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Zorluk: KolayBreast and Endocrine Surgery

A 45-year-old woman comes to the clinic after noticing a lump in the front of her neck two weeks ago. She has also experienced a 4-kg (8.8-lb) unintentional weight loss, intermittent palpitations, and increased sweating over the past month. Her temperature is 37.0°C (98.6°F), blood pressure is 135/85 mm Hg, and pulse is 108/min. Physical examination shows a 2.5-cm, firm, mobile nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show:

TSH: 0.05 mU/L (normal: 0.4-4.0 mU/L)
Free T4: 2.6 ng/dL (normal: 0.8-1.8 ng/dL)

An ultrasound of the neck demonstrates a 2.5-cm solid, hypoechoic nodule in the right thyroid lobe. Which of the following is the most appropriate next step in the management of this patient?

  1. Radionuclide thyroid scintigraphyCevap
  2. B
    Fine-needle aspiration biopsy of the nodule
  3. C
    Total thyroidectomy
  4. D
    Reassurance and repeat ultrasound in 6 months
  5. E
    Measurement of serum thyroglobulin level

Cevap

The most appropriate next step is radionuclide thyroid scintigraphy.
The correct answer is radionuclide thyroid scintigraphy. The initial evaluation of a newly discovered thyroid nodule always includes measurement of serum TSH and a thyroid ultrasound. If the TSH is subnormal (suppressed), it indicates the presence of autonomous thyroid hormone production. The next step is a radionuclide thyroid scan to determine if the nodule is the source of the excess hormone (a 'hot' nodule) or if the rest of the gland is overactive while the nodule is nonfunctioning (a 'cold' nodule). Because hyperfunctioning nodules are almost always benign, FNA is generally not required for hot nodules.

Adım Adım Çözüm

1
Analyze the clinical presentation and laboratory results.
The patient has a 2.5-cm thyroid nodule, symptoms of hyperthyroidism, a suppressed TSH (0.05 mU/L), and an elevated Free T4 (2.6 ng/dL).
Establishing the functional status of the thyroid gland is the first step in evaluating a thyroid nodule.
2
Apply the thyroid nodule diagnostic algorithm for a patient with suppressed TSH.
The algorithm dictates that if TSH is subnormal, a radionuclide thyroid scan (scintigraphy) should be performed next.
A radionuclide scan determines if the nodule is hyperfunctioning ('hot', concentrating the tracer) or nonfunctioning ('cold'). Hot nodules are rarely malignant and do not require FNA, whereas cold nodules require FNA to rule out malignancy.

Anahtar Kavram

In the evaluation of a thyroid nodule, a suppressed TSH level indicates the need for radionuclide thyroid scintigraphy to differentiate a hyperfunctioning (hot) nodule from a nonfunctioning (cold) nodule.
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Breast and Endocrine Surgery

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