A 24-year-old woman has a 2.1-cm nodule in her right thyroid lobe. She is otherwise healthy and takes no medications. The patient has no past history of radiation exposure or family history of thyroid disease. She does not experience pain, difficulty swallowing, or voice changes. Physical examination is within normal limits. Laboratory studies show normal T3, T4, and TSH levels. An ultrasound of the thyroid gland reveals a solid nodule measuring 2.6 x 1.7 x 1.3 cm in the right lobe. The left lobe appears to be normal in size and echotexture.
Which of the following is the best next step in the management of this patient?

Question

A 24-year-old woman has a 2.1-cm nodule in her right thyroid lobe.  She is otherwise healthy and takes no medications.  The patient has no past history of radiation exposure or family history of thyroid disease.  She does not experience pain, difficulty swallowing, or voice changes.  Physical examination is within normal limits.  Laboratory studies show normal T3, T4, and TSH levels.  An ultrasound of the thyroid gland reveals a solid nodule measuring 2.6 x 1.7 x 1.3 cm in the right lobe.  The left lobe appears to be normal in size and echotexture. 
Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beda_bff1_8f63_99a1a19abbb0_MD0005_00 Patients with thyroid nodules >1 cm should be evaluated based on their cancer risk factors (eg, family history, past radiation exposure, cervical lymphadenopathy), compressive symptoms (eg, hoarseness, difficulty swallowing), and thyroid functional status (ie, euthyroid, hyperthyroid, or hypothyroid). In general, an ultrasound of the thyroid should be obtained first. Patients with suspicious ultrasound findings (eg, hypoechoic, microcalcifications, internal vascularity) or cancer risk factors should undergo fine-needle aspiration (FNA). Measurement of serum TSH can further stratify the risk of malignancy in patients with a thyroid nodule. Patients with normal or elevated TSH levels have a higher risk of malignancy and should be evaluated with FNA. Patients with low TSH levels should be evaluated using thyroid scintigraphy, usually with iodine 123 (Choice B). A hyperfunctioning ("hot") nodule (increased isotope uptake in the nodule with decreased surrounding uptake) is rarely malignant and may be treated as benign hyperthyroidism. An indeterminate or hypofunctioning ("cold") nodule indicates a higher risk of cancer and requires further evaluation with FNA. This patient has a painless thyroid nodule without clinical risk factors for thyroid cancer, compressive symptoms, or features suggesting hyper- or hypothyroidism. However, due to the size of the nodule and normal TSH level, this patient should have FNA to rule out malignancy. (Choice C) Surgery referral following FNA is usually required when nodules are malignant or suspicious for malignancy. Surgery can also be considered for benign nodules if patients have significant associated compressive symptoms. (Choice D) Repeat ultrasound is recommended for follow-up of benign nodules after confirmation with FNA. Ultrasound can also be used to monitor nodules <1 cm that are not suspicious for malignancy. (Choice E) Benign nodules grow very slowly. Suppressive levothyroxine is usually not recommended as it does not effectively decrease nodule size. In addition, suppressive doses of levothyroxine can lead to adverse effects (eg, bone loss, atrial fibrillation). Educational objective: Thyroid nodules should be evaluated using TSH level and thyroid ultrasound. Patients with normal or high TSH and a confirmed nodule >1 cm in diameter on ultrasound should undergo fine-needle aspiration with nodule cytology. Patients with low TSH should have a radionuclide thyroid 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) Evaluation of a thyroid nodule. (http://www.ncbi.nlm.nih.gov/pubmed/20510711)

A 24-Year-Old Woman Has a 2