A 30-year-old woman without significant past medical history comes to the physician with a palpable lump in her neck. She has no associated symptoms and no family history of thyroid or other endocrine disorders. Her TSH level is 1.3 µU/mL (normal 0.5-5.0 µU/mL). Thyroid ultrasound shows a 16-mm round, hypoechoic nodule in the right lobe of the thyroid. There is no lymph node enlargement.
Which of the following is the most appropriate course of action?

Question

A 30-year-old woman without significant past medical history comes to the physician with a palpable lump in her neck.  She has no associated symptoms and no family history of thyroid or other endocrine disorders.  Her TSH level is 1.3 µU/mL (normal 0.5-5.0 µU/mL).  Thyroid ultrasound shows a 16-mm round, hypoechoic nodule in the right lobe of the thyroid.  There is no lymph node enlargement.
Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec193a_97d4_40df_853d_abc12e05d539_MD0002_00 Thyroid nodules can be malignant in 4%-6% of cases. The likelihood of malignancy can be estimated based on nodule size, historical factors, TSH level, and ultrasound characteristics: Historical risk factors include a personal or first-degree family history of thyroid cancer, head/neck or total body radiation exposure in childhood, rapid nodule growth, and cervical lymphadenopathyLow (suppressed) TSH levels suggest a hyperfunctioning nodule, which is usually benign; a normal or elevated TSH raises risk of thyroid malignancySuspicious ultrasound findings include larger nodules, microcalcifications, increased nodular vascularity, hypoechoic appearance, and indistinct nodule margins Historical risk factors include a personal or first-degree family history of thyroid cancer, head/neck or total body radiation exposure in childhood, rapid nodule growth, and cervical lymphadenopathy Low (suppressed) TSH levels suggest a hyperfunctioning nodule, which is usually benign; a normal or elevated TSH raises risk of thyroid malignancy Suspicious ultrasound findings include larger nodules, microcalcifications, increased nodular vascularity, hypoechoic appearance, and indistinct nodule margins Fine-needle aspiration (FNA) is recommended in patients with high risk for malignancy based on initial assessment. In most cases, patients with a normal/elevated TSH and a solid nodule >1 cm in diameter should be evaluated further with FNA. initial assessment (Choice A) Anti-thyroid peroxidase (TPO) antibodies suggest Hashimoto's thyroiditis (chronic autoimmune thyroiditis). They are most often assayed in patients with goiter or with thyroid nodules and elevated TSH. However, TPO antibodies do not exclude malignancy or alter indications for FNA. (Choice C) Repeat thyroid ultrasound in 6-12 months is recommended for patients with FNA showing benign thyroid nodules. This patient would first need FNA to evaluate whether the nodule is benign or malignant. (Choice D) Surgery is indicated for patients with FNA showing cytological features (definitive or suspicious) of malignancy, non-diagnostic cytology on multiple FNAs, or compressive symptoms. (Choice E) Thyroid scintigraphy is used to assess hyperfunctioning nodules or a multinodular goiter in patients with low TSH, which is not present in this patient. Educational objective: TSH and thyroid ultrasound should be performed in all patients with thyroid nodules. The risk of malignancy can be assessed based on historical risk factors, TSH, nodule size, and ultrasound characteristics. High-risk nodules should be further evaluated with fine-needle aspiration. __________ References: Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. (http://www.ncbi.nlm.nih.gov/pubmed/19860577) Ultrasonographic evaluation of thyroid nodules: comparison of ultrasonographic, cytological, and histopathological findings. (http://www.ncbi.nlm.nih.gov/pubmed/19859839)

A 30-Year-Old Woman Without Significant Past Medical History Comes to the Physician