT or MRI examination can not be revealed the malignant form because there is no characteristic to differentiated them.

pet examination
PET Examination

Prevalence of T.I. : 1.1% - 8.4%

Mostly of cases are benign lesions.

32.4% malignant cases : the most histopatology result is micropapillary thyroid carcinoma which is a slow growing, good prognosis and the 10-year diseases specific mortality < 1%


FDG uptake in the thyroid gland, PET interpretation which was greater than background activity in adjacent tissues and blood pool, was classifed as :

Focal Multifocal Diffuse

Focal uptake descriptionindicated is neoplastic process.

pet interpretation
PET Interpretation

Standart Uptake Value (SUV)

The relationship betweenmalignant with SUV is still debatable.

Size of nodule

No significant different between nodule > 1 cm in diameter compared with 1 cm or lessnodule in diameter to determine malignancy.

the principle s of t i management
The Principles of T.I. Management
  • We should be considered the balancing between benefitof early diagnosis and treatment with cost-effectiveness.
  • The prognosis of the primary tumorshould be take into account before investigating a potential thyroid lesion.

There is no benefit to investigate T.I. in patient with widespread distant metastasis and poor overall survival from the primary tumor.


we summarized the management of T.I. in

an algorithm, hopefullycan explain the related dilematic issues.

We emphasized in yellow highlight form.


PET. Exam


Multifocal / Diffuse

Management Algorithm for T.I.


Clinical Feature

Suspicious Malignancy

Non Suspicious Malignancy

USG Exam

Suspicious Malignancy

Non Suspicious Malignancy

Regular Follow - up with USG

USG-Guided FNA

Malignant or Suspicious



  • Until today, the management of T.I. is still controversial.
  • We should be considered the balancing between benefitof early diagnosis and treatment with cost-effectiveness

In cases of T.I. which are male, age < 20 years or > 60 years, previous head and neck irradiation, family history of thyroid cancer and lateral neck lymphadenopathy which should be undergo further investigation.

  • In case without clinical features of malignancy we can do observation with repeat ultrasound to evaluate change of size and determine sign malignancy based on USG characteristics.