present with subclinical hypothyroidism (where tsh is elevated, but free t4 is normal), and can help predict progression to overt hypothyroidism. the american association thyroid association thus recommends measuring tpoab levels when evaluating subclinical hypothyroidism or when trying to identify whether nodular thyroid disease is due to autoimmune thyroid disease. when the etiology of hyperthyroidism is not clear after initial clinical and biochemical evaluation, measurement of tsh receptor antibodies (tshrab) can help make the diagnosis. in grave's disease, tshrab levels are elevated as they are responsible for activating the tsh receptor and causing increased thyroid hormone production. other markers there are two markers for thyroid-derived cancers. thyroglobulin (tg) levels can be elevated in well-differentiated papillary or follicular adenocarcinoma. it is often used to provide information on residual, recurrent or metastatic disease in patients with differentiated thyroid cancer. however, serum tg levels can be elevated in most thyroid diseases. routine measurement of serum tg for evaluation of thyroid nodules is thus currently not recommended by the american thyroid association. elevated calcitonin levels in the blood have been shown to be associated with the rare medullary thyroid cancer. however, the measurement of calcitonin levels as a diagnostic tool is currently controversial due to falsely high or low calcitonin levels in a variety of diseases other than medullary thyroid cancer. very infrequently, tbg and transthyretin levels may be abnormal; these are not routinely tested. to differentiate between different types of hypothyroidism, a specific test may be used. thyrotropin-releasing hormone (trh) is injected into the body through a vein. this hormone is naturally secreted by the hypothalamus and stimulates the pituitary gland. the pituitary responds by releasing thyroid-stimulating hormone (tsh). large amounts of externally administered trh can suppress the subsequent release of tsh. this amount of release-suppression is exaggerated in primary hypothyroidism, major depression, cocaine dependence, amphetamine dependence and chronic phencyclidine abuse. there is a failure to suppress in the manic phase of bipolar disorder. ultrasound many people may develop a thyroid nodule at some point in their lives. although many who experience this worry that it is thyroid cancer, there are many causes of nodules that are benign and not cancerous. if a possible nodule is present, a doctor may order thyroid function tests to determine if the thyroid gland's activity is being affected. if more information is needed after a clinical exam and lab tests, medical ultrasonography can help determine the nature of thyroid nodule(s). there are some notable differences in typical benign vs. cancerous thyroid nodules that can particularly be detected by the high-frequency sound waves in an ultrasound scan. the ultrasound may also locate nodules that are too small for a doctor to feel on a physical exam, and can demonstrate whether a nodule is primarily solid, liquid (cystic), or a mixture of both. it is an imaging process that can often be done in a doctor's office, is painless, and does not expose the individual to any radiation. the main characteristics that can help distinguish a benign vs. malignant (cancerous) thyroid nodule on ultrasound are as follows: possible thyroid cancermore likely benign irregular borderssmooth borders hypoechoic (less echogenic than the surrounding tissue)hyperechoic incomplete "halo"spongiform appearance significant intranodular / central blood flow by power dopplermarked peripheral blood flow microcalcificationslarger, broad calcifications (note: these can be seen in medullary thyroid cancer) nodule appears more tall than wide on transverse study "comet tail" artifact as sound waves bounce off intranodular colloid documented progressive increase in size of nodule on ultrasound although ultrasonography is a very important diagnostic tool, this method is not always able to separate benign from malignant nodules with certainty. in suspicious cases, a tissue sample is often obtained by biopsy for microscopic examination. radioiodine scanning and uptake five scintigrams taken from thyroids with different syndromes: a) normal thyroid, b) graves disease, diffuse increased uptake in both thyroid lobes, c) plummer's disease, d) toxic adenoma, e) thyroiditis. thyroid scintigraphy, in which the thyroid is imaged with the aid of radioactive iodine (usually iodine-123, which does not harm thyroid cells, or rarely, iodine-131), is performed in the nuclear medicine department of a hospital or clinic. radioiodine collects in the thyroid gland before being excreted in the urine. while in the thyroid, the radioactive emissions can be detected by a camera, producing a rough image of the shape (a radioiodine scan) and tissue activity (a radioiodine uptake) of the thyroid gland. a normal radioiodine scan shows even uptake and activity throughout the gland. irregular uptake can reflect an abnormally shaped or abnormally located gland, or it can indicate that a portion of the gland is overactive or underactive. for example, a nodule that is overactive ("hot") -- to the point of suppressing the activity of the rest of the gland—is usually a thyrotoxic adenoma, a surgically curable form of hyperthyroidism that is rarely malignant. in contrast, finding that a substantial section of the thyroid is inactive ("cold") may indicate an area of non-functioning tissue, such as thyroid cancer. the amount of radioactivity can be quantified and serves as an indicator of the metabolic activity of the gland. a normal quantitation of radioiodine uptake demonstrates that about 8-35% of the administered dose can be detected in the thyroid 24 hours later. overactivity or underactivity of the gland, as may occur with hyperthyroidism or hypothyroidism, is usually reflected in increased or decreased radioiodine uptake. different patterns may occur with different causes of hypo- or hyperthyroidism. biopsy a medical biopsy refers to the obtaining of a tissue sample for examination under the microscope or other testing, usually to distinguish cancer from noncancerous conditions. thyroid tissue may be obtained for biopsy by fine needle aspiration (fna) or by surgery. fine needle aspiration has the advantage of being a brief, safe, outpatient procedure that is safer and less expensive than surgery and does not leave a visible scar. needle biopsies became widely used in the 1980s, but it was recognized that the accuracy of identification of cancer was good, but not perfect. the accuracy of the diagnosis depends on obtaining tissue from all of the suspicious areas of an abnormal thyroid gland. the reliability of fine needle aspiration is increased when sampling can be guided by ultrasound, and over the last 15 years, this has become the preferred method for thyroid biopsy in north america. treatment medication levothyroxine is a stereoisomer of thyroxine (t4) which is degraded much more slowly and can be administered once daily in patients with hypothyroidism. natural thyroid hormone from pigs is sometimes also used, especially for people who cannot tolerate the synthetic version. hyperthyroidism caused by graves' disease may be treated with the thioamide drugs propylthiouracil, carbimazole or methimazole, or rarely with lugol's solution. additionally, hyperthyroidism and thyroid tumors may be treated with radioactive iodine. ethanol injections for the treatment of recurrent thyroid cysts and metastatic thyroid cancer in lymph nodes can also be an alternative to surgery. surgery thyroid surgery is performed for a variety of reasons. a nodule or lobe of the thyroid is sometimes removed for biopsy or because of the presence of an autonomously functioning adenoma causing hyperthyroidism. a large majority of the thyroid may be removed (subtotal thyroidectomy) to treat the hyperthyroidism of graves' disease, or to remove a goiter that is unsightly or impinges on vital structures. a complete thyroidectomy of the entire thyroid, including associated lymph nodes, is the preferred treatment for thyroid cancer. removal of the bulk of the thyroid gland usually produces hypothyroidism unless the person takes thyroid hormone replacement. consequently, individuals who have undergone a total thyroidectomy are typically placed on thyroid hormone replacement (e.g. levothyroxine) for the remainder of their lives. higher than normal doses are often administered to prevent recurrence. if the thyroid gland must be removed surgically, care must be taken to avoid damage to adjacent structures, the parathyroid glands and the recurrent laryngeal nerve. both are susceptible to accidental removal and/or injury during thyroid surgery. the parathyroid glands produce parathyroid hormone (pth), a hormone needed to maintain adequate amounts of calcium in the blood. removal results in hypoparathyroidism and a need for supplemental calcium and vitamin d each day. in the event that the blood supply to any one of the parathyroid glands is endangered through surgery, the parathyroid gland(s) involved may be re-implanted in surrounding muscle tissue. the recurrent laryngeal nerves provide motor control for all external muscles of the larynx except for the cricothyroid muscle, which also runs along the posterior thyroid. accidental laceration of either of the two or both recurrent laryngeal nerves may cause paralysis of the vocal cords and their associated muscles, changing the voice quality. a 2019 systematic review concluded that the available evidence shows no difference between visually identifying the nerve or utilizing intraoperative neuroimaging during surgery, when trying to prevent injury to recurrent laryngeal nerve during thyroid surgery. radioiodine radioiodine therapy with iodine-131 can be used to shrink the thyroid gland (for instance, in the case of large goiters that cause symptoms but do not harbor cancer—after evaluation and biopsy of suspicious nodules has been done), or to destroy hyperactive thyroid cells (for example, in cases of thyroid cancer). the iodine uptake can be high in countries with iodine deficiency, but low in iodine sufficient countries. to enhance iodine-131 uptake by the thyroid and allow for more successful treatment, tsh is raised prior to therapy in order to stimulate the existing thyroid cells. this is done either by withdrawal of thyroid hormone medication or injections of recombinant human tsh (thyrogen), released in the united states in 1999. thyrogen injections can reportedly boost uptake up to 50-60%. radioiodine treatment can also cause hypothyroidism (which is sometimes the end goal of treatment) and, although rare, a pain syndrome (due to radiation thyroiditis). epidemiology in the united states, autoimmune inflammation is the most common form of thyroid disease while worldwide hypothyroidism and goiter due to dietary iodine deficiency is the most common. according to the american thyroid association in 2015, approximately 20 million people in the united states alone are affected by thyroid disease. hypothyroidism affects 3-10% percent of adults, with a higher incidence in women and the elderly. an estimated one-third of the world's population currently lives in areas of low dietary iodine levels. in regions of severe iodine deficiency, the prevalence of goiter is as high as 80%. in areas where iodine-deficiency is not found, the most common type of hypothyroidism is an autoimmune subtype called hashimoto's thyroiditis, with a prevalence of 1-2%. as for hyperthyroidism, graves' disease, another autoimmune condition, is the most common type with a prevalence of 0.5% in males and 3% in females. although thyroid nodules are common, thyroid cancer is rare. thyroid cancer accounts for less than 1% of all cancer in the uk, though it is the most common endocrine tumor and makes up greater than 90% of all cancers of the endocrine glands.