Question of the week #46, 47

46. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?

A. Ultrasound of thyroid

B. TSH level

C. Fine Needle Aspiration ( FNAC)

D. Observation

E. Suppressive therapy with levothyroxine

47. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:

A. Radio iodine therapy ( RAI)

B. Partial thyroidectomy

C. Total thyroidectomy

D. Life long levothyroxine + Total Thyroidectomy + RAI therapy

E. Total Thyroidectomy + Life long levothyroxine

F. Partial thyroidectomy + life long levothyroxine

16 Responses

  1. 46.C. FNAC

    47.E. Total Thyroidectomy + Life long levothyroxine

  2. B
    E

  3. c
    d

  4. Q46. Ans b . TSH level is the first step for palpable thyroid nodule. A high or normal TSH indicates a cold nodule and this requires further evaluation with FNAC. If the TSH is low, next step would be RAIU scan.

    Choice A is incorrect. Ultrasound helps to detect non palpable nodules and also, gives some useful information on whether the nodule is benign vs. malignant. However, when a thyroid nodule is palpable, TSH should be performed first and further approach should be defined based on TSH results.

    Choice C is incorrect. FNAC should be subsequent step after TSH . If TSH is high or normal suggesting a cold nodule, proceed with FNAC

    Choice D is incorrect because the nodule is greater than 1.5 cm and requires further evaluation as per AACE guidelines.

    Choice E is incorrect. This is an appropriate option if the work-up reveals a hot nodule.

    Q47. Ans. D

    Papillary carcinoma of thyroid requires Total thyroidectomy and adjuvant Radio-Iodine therapy to destroy any remaining thyroid tissue. After surgery and RAIU therapy, patients are inevitably hypothyroid. Hence, they require life long levothyroxine. Life long levothyroxine is also important to keep TSH low in order to prevent recurrence of thyroid cancer. Thyroglobulin level must be carefully monitored every 6 months in patients with history of thyroid cancer to detect recurrence or persistent or metastatic disease.

    Choices A, B, C, E and F are sub-optimal management and does not completely eradicate thyroid cancer.

    • I am sorry, but you never start with TSH, always is FNAC.

      • No I think whenever there is nodule u go for blood work first and see tsh level,if normal go for fnac to know pathology ,and it is true in real life also

      • you are wrong, always TSH first to differentiate between ‘hot’ or ‘cold’ nodule, management is different for both

  5. On Medscape they mention most MD ‘s prefer beginning with the FNA directly…

    • In clinical medicine, evidence based guidelines are different from what some physicians believe to be a best practice. For the exam and also, for following the correct approach; it is beneficial to stick with guidelines. AACE guidelines as well as NEJM both advocate TSH testing in any nodule. The rationale is simple, if some one presents with a nodule – it is important to know if it is functioning or not because toxic adenomas can present as solitary nodules. Your FNAC can wait until TSH comes back .
      NEJM : http://www.nejm.org/doi/full/10.1056/NEJMcp031436

  6. In nodules with normal or increased TSH levels, the next step is to carry out a fine needle biopsy of the thyroid nodule. Cells and fluid are removed from the thyroid gland and examined by a pathologist to determine whether this is benign or malignant. A needle may also be placed into a thyroid cyst and fluid is drawn into the syringe. Very occasionally, pus is drawn, indicating that the nodule is a thyroid abscess. If a nodule is associated with decreased TSH levels the next step is to carry out a thyroid scan and iodine uptake in the nuclear medicine department. If the nodule traps iodine (also called “hot nodule”) appropriate treatment for hyperthyroidism should be undertaken. If the nodule does not take up radioactive iodine, also called “cold” nodule, a thyroid biopsy should be performed

    But again, in a man, a thyroide nodule is malignat until proven otherwise, so go for FNA at first stape and dont play with the cancer.

    • In clinical medicine, evidence based guidelines are different from what some physicians believe to be a best practice. For the exam and also, for following the correct approach; it is beneficial to stick with guidelines. AACE guidelines as well as NEJM both advocate TSH testing in any nodule. The rationale is simple, if some one presents with a nodule – it is important to know if it is functioning or not because toxic adenomas can present as solitary nodules. Your FNAC can wait until TSH comes back

  7. archer is great

  8. It makes sense to check TSH levels…Its fast,non invasive, and it needs to be documented. High or low
    Dont skip this test
    I fell for it also… But if you r in the clinic thats what u would do instinctivly. Do a TSH

  9. usmlegalaxy is right. see NCCN guidelines: http://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf

  10. The point is that if you want the point on USMLE, you should go for the TSH first.

  11. i love reading the discussion. especially when archer chimes in. hearing all these great minds exchange thoughts really helps drive the point home.

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