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 Thyroid  



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Author11 Posts
  #1

A 31-year-old male immigrant from ndia is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and a fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management?



A. No further care is needed

B. Thyroid function tests should be repeated yearly

C. Thyroid scan and sonogram are needed

D. FNA should be repeated until it can be read as benign or malignant

E. Thyroid lobectomy




  #2

E?


  #3

c


  #4

The correct answer is E. The patient is at high risk for thyroid cancer (young, male, with a single nodule and a history of radiation), and a reading of "indeterminate" in an FNA is a surgical Indication.



Thyroid scan and sonogram (choice C) were formerly valuable criteria to select surgical Candidates (cold solid nodules meant a high risk of cancer), but the FNA provides a higher yield of malignancy in resected specimens, and thus has rendered the other tests obsolete for this purpose.


  #5

yes agreed thats thyorid lobectomy..

any thyroid fnac cmin inderminate or even malignant do a lobectomy,and surgery reqd or no is decided by the frozen section..


  #6

I doubt.....the rule to solitary thyriod nodule is,

1) if patient is asympt and nodule is palpable....and no significant history suggesting high risk for malignancy...like family history or history of radiation in past....or even presence of other malignancy, recurrent thyroiditis.

only thing here is keep patient in touch with patient and regular follow up.

2) if suspicious history present....and patient is asymptomatic....go for a thyroid scan....and later depending upon what is the result further management is required.

3) if patient is symptomatic....aggressive management is required like excision biopsy....







  #7

he has high risk for malignancy - history of irradiation, male sex, nodule >2 cm and firm. Indeterminate FNA - next step RIAS or surgery, here with high risk - surgery is better option.
if you need guidelines for thyroid nodules -


www.aace.com/pub/pdf/guidel...elines/thyroid_nodules.pdf


  #8

hero wrote:
he has high risk for malignancy - history of irradiation, male sex, nodule >2 cm and firm. Indeterminate FNA - next step RIAS or surgery, here with high risk - surgery is better option.
if you need guidelines for thyroid nodules -


www.aace.com/pub/pdf/guidel...elines/thyroid_nodules.pdf


thanks a lot hero......it was helpful, I really like the flowchart..

I usually refer CMDT and Harrison for queries...what i see from harrison is,

Nondiagnostic biopsies occur for many reasons, including a fibrotic reaction with relatively few cells available for aspiration, a cystic lesion in which cellular components reside along the cyst margin, or a nodule that may be too small for accurate aspiration. For these reasons, ultrasound-guided FNA is indicated when the FNA is repeated.

Ultrasound is also increasingly used for initial biopsies in an effort to enhance nodule localization and the accuracy of sampling. Ultrasound characteristics are also useful for deciding which nodules to biopsy when multiple nodules are present.
Sonographic characteristics suggestive of malignancy include microcalcifications, increased vascularity, and hypoechogenicity within the nodule.

sonography should be repeated in this patient periodically...along with FNAC, if anything suspicious found anytime, it should be excised.

repeated FNACs are very troublesome for patents, so sonogram are much better choice...and should be accompanied with biopsy or FNAC occasionally.


  #9

i still stick wit lobectomy ,will hav to go thru kap ntes again..will check ,but even in the site posted above by hero in table 16 its mentioned for inderm fnac results u go for surgery ...


  #10

okay u mentioned surgery,got it ,nice discussion anyways..


  #11

I went for thyroid scan,

so believe than the correct is E. surgery bc of high risk . Good one.





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