STATE OF ART Thyroid nodule and thyroid cancer management pre- and post-cardiac transplantation Nicole V. Tilluckdharry, MD, a Rajan Krishnamani, MD, b David DeNofrio, MD, b Kenneth D. Burman, MD, c and Caroline S. Kim, MD a From the a Division of Endocrinology, Diabetes and Metabolism, and b Cardiac Transplantation Program, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts; and c Endocrine Section, Washington Hospital Center, Washington, District of Columbia. Thyroid nodules are common in the adult population. Widespread use of sensitive imaging studies often leads to their incidental discovery. Recent guidelines recommend thyroid-stimulating hormone deter- mination and ultrasonography during initial nodule evaluation. Fine-needle aspiration is often per- formed to detect malignancy. However, the management of thyroid nodules in cardiac transplantation patients has not been directly addressed by recent guidelines. Confounding medications such as amiodarone and anti-coagulants present a management dilemma. The timing of fine-needle aspiration is crucial because (1) malignancy diagnosed pre-operatively usually precludes organ transplantation, and (2) patients undergoing solid-organ transplantation are at increased risk of developing de novo malignancies, including thyroid. With the rising incidence of thyroid cancer, donor-related malignancy will likely become a more prominent issue. This review addresses thyroid nodule management in the cardiac transplant population and provides recommendations for organ donation and transplantation in donors and recipients with thyroid cancer. J Heart Lung Transplant 2010;29:831–7 © 2010 International Society for Heart and Lung Transplantation. All rights reserved. KEY WORDS: thyroid nodule; fine needle aspiration; cardiac transplant; donor-related malignancy Cardiac transplantation is the treatment of choice in selected patients with end-stage cardiomyopathy. Thyroid nodules are a common finding in adults and are being increasingly recognized, possibly because of more frequent use of imaging studies. Diagnosis of this entity presents a management dilemma, especially in patients awaiting car- diac transplantation. We present a patient that illustrates the complexity of thyroid nodule evaluation in this population. This review aims to address the issues of thyroid nodules and cancer within the cardiac transplant population and discuss some of the challenges encountered with their eval- uation and management. Case report A 50-year-old man with atrial fibrillation on Coumadin (Bristol Myers-Squibb, Princeton, NJ) and a 10-year history of non-ischemic cardiomyopathy, underwent left ventricular assist device (LVAD) placement while awaiting cardiac transplant and was subsequently admitted with persistent low-grade fevers attributed to an LVAD driveline exit site infection. A non-contrast chest computed tomography (CT) scan revealed incidental thyroid nodules. Thyroid ultrasound im- aging confirmed a multinodular goiter with a septated, cys- tic right upper lobe nodule measuring 1.2  0.9  1 cm and a mixed right lower pole nodule measuring 1.7  1.4  1.3 cm. Serum thyroid-stimulating hormone (TSH) was 0.03 IU/ml (normal, 0.35–5.50), total thyroxine (T4) was 6.6 g/dl (normal, 4.5–10.9), free thyroxine (FT4) was 1.90 ng/dl (normal, 0.80 –1.80), and total triiodothyronine (T3) Reprint requests: Caroline S. Kim, MD, Division of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, 800 Washington St, No. 268, Boston, MA 02111. Telephone: 1-617-636-5689. E-mail address: ckim3@tuftsmedicalcenter.org http://www.jhltonline.org 1053-2498/$ -see front matter © 2010 International Society for Heart and Lung Transplantation. All rights reserved. doi:10.1016/j.healun.2010.04.003