Unknown #185 Case 35yo F presents for her annual physical ...

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Unknown #185 Case 35yo F presents for her annual physical ...

  1. 1. Unknown #185
  2. 2. Case <ul><li>35yo F presents for her annual physical examination. The patient says she feel well. She has no pertinent personal or family medical history and takes no medications. </li></ul>
  3. 3. Exam <ul><li>37.0, 70, 120/80, 16, 100% on RA </li></ul><ul><li>Neck - Palpation of the thyroid gland suggests the presence of a nodule </li></ul><ul><li>CV – RRR no m,r,g </li></ul><ul><li>Pulm – CTA bilaterally </li></ul><ul><li>Abd – soft, NT/ND, +BS </li></ul><ul><li>Ext – no c/c/e </li></ul>
  4. 4. Studies <ul><li>TSH = 1.3 µU/mL </li></ul><ul><li>free thyroxine (T4) = 1.3 ng/dL </li></ul><ul><li>An ultrasound of the thyroid gland reveals a normal-sized gland with a 2-cm hypoechoic right midpole nodule </li></ul>
  5. 5. Which of the following is the most appropriate next step in management? <ul><li>Fine-needle aspiration biopsy of the nodule </li></ul><ul><li>Measurement of anti-thyroperoxidase and anti–thyroglobulin antibody titers </li></ul><ul><li>Neck CT with contrast </li></ul><ul><li>Thyroid scan with technetium </li></ul><ul><li>Trial of levothyroxine therapy </li></ul>
  6. 6. Which of the following is the most appropriate next step in management? <ul><li>Fine-needle aspiration biopsy of the nodule </li></ul><ul><li>Measurement of anti-thyroperoxidase and anti–thyroglobulin antibody titers </li></ul><ul><li>Neck CT with contrast </li></ul><ul><li>Thyroid scan with technetium </li></ul><ul><li>Trial of levothyroxine therapy </li></ul>
  7. 7. Thyroid Nodule Pearls <ul><li>Why do we evaluate thyroid nodules? </li></ul><ul><ul><li>To rule out malignancy </li></ul></ul><ul><ul><li>Higher prevalence of malignancy in: </li></ul></ul><ul><ul><ul><li>Children </li></ul></ul></ul><ul><ul><ul><li>Adults <30 or >60yo </li></ul></ul></ul><ul><ul><ul><li>Pts with h/o neck radiation </li></ul></ul></ul><ul><ul><ul><li>Pts with family h/o thyroid cancer </li></ul></ul></ul><ul><li>Hyperfunctioning (“hot”) nodules are virtually always benign </li></ul>
  8. 8. What Causes Thyroid Nodules? <ul><li>Benign (93-96%) </li></ul><ul><li>Multinodular goiter </li></ul><ul><li>Hashimoto’s thyroiditis </li></ul><ul><li>Cysts: colloid, simple, hemorrhagis </li></ul><ul><li>Follicular adenomas </li></ul><ul><li>Hurthle-cell adenomas </li></ul><ul><li>Malignant (4-7%) </li></ul><ul><li>Papillary carcinoma </li></ul><ul><li>Follicular carcinoma </li></ul><ul><li>Medullary carcinoma </li></ul><ul><li>Anaplastic carcinoma </li></ul><ul><li>Primary thyroid lymphoma </li></ul><ul><li>Metastatic carcinoma </li></ul>
  9. 9. General Approach to Nodules: Start with a TSH <ul><li>Low TSH </li></ul><ul><li>Obtain thyroid scintography/radioisotope scan </li></ul><ul><ul><li>Hot nodules not malignant </li></ul></ul><ul><li>Normal TSH </li></ul><ul><li>FNA of solid hypoechoic nodules ≥ 1cm </li></ul><ul><ul><li>Sens 83%, spec 92% </li></ul></ul><ul><ul><li>Cytology classifications </li></ul></ul><ul><ul><ul><li>Nondiagnostic </li></ul></ul></ul><ul><ul><ul><li>Benign </li></ul></ul></ul><ul><ul><ul><li>Follicular lesions </li></ul></ul></ul><ul><ul><ul><li>Suspicious </li></ul></ul></ul><ul><ul><ul><li>Malignant </li></ul></ul></ul>
  10. 10. Role of Ultrasound <ul><li>To identify non-palpable nodules </li></ul><ul><li>Measure size of nodules </li></ul><ul><li>See characteristics of nodules </li></ul><ul><ul><li>Cystic, solid, heterogeneous </li></ul></ul><ul><ul><li>Microcalcifications increase risk of malignancy 29% </li></ul></ul><ul><ul><li>Vascular characteristics </li></ul></ul>
  11. 11. Management by Results of FNA <ul><li>Nondiagnostic </li></ul><ul><ul><li>Repeat FNA in 3 months, increase yield with u/s guidance </li></ul></ul><ul><ul><li>If repeat nondiagnostic, refer for surgical resection </li></ul></ul><ul><li>Benign </li></ul><ul><ul><li>Repeat TSH and u/s q6-12 mths. Re-FNA if rapid growth </li></ul></ul><ul><li>Follicular </li></ul><ul><ul><li>Refer for surgical resection (20% are malignant) </li></ul></ul><ul><li>Suspicious </li></ul><ul><ul><li>Refer for surgical resection (60% are malignant) </li></ul></ul><ul><li>Malignant </li></ul><ul><ul><li>Refer for appropriate oncologic or surgical treatment </li></ul></ul>
  12. 12. Manage a Solitary Thyroid Nodule <ul><li>Fine-needle aspiration is the mainstay in evaluation of nontoxic thyroid nodules. </li></ul><ul><li>Nodules can harbor malignancy regardless of the presence or absence of autoimmune disease. Therefore, determination of anti–thyroperoxidase antibody and anti–thyroglobulin antibody titers in this patient is unlikely to be helpful. </li></ul><ul><li>Ultrasonography is superior to CT in the evaluation of thyroid nodules, except when there is a goiter with substantial substernal extension. This patient has no such goiter. Because the thyroid nodule has been verified on an ultrasound, further imaging is unnecessary before obtaining a tissue sample. </li></ul><ul><li>Thyroid scanning has no role in the initial workup of thyroid nodules because both benign and malignant nodules tend to be hypofunctional or “cold” on a thyroid scan. Thyroid scanning may be helpful when the thyroid-stimulating hormone (TSH) level is suppressed (which this patient’s is not) to assess for a hyperfunctioning (“hot”) nodule that does not require fine-needle aspiration biopsy. Hyperfunctioning nodules are rarely malignant. </li></ul><ul><li>Suppression of the TSH level with levothyroxine has fallen out of favor in the management of benign nodular thyroid disease because most randomized prospective trials have shown no net reduction in nodule size, and concerns are increasing about the adverse effects of iatrogenic thyrotoxicosis. Suppressive therapy is generally now reserved for patients with a cancer diagnosis. </li></ul>

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