achilles
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A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. Which of the following is the most appropriate next step in diagnosis?
A. Exploratory neck surgery
B. MRI of the pituitary gland
C. Needle core biopsy of the thyroid mass
D. Radionuclide thyroid scan
E. Serum levels of T3
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| chemamr
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C is the next step
Edited by chemamr on 02/23/06 - 10:24 AM
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| chemamr
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hey achilles, it seems to be that you love cars and motorcycles, right?. 
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| achilles
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yup  i am in love with them....
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| chemamr
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am i correct with the answer?
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| stepkiller
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I go for scintilliscan. Hot nodules are generally not malignant
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| an
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agree with D.
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| cyra
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C
The only test that can differentiate benign from cancerous thyroid nodule is a biopsy.Although thyroid scanning can give a probability that a nodule is benign or malignant, it cannot truly differentiate benign or malignant nodules and usually should not be used as the only basis for recommending treatment of the nodule, including thyroid surgery.
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| DrS
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C. Needle core biopsy of the thyroid mass
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| ruhighazi
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I chose D, because TSH is suppressed so the nodule is a "functioning nodule". So we perform thyroid scan & if it's "Hot" (as in this case with a high probability) we should just observe the nodule & treat the overt hyperthyroidism.
see the attached file
Attached Files:
algori23.gif (9 KB, 15 downloads)
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Ruhighazi
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| chemamr
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i think this is a controversial issue.
-according to the Ruhighazi´s algorithm the answer is radioisotope scan (D)
-according to Schwartz (surgery´s textbook), the 1st step always is FNA (C)
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| achilles
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well i can tell you all the answer (and this is also the given answer) i know and this is also given in kaplan notes. i havent read the schwartz textbook of surgery so dont know about what is given in it. but if anyone can come up with something pls let us all know.
the answer is D. the diagnosis is a thyroid nodule and thyroid nodules in a hyperthyroid patient are almost never cancer but they are the source of hyperfunction ( hot adenomas ) and the radionuclide scan will show that the nodule traps all the iodine with supression of rest of the gland.
hyperthyroidism and thyroid cancer rarely coexist and thus FNAC will not be the first test here. thyroid nodules in a euthyroid patient can be cancer though and in that case FNAC will be the first test of choice. this patient has all the symptoms of hyperthyroidism and so the test of choice in this case will be a radionuclide scan.
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| DrS
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The vignette clearly describes a "toxic nodule" so i don't think there's any doubt as to whether its "hot" or "cold" since it has to be hot. But there is a very small chance of a hot nodule being malignant and probably this has to be excluded and the only way to do that would be with FNAC or needle core biopsy.
However as chemamr says it is a controversial issue and I guess its over to achilles for the answer 
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| achilles
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and what would be the Rx for this ?
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| achilles
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i checked it up in CMDT too...and according to the textbook the answer is D.
a solitary thyroid nodule in a euthyroid patient or in a patient with a history of radiation therapy to the head and neck region is more likely to be malignant and in that case one has to go for FNAC.
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| chemamr
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i think that for USMLE purposes: choose D.
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| achilles
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yup , but does anybody know what is done in real practice...
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| stepkiller
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hey achilles and chemaner. i any setting an exam or practice it is the same. hot nodules are never malignant. first to a scintiliscan and find out if the whole gland is active or which part of which lobe. give radioiodine and then take it away.
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| cyra
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I was listening to the kaplan lectures on endocrinology and Dr.Faselis said that an FNAC needs to be done on any thyroid nodule PROVIDED it is not active(i.e not functional).You can determine whether the nodule is functional or not by the TSH which in this case is low and so the nodule is functional.From here,this should be managed s a toxic nodule and yes the next step would be a radionucleotide thyroid scan(D).
And I just noticed...FNA isn't even an option.Needle core biopsy is different from an FNA.
In an FNA, a very fine, thin needle is inserted into the thyroid, and aspirates (or "suctions") cells and/or fluid from a thyroid nodule or mass into the needle. The sample obtained can then be evaluated for the presence of cancerous cells.
In a needle core biopsy, a thicker, large needle is used to obtain a "core" tissue sample for analysis, and the larger sample that can be recut for smaller samples that can be sent out for further analysis. Needle biopsies are typically done using local anesthesia, and these procedures have slightly greater risk of bleeding associated with them, so they are more often done by a surgeon in outpatient or ambulatory surgical facilities. This procedure, while more invasive for patients, requires less skill to obtain a valid sample, and less skill for pathologists to read and interpet.
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| mani
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it has to be D. There is only 1 genuine indication fot thyroid scan.. toxicity with nudularity
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