Nonpalpable Nodules Research Articles

Thyroid Incidentalomas: Scrutinizing the Mode of Detection and Evaluating its Contribution to Thyroid Cancer Diagnosis.

In total, 576 patients were analyzed, with a total of 1014 nodules described. In 347 (60.2%) cases, the diagnosis of a thyroid nodule was incidental, mostly during imaging tests for other reasons. Incidental diagnosis occurred among all ranges of nodule diameter and between palpable and non-palpable cases, even within a small proportion of symptomatic cases. In univariate analysis, incidental diagnosis was associated with smaller nodule diameter, non-palpable nodules, asymptomatic cases, older patient age, less advanced stages (T1-2), and conservative management. After multivariate analysis, older age, euthyroidism, and smaller diameter were statistically significant. Incidental diagnosis contributed to the diagnosis of 53.8% of the cases of cancer. Advanced T stages (T3-4) were more common in non-incidental diagnoses. Our results indicate that incidental diagnosis of thyroid nodules is a significant contributor to thyroid cancer diagnosis in all ranges of nodule diameter, especially at earlier stages.

Image-Guided Radar Reflector Localization for Small Soft-Tissue Lesions in the Musculoskeletal System.

Preoperative localization of nonpalpable breast lesions using a radar reflector surgical guidance system has become commonplace, but the clinical utility of this emerging technology in the musculoskeletal system has not yet been well established. The system components include a console, a handpiece, an implanted radiofrequency reflector that works as a lesion marker, and an infrared light-emitting probe to guide the surgeon. The reflector can be deployed to localize small nonpalpable nodules within the subcutaneous fat as well as lesions within the deeper soft tissues. It can also be used for lymph nodes and foreign bodies. Localization can be performed both before and after treatment. The objective of this article is to describe the potential applications and our technique and initial experience for radar reflector localization within the musculoskeletal system.

Diagnostic efficacy of ultrasonography-guided fine needle aspiration cytology on thyroid swellings

IntroductionPatients presenting with a thyroid nodule, if malignant, may call for removal. A good screening tool with high diagnostic value for preoperative evaluation is preferred. Through real-time visualization of the needle to aspirate from the suspicious site, ultrasonography-guided fine-needle aspiration cytology could be an excellent screening tool.Materials and methodA cross-sectional descriptive study was conducted at Ganesh Man Singh Memorial Academy of Ear Nose Throat–Head and Neck Studies, Kathmandu, Nepal, from September 2018 to November 2019. We included 59 subjects of 15–72 years meeting the inclusion criteria. All study participants underwent preoperative ultrasonography-guided fine-needle aspiration cytological evaluation of thyroid nodule, which was correlated with their histopathological findings to determine diagnostic values.ResultThe sensitivity, specificity, and accuracy of ultrasonography-guided fine-needle aspiration cytology of thyroid nodule was 96.96%, 61.53%, and 81.35%, respectively. On stratification according to size, high sensitivity of 100% was observed in evaluating lesions of size < 2 cm and > 4 cm. There was a good inter-rater agreement between findings of ultrasonography-guided fine-needle aspiration cytology and histopathology with a kappa coefficient of 0.607.ConclusionUltrasonography-guided fine needle aspiration cytology is a reliable procedure to evaluate thyroid lesions with high diagnostic value. It is an excellent tool for evaluating small, non-palpable nodules.

EP02.03-007 Seeds of Gold. Triple Contrast Marking in Hybrid Operative Room for All-in One Diagnostic and Therapeutic Precision Surgery

The minimally invasive management of small lung lesions represents a quite challenging task for thoracic surgeons. As a matter of fact, video-assisted thoracic surgery (VATS) wedge resection could usually require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (H-OR) can serve as a helpful tool in providing real-time lesion imaging and targeting, allowing the preoperative placement of different marking techniques to help locate non-palpable nodules. Our aim is to assess the efficacy of our triple contrast technique based on the simultaneous use of three different marking systems, including gold seed Biomarc - Vigeo S.r.l.), methylene blue (Methylthioninium Chloride - Bioindustria L.I.M.), and indocyanine green (-ICG- Verdye - Diagnostic Green Gmbh) to help locate non-palpable lung lesion.

Clinicopathological study of surgery for pulmonary metastases of hepatoblastoma with indocyanine green fluorescent imaging.

The prognosis of metastatic hepatoblastoma remains poor; to improve it, pulmonary metastasis must be controlled. Indocyanine green (ICG) fluorescent imaging has been used recently for lung metastasectomy. The objective of our study was to clarify the usefulness of ICG imaging for lung metastasectomy of hepatoblastoma using detailed clinicopathological analysis. Patients with hepatoblastoma who underwent resection of pulmonary metastases with ICG fluorescent imaging were studied using a retrospective analysis of clinical information, a review of their surgical records, and a histological analysis of their metastatic nodules. Sixteen patients were enrolled. In total, 61 ICG imaging-guided pulmonary metastasectomies were performed, and 350 ICG-positive and 23 ICG-negative specimens were identified. Tumors were confirmed in 250 of the ICG-positive specimens, including eight nonpalpable nodules, on microscopic examination. ICG-positive and tumor-negative specimens showed histological changes suggesting the regression of a tumor or bloodstream disturbance. Surgical resection is one of the few treatment strategies available to patients with hepatoblastoma with multiple relapses of pulmonary metastasis resistant to chemotherapy. This study demonstrates the high sensitivity of ICG imaging and that thorough metastasectomy can be achieved with ICG imaging. Because a number of false-positive specimens were detected, further optimization of the dose of ICG and the timing of its administration, and establishment of detection of ICG-positive, tumor-negative nodules during surgery are important issues. Several false-negative specimens were also detected, suggesting the presence of ICG-negative metastatic tumors. Palpation during surgery and imaging studies remain essential for detecting metastatic lesions, even in the era of ICG imaging.

3D Specimen Mapping Expedites Frozen Section Diagnosis of Nonpalpable Ground Glass Opacities

BackgroundPulmonary ground glass opacities (GGOs) are early-stage adenocarcinoma spectrum lesions that are not easily palpable. Challenges in localizing GGOs during intraoperative pathology can lead to imprecise diagnoses and additional time under anesthesia. To improve localization of GGOs during frozen section diagnosis, we evaluated a novel technique, 3-dimensional near-infrared specimen mapping (3D-NSM). MethodsFifty-five patients with a cT1 GGO were enrolled and received a fluorescent tracer preoperatively. After resection, specimens were inspected to identify lesions. Palpable and nonpalpable nodules underwent 3D-NSM and the area of highest fluorescence was marked with a suture. Time for 3D-NSM, time for frozen section diagnosis, and number of tissue sections examined were recorded. To compare 3D-NSM with standard-of-care techniques, a control cohort of 20 subjects with identical inclusion criteria were enrolled. Specimens did not undergo 3D-NSM and were sent directly to pathology. Results3D-NSM localized 54 of 55 lesions with 1 false negative. All 41 palpable lesions were identified by 3D-NSM. Thirteen (92.8%) of 14 nonpalpable lesions were located by 3D-NSM. Time to diagnosis for the 3D-NSM cohort was 23.5 minutes, compared with 26.0 minutes in the control cohort (P = .04). 3D-NSM did not affect time to diagnosis of palpable lesions (23.2 minutes vs 21.4 minutes; P = .10). 3D-NSM significantly reduced time to diagnosis for nonpalpable lesions (23.3 minutes vs 34.4 minutes; P < .0001). 3D-NSM also reduced the number of tissue sections analyzed in nonpalpable lesions (4.50 vs 11.00; P < .0001). Conclusions3D-NSM accurately localizes GGOs and expedites intraoperative diagnosis by reducing the number of tissue sections analyzed for nonpalpable GGOs.

Improved visualization of virtual-assisted lung mapping by indocyanine green.

ObjectivesVirtual-assisted lung mapping (VAL-MAP) is a bronchoscopic marking method of dye application on the surface of the lungs before resecting nonpalpable nodules. However, in some cases, it can be difficult to identify the markings of VAL-MAP on computed tomography and intraoperative thoracoscopy. We developed and assessed the feasibility of indocyanine green VAL-MAP (ICG-VAL-MAP).MethodsA historical control trial was conducted to investigate the effectiveness of ICG-VAL-MAP for marking visualization compared with that of VAL-MAP. In ICG-VAL-MAP, instead of indigo carmine, ICG and computed tomography contrast agents were used for dye marking, and near-infrared fluorescence endoscopy was employed to visualize the ICG markings. The other processes in VAL-MAP were carried out. The marking visibility was assessed in 3 grades of easy, faint, or not identifiable. We compared the visibility of the markings on computed tomography images and during thoracoscopic operations between VAL-MAP (567 markings in 147 cases) and ICG-VAL-MAP (142 markings in 63 cases).ResultsOn the preoperative computed tomography images, ICG-VAL-MAP provided significantly better marking visualization than VAL-MAP (easy/faint/not identifiable = 142/0/0 vs 427/100/30; P < .0001). ICG-VAL-MAP provided significantly better intraoperative markings than VAL-MAP (easy/faint/not identifiable = 141/0/1, respectively, vs 475/50/42, respectively; P < .0001). Regarding complications, pneumothorax occurred in 8 (5.4%) cases of VAL-MAP and zero cases (0%) of ICG-VAL-MAP (P = .12); fever was observed in 7 (5.0%) cases of VAL-MAP and 2 (3.2%) cases of ICG-VAL-MAP (P = .72).ConclusionsICG-VAL-MAP provided significantly better visibility of markings than VAL-MAP. It might be useful in the resection of nonpalpable small lung lesions.

The Diagnostic Value of Ultrasound Elastography and Colour Doppler Ultrasonograhy in Predicting Malignancy in Intermediate Thyroid Nodules

Abstract Background: Nodules of thyroid gland are very common and the majority of them are benign. Sonography has many favorable features, such as detection of non-palpable nodules, estimation of size and volume of the nodule and guidance for Fine Needle Biopsy (FNB). High-resolution ultrasound is very sensitive in detection of thyroid nodules, enabling dif-ferentiation of solid and fluid-containing lesions. Indeterminate and non diagnostic patterns represent the main limitation of Fine Needle Aspiration (FNA) cytology of thyroid nodules, clinical and echographic features can poorly predictive of malignancy. The newly developed real-time Ultrasound Elas-tography (USE) has been applied to differentiate malignant from benign lesions. Aim of Study: To evaluate indeterminate thyroid nodules by US elastography and colour Doppler study. Material and Methods: In this study, 73 cases were in-cluded from which 57 cases were benign and 16 cases were malignant. The cases were subjected to complete U/S, Doppler examination, Micro pure imaging and US elastography the results were compared to U/S guided FNAC. Results: The most predictive combined ultrasound features are disappearing halo sign with the appearance of dots of micro calcifications and by colour Doppler ultrasound marked intra nodular and absent or slight peri nodular blood flow represented with malignant nodules more than benign, the combination of US elastography with US findings clears that hypoechogenicity/score 4-5 was the most predictive of malig-nancy with sensitivity 80% and specificity 100%; and accuracy 93.4%. Conclusion: US-elastography combined with colour Dop-pler US, has rapid and easy performance and can help to identify nodules of thyroid gland that are likely seems to be malignant.

Single-Stage Localization and Thoracoscopic Removal of Nonpalpable Pulmonary Nodules in a Hybrid Operating Room.

We report our experience with simultaneous localization and thoracoscopic removal for nonpalpable undiagnosed pulmonary nodules. All patients with nonpalpable lesions requiring video-assisted thoracoscopic surgery (VATS) wedge resection underwent localization of the targets and surgical removal in a hybrid operating room. Lesions were considered nonpalpable if they were small (<1 cm), deep (>1 cm from the surface), subsolid, or located within a dystrophic area. In all cases, intraoperative cone-beam computed tomography was performed for nodule localization and targeting, metal hookwires, or coils were alternatively used for intraoperative marking. From April 2016 to November 2019, 39 image-guided VATS (iVATS) were performed. The mean lesion size was 12 ± 6 mm. The mean distance from the deep edge of the lesion to the pleural surface was 24 ± 9 mm. The localization was performed with 20 hookwires and 19 coils. iVATS localization was successful in 36 patients (92.3%). Thirty-seven wedge resections were completed by VATS, 2 (5%) required conversion to thoracotomy. In 9 patients with intraoperative diagnosis of lung cancer, a lobectomy was performed (7 VATS and 2 thoracotomies). Mean length of iVATS localization was 30 ± 13 minutes. Median postoperative length of stay was 4 days (IQR 3 to 5). iVATS seems to be a helpful tool for simultaneous localization and removal of nonpalpable nodules. A versatile approach using different devices seems advisable for the removal of targets in every clinical scenario reducing VATS conversion rate. Future research is required to compare iVATS with traditional preoperative localization techniques.

Use of the hybrid room for thoracic surgery procedures: single-stage localization and removal of non-palpable nodules.

With the widespread availability of lung cancer screening programs, the number of small lung nodules requiring histological characterization has dramatically increased. Because computed tomography-guided fine-needle aspiration may frequently yield false-negative results, excisional biopsy using thoracoscopy is frequently required. Although thoracoscopic procedure has been known to be ideal for nodule resection, the identification of very small, subsolid and deep pulmonary nodules may still be challenging. Precise lesion localization is a key prerequisite to avoid conversion to an unplanned thoracotomy. In the traditional workflow, the localization procedure is performed in the radiology suite, after which the patient is moved to an operating room. With the availability of hybrid operating rooms, a new approach encompassing simultaneous localization and removal of non-palpable lung nodules has become feasible. In this article, we review the procedural workflow of this new technique and discuss its indications and results.

Thyroid nodules: a clinical update for primary care.

Thyroid nodules are very common in the adult population. In the Framingham study, clinically apparent thyroid nodules were present in 6.4% of females and 1.5% of males.1 There may be even more thyroid nodules that are undetected, and postmortem studies demonstrate thyroid nodules in half of all patients.2 Many nodules can be managed in primary care, but some patients will require referral to secondary care. The aim of this article is to arm a GP with the information required to confidently assess which patients require referral, and in what timeframe. The gap between the 1.5–6.4% of palpable nodules found in the Framingham study and the 50% found at post-mortem implies that there is an enormous volume of nodules that are not clinically apparent. With the development of increasingly sophisticated imaging modalities there has been an epidemic of thyroid ‘incidentalomas’. These non-palpable nodules are seen in at least 20% of ultrasound scans, 25% of contrast-enhanced chest CTs, 15% of MRI neck scans, and 30% of PET-CT scans.3 Most patients with incidentally discovered thyroid nodules can be managed by the same principles of history and examination as those with palpable lumps. There are two exceptions to this rule, the first being incidental thyroid lumps on CT, MRI, or ultrasound scan (USS) that are <1 cm and have no associated lymphadenopathy. There is no need for …

Individualized Strategies for Intraoperative Localization of Non-palpable Pulmonary Nodules in a Hybrid Operating Room.

Background: Precise preoperative localization of small pulmonary nodules is a key prerequisite to their successful excision. With the advent of hybrid operating rooms (HORs), a patient-tailored approach encompassing simultaneous localization and removal of small pulmonary nodules has become feasible. In this study, we describe our individualized image-guided video assisted thoracoscopic surgery (iVATS) strategies implemented within a HOR environment. Specifically, localization was performed through different marking approaches (single- vs. double-marker) and access routes [percutaneous technique with Dyna-computed tomography (DynaCT) imaging vs. electromagnetic navigation bronchoscopy (ENB)].Methods: Between April 2017 and November 2018, a total of 159 consecutive patients (harboring 174 pulmonary nodules) were treated with iVATS. The marking approach and access route were individually tailored according to lesion localization and its distance from the pleural surface. The efficacy and safety of our iVATS technique were determined through a retrospective review of clinical charts.Results: All of the localization procedures were performed in a HOR by a single team of thoracic surgeons. The mean tumor size on preoperative CT was 8.28 mm (95% confidence interval [CI]: 7.6–8.96 mm), whereas their mean distance from the pleural surface was 9.44 mm (95% CI: 8.11–10.77 mm). Of the 174 tumors, 150 were localized through a percutaneous DynaCT-guided approach (single-marker: 139, dual-marker: 11), whereas localization in the remaining 24 was accomplished via the ENB-guided approach (single-marker: 4; dual-marker: 20). The mean localization time was 17.78 min (95% CI:16.17–19.39 min). The overall localization success rate was 95.9%. We failed to localize a total of seven nodules either because of technical complications (pneumothorax, n = 3; microcoil dislodgement; n = 1) or machine failure (n = 3). No operative deaths were observed, and the mean length of postoperative stay was 3.65 days (95% CI: 3.19–4.11 days).Conclusions: The use of tailored marking approaches and access routes allowed us to individualize the iVATS procedure for small pulmonary nodules, ultimately promoting a more patient-centered workflow.

Identification of Pulmonary Nodules by Sweeping the Surface of the Lung with an Electrical Bioimpedance Probe: A Feasibility Study

ABSTRACTPurpose: Identifying and localizing the invisible and nonpalpable pulmonary nodules are among the main challenges surgeons face during open and thoracoscopic surgeries. This in vitro study explores the feasibility of utilizing a simple and safe electrical bioimpedance probe in locating the pulmonary nodules by sweeping the surface of the lung tissue. Methods: A probe was designed with four spherical electrodes that were used for recording the bioimpedance spectrum of the lung tissue in a frequency range of 50 kHz to 5 MHz. In each of the 10 resected surgical specimens, the bioimpedance of normal lung tissue as well as the tumoral lung tissue were recorded and compared with each other. Results: By drawing the Nyquist curves, it was determined that the amplitude of the electrical impedance measured by moving the probe from the healthy point to the region of the pulmonary nodule decreases and the frequency characteristics of the bioimpedance spectrum increases. Conclusion: This method could be potentially beneficial in the localization of invisible and even nonpalpable in-depth pulmonary nodules in thoracic surgeries.

Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology.

VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS. To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1cm), deep (>1cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30minutes (range 17-56minutes). The median estimated total effective dose was 11.6mSv (range 1.9-24.7mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.

Ultrasonography for Localization of Subcentimetre Lung Nodules

Localization of deeply, small, non-visible and non-palpable subcentimetre nodules can be difficult during videoassisted thoracoscopic surgery (VATS) and even during minithoracotomy. Linear ultrasound probe helps surgeon find these undetermined nodules by VATS or thoracotomy technique without any need of digital palpation and has been demonstrated a safe and feasible technique alternative to computed tomography guided procedure (coils, hook wires, methylene blue, lipidol and barium staining). Herein, we describe a case who we preoperatively labeled peripheral lung lesion in the right lower lobe with methylene blue digitalization were not possible by palpation and peripheral two lesions were successfully demonstrated with the use of linear ultrasound probe during thoracic surgery.

Evaluation of a New Ultrasound Thoracoscope for Localization of Lung Nodules in Ex Vivo Human Lungs

Localization of small, nonvisible and nonpalpable nodules is challenging during video-assisted thoracoscopic surgery. We evaluated the feasibility of using a new ultrasound thoracoscope to localize nodules in resected exvivo human lungs. The tumor was localized and measured in its greatest dimension with a prototype ultrasound thoracoscope (XLTF-UC180; Olympus Corporation, Tokyo, Japan) at different frequencies (5.0 to 12.0 MHz) and different lung specimen states (deflated, semiinflated). Measured tumor size and depth from lung surface were compared and correlated to the true diameter and depth from lung surface acquired from pathologic morphology. Exvivo evaluation was performed on 16 solid nodules and nine part solid ground-glass nodules. All tumors were successfully localized in the deflated lung specimens (average size, 13.7 ± 5.2 mm). The tumor boundaries were best evaluated with an ultrasound frequency of 10 MHz. Solid nodules were more easily visualized than ground-glass nodules. Part solid ground-glass nodules were not easily detected in the semiinflated specimen owing to peritumoral air surrounding the tumor. Tumor boundaries were also difficult to identify in deeply situated tumors and in lungs with underlying disease. A strong positive correlation existed between the ultrasound measurement and true measurement of tumor size (R2= 0.89, p < 0.001). The ultrasound thoracoscope can be used to localize nodules in resected human lungs. The clarity of the tumor boundaries is influenced by the tumor type and depth and the underlying pulmonary disease. Complete lung deflation and the use of 10 MHz ultrasound frequency optimize the visualization of target tumors.

Screening for thyroid cancer according to French recommendations with thyroid ultrasound in newly diagnosed Graves’ disease without palpable nodule is not useful

ObjectiveThe aim of the study was to evaluate systematic thyroid ultrasonography (US) relevance in newly diagnosed Graves’ disease among patients presenting without palpable nodules. Subjects and methodsWe consecutively recruited 208 cases of Graves’ disease without palpable nodule. All patients were screened for thyroid antibodies and underwent a thyroid US. Ultrasonically guided biopsy was proposed for the assessment of all nodules upper or equal to 10mm in diameter. ResultsTwo third of patients had an abnormal thyroid at palpation requiring an US. One third of patients had a normal thyroid at palpation and US was consequently unwarranted. Among all patients, US detected non-palpable nodules in 26% of cases. We found no smears suspected to be cancerous. ConclusionsIn newly diagnosed Graves’ disease, the US relevance is only questionable in patients without abnormal thyroid at palpation. Ultrasonography detected non-palpable nodules and none was suspected to be cancerous. These data suggest that US is not useful in patients without abnormal thyroid at palpation. Nevertheless, the recent Thyroid Imaging-Reporting And Data System classification (TI-RADS) might change our conclusions. The TI-RADS classification indeed improves the selection of nodules lower than 10mm in diameter requiring a biopsy. Nodules lower than 10mm in diameter were not biopsied in the present study. The other US data presented herein (echogenicity, vascularisation) provide no further relevance for systematic US in newly diagnosed patients.

Elastography for hepato-biliary-pancreatic surgery

Palpation is a subjective and non-sharable diagnostic method. Recently, palpation has been supported and replaced by elastography, which provides a novel parameter of “stiffness” as a visual representation or quantified value. Today, elastography is performed using two major modalities: strain elastography and shear wave elastography. Strain elastography converts the extent of deformation during external compression into colors, displaying these colors as a strain map in a motion picture representing the relative elasticity inside the region of interest. Shear wave elastography can quantify the elasticity of a target by calculating the velocity of shear waves generated by a probe. In addition to superficial organs, elastography has also been applied to upper abdominal organs, including the liver, pancreas and spleen. The visualization of the stiffness of focal lesions in the liver or the pancreas has enabled a more sensitive and specific depiction of small, non-palpable nodules, which are difficult to depict using B-mode ultrasonography. The quantification of stiffness also enables non-invasive estimates of liver fibrosis, the risk of postoperative liver insufficiency and the risk of recurrence of viral hepatitis after transplantation. In this article, we review the major reports that have recently been published describing the effective application of elastography to solid upper abdominal organs in a clinical setting.

Outcomes of incidentally discovered thyroid nodules referred to a high‐volume head and neck surgeon

Incidental thyroid nodules are commonly found by radiological studies done for other indications. The yearly incidence of thyroid cancer is increasing, in part because of detection of nonpalpable nodules on imaging performed for unrelated issues. All new patients referred to a high-volume thyroid surgeon for thyroid nodules were reviewed between February 2009 and January 2011. Data regarding patient demographics, risk factors, referring physician, radiologic findings, fine-needle aspiration (FNA) results, and management were reviewed. One hundred thirty-three of 729 patients (18.2%) had a thyroid nodule or nodules incidentally found on ultrasound, MRI, CT, nuclear imaging, or chest x-ray. Fifty-five patients (41.4%) were managed surgically, with 35 (63.6%) of those having thyroid cancer on final surgical pathology. Based on radiologic findings, risk factors, and FNA results, many incidental thyroid nodules can be observed. Incidental thyroid nodules should be evaluated in the same fashion as a palpable thyroid nodule.

Malignant thyroglossal duct cyst with synchronous occult thyroid gland papillary carcinoma

A 52-year-old male was referred to our department with complaints of a painless midline neck swelling. Clinico-radiological evaluation suggested a 6 × 5 cm thyroglossal cyst with non-palpable nodules in isthmus and right lobe of thyroid gland. FNAC of the thyroglossal cyst was suggestive of papillary carcinoma. He underwent Sistrunk's operation, total thyroidectomy, and central compartment neck dissection. Co-existence of papillary carcinoma of thyroid gland and thyroglossal cyst is a rare presentation and in this report, we describe our management and propose an evidence-based algorithm to assist decision-making in the management of these patients in future.