A 40-year-old woman comes to the clinic after noticing a small swelling in the front of her neck. She has no pain, dysphagia, hoarseness, or difficulty breathing. She also has no hyper- or hypothyroid symptoms such as heat or cold intolerance, fatigue, or weight changes. Physical examination shows a mobile nodule in her left thyroid lobe. The patient has no history of neck irradiation or family history of thyroid illness. She currently takes no medications. The rest of the physical examination is unremarkable. After performing the appropriate investigation, a diagnosis of papillary thyroid cancer is made. Which of the following is the best next step in management of this patient?

Question

A 40-year-old woman comes to the clinic after noticing a small swelling in the front of her neck.  She has no pain, dysphagia, hoarseness, or difficulty breathing.  She also has no hyper- or hypothyroid symptoms such as heat or cold intolerance, fatigue, or weight changes.  Physical examination shows a mobile nodule in her left thyroid lobe.  The patient has no history of neck irradiation or family history of thyroid illness.  She currently takes no medications.  The rest of the physical examination is unremarkable. After performing the appropriate investigation, a diagnosis of papillary thyroid cancer is made.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Management of differentiated thyroid cancer (papillary, follicular) depends on the extent of disease, patient age, and comorbid conditions. Surgery is recommended for differentiated thyroid cancer in patients who are good surgical candidates, but the specific surgery and adjuvant therapies depend on the stage at diagnosis. Ultrasound of the neck and cervical lymph nodes is the primary modality for initial staging of thyroid cancer. Total thyroidectomy is recommended for large papillary thyroid cancers, extra-thyroid tumor extension, distant metastases, and in patients with a history of head or neck radiation exposure (Choice C). More extensive neck dissection is indicated for patients with involvement of adjacent neck structures or regional lymph nodes. Papillary cancers <1 cm (microcarcinoma) with no lymph node involvement usually have a favorable prognosis and may be managed with simple thyroid lobectomy (Choice D). (Choice A) TSH is a growth factor for papillary thyroid cancer. High-dose levothyroxine is used following thyroidectomy to replace normal thyroxine production and to suppress TSH stimulation of any potentially residual malignant tissue. (Choice B) Radioactive iodine is used as adjuvant therapy following thyroidectomy for patients at risk for metastatic disease, such as those with very large tumors, invasive tumors, or lymph node involvement. Educational objective: Ultrasound of the neck and cervical lymph nodes is the primary modality for initial staging of thyroid cancer. Patients with a small (<1 cm) papillary thyroid tumor may be treated with thyroid lobectomy. Total thyroidectomy is recommended for tumors >1 cm in diameter, tumor extension outside of the thyroid, distant metastases, and in patients with a history of head or neck radiation exposure. 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 40-Year-Old Woman Comes to the Clinic After Noticing a Small