  Case of the Week - Patient Summary 8051
Peer Reviewed and Certified - |
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| Demographics: 31 y.o. woman |
| History & Chief complaint: |
31 yo female presents for CT following deviated trachea noted on routine CXR.
Following CT, she develops increased jitteriness, palpitations, intermittent hot sensation.
Ultimately sent for Nuclear medicine I-123 scan for further evaluation of Thyroid.
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| Physical exam and Laboratory: |
Normal appearing, normal cardiac exam, normal VS
Thyroid with 3 cm palpable, freely mobile mass inferior to the right thyroid lobe.
Labs
Pre-CT: TSH 0.24 (nml >0.35)
Post-CT: TSH 0.003
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| Summary of Findings: |
Heterogenously enhancing, large mass contiguous with the inferior margin of the right thyroid lobe. No lymphadenopathy or other masses.
Mildly heterogeneous and hypoenhancing mass/nodule corresponding to CT, with otherwise normal thyroid uptake on I-123 scan
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| Differential Diagnosis: |
Intermediate nodule, likely benign.
Since it is not "hot", it will be treated as a cold nodule and the patient is sent for FNA.
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| Diagnosis: |
 Solitary thyroid nodule
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| Confirmed by: Pending FNA and surgical consult |
| Treatment and Followup: |
Endocrine and surgery consults pending
FNA will likely be followed by surgery regardless of histology
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| Patient Specific Discussion: (Also Read the Disease Discussion) |
Decrease in TSH following CT is the Jod-Basedow effect, the nodule converts the iodine from the contrast load into thyroid hormone, thus further suppressing her marginally low TSH pre-CT
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Nodules are a common occurance in the thyroid gland, increasing in prevelance with age. Approximately 1:15 females and 1:40 males over the age of 40 have thyroid nodules. Even when solitary, 90-95% of all thyroid nodules are benign, representing cysts or adenomas. Features that increase concern that a nodule may represent a malignancy include patient age of less than 20 y/o or greater than 70 y/o, male, prior neck irradiation, history of thyroid cancer and development of lymphadenopathy, hoarseness or swallowing difficulties. On ultrasound, the findings of heterogenous complexity or solid lesion is more common although no specific feature indicates benignity or malignancy. By nuclear medicine thyroid scan, non-functioning (or cold) nodules carry a greater risk of malignancy but this is on the order of 12-15%. Ultimately, the method of distinguishing benign from malignant thyroid nodules lies in tissue evaluation, with fine needle aspiration (FNA) being very effective, of low morbidity and easily done in an outpatient setting. While approximately 5-10% of FNA yield a non-diagnostic specimen on first attempt, a tissue diagnosis is obtained in an additional 50% of these during a second visit.
Upto 80% of all malignancies of the thyroid are papillary carcinoma. The which has a 20-year survival rate of 98% for low-risk patients and 50% for high-risk patients. Treatment involves total thyroidectomy with 50+% of specimens demonstrating a multifocality of disease on pathologic evaluation. Further Iodine-131 ablation of residual thyroid tissue reduces the local recurrance rate to less than 5% and allows for thyroglobulin serum measurement as a means for surveillance for recurrance.
This patient was a 43 y/o male with the history of an mass in the thyroid region x 3 months. He underwent an FNA with well differentiated papillary thyroid carcinoma diagnosed. |
