A 32-year-old woman complains of the sensation of a foreign body in her throat for the last 2 months. The feeling is persistent but gets worse with anxiety. She has no loss of appetite, fever, weight loss, nausea, vomiting, or dark stools. The patient was diagnosed with a 2-cm nonmetastatic papillary thyroid cancer 3 years ago and was treated with near-total thyroidectomy followed by radioactive iodine ablation of the remnant thyroid tissue. She had an uncomplicated postoperative course and has been on a stable dose of levothyroxine for the past 3 years. Her total body radioactive iodine scan done 1 year ago showed no abnormal uptake. In addition, ultrasound at that time showed normal thyroid bed and no lymphadenopathy in her neck.
Examination shows a well-healed neck scar with no masses or lymph node enlargement.
Which of the following is the best initial step in managing this patient?

Question

A 32-year-old woman complains of the sensation of a foreign body in her throat for the last 2 months.  The feeling is persistent but gets worse with anxiety.  She has no loss of appetite, fever, weight loss, nausea, vomiting, or dark stools.  The patient was diagnosed with a 2-cm nonmetastatic papillary thyroid cancer 3 years ago and was treated with near-total thyroidectomy followed by radioactive iodine ablation of the remnant thyroid tissue.  She had an uncomplicated postoperative course and has been on a stable dose of levothyroxine for the past 3 years.  Her total body radioactive iodine scan done 1 year ago showed no abnormal uptake.  In addition, ultrasound at that time showed normal thyroid bed and no lymphadenopathy in her neck.
Examination shows a well-healed neck scar with no masses or lymph node enlargement.
Which of the following is the best initial step in managing this patient?

Quizplus · Accepted Answer

11ec193a_9839_b943_853d_9980cddf9f6f_MD0002_00 This patient has a low risk for recurrent thyroid cancer due to young age (< 45 years) and small (< 4 cm) nonmetastatic tumor. Papillary thyroid cancer is the most common type of thyroid cancer and usually recurs in the neck. The prognosis is usually very good in small tumors without high-risk features (eg, vascular invasion, more aggressive histologic subtypes, or poorly differentiated histologies on pathology). Most cancers require initial thyroidectomy and post-surgical radioiodine therapy. Thyroglobulin is secreted by most differentiated thyroid cancers (papillary and follicular) and is a useful marker of persistent or recurrent tumor after thyroidectomy and radioablation of normal thyroid tissue. Undetectable thyroglobulin in treated thyroid cancer patients signifies absent disease. Follow-up surveillance (Table) includes serial TSH, free T4, and thyroglobulin measurements. Neck ultrasound is recommended twice initially in the first year after cancer treatment and then every 1-3 years or less frequently in low-risk patients. Diagnostic radioiodine scan is recommended for elevated thyroglobulin. This patient has been followed for 3 years without evidence of residual thyroid cancer. Her symptoms are nonspecific, and she first needs serum TSH, free T4, and thyroglobulin to assess for recurrent thyroid cancer (Choice C). If thyroglobulin is elevated, she may require further testing, including neck ultrasound and diagnostic radioiodine scan (Choices B and D). (Choice A) Serum calcitonin is the tumor marker for medullary thyroid cancer. Educational objective: Thyroglobulin is secreted by most differentiated thyroid cancers and is a useful marker of recurrent or persistent cancer following thyroidectomy and radioactive iodine ablation. Elevated thyroglobulin requires further testing with neck ultrasound and diagnostic radioiodine scan. __________ References: Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. (http://www.ncbi.nlm.nih.gov/pubmed/19860577)

A 32-Year-Old Woman Complains of the Sensation of a Foreign