tommyk
04-09-2006, 06:56 PM
Hy 2121
A 34-year-old woman named Jennifer Ashton was applying her make-up while also drinking her morning cup of coffee. She noticed in the mirror that a round, 2-cm mass would move up and down in the lower part of her neck whenever she swallowed.
Her physician confirms that she has a single, firm, thyroid nodule in the right lobe. There are no other abnormalities in the history or physical examination.
Her pulse is 82/min and regular. Thyroid stimulating hormone (TSH) is within normal limits. She calls you day and night for advice. What is required for diagnosis at this time? :(
1-TSH level
2-T4, T3 level
3-Calcium level
4-FNA (fine needle aspiration)
5-Emergent lobectomy
6-Advise patient to switch brands of coffee
Most thyroid nodules are benign, and hey she is young too, and surgery must be reserved for selected candidates with the highest likelihood of malignancy. Fine needle aspiration (FNA) is the best way to make the selection. If read by an experienced pathologist as negative for cancer, patients can be safely followed. If read as either indeterminate or positive for cancer, surgery would be required. Choosing surgical candidates this way, cancer is found at surgery in 20% to 40% of patients operated, a vast improvement over earlier selection methods, where the yield was around 10% to 15%. Hey, what is the most common thyroid neoplasm??? (Ans: Papillary) Clinical observation alone would not be appropriate. Thyroid cancers grow slowly, but they still need to be diagnosed and treated. Incidentally, they typically do not affect thyroid function, so that following the TSH would not alert you to the presence of malignancy. Thyroid nodules can be benign but hyperfunctioning (toxic adenoma), and therefore thyroid function must be determined. But, that has already been done here with the normal TSH. Further pursuit of T3 and T4 is unnecessary in someone with no clinical evidence of hyperfunction (normal pulse). Thyroid scan would have been the answer 10 or 20 years ago, before FNA displaced it as the best way to select surgical candidates. In the old days, a cold nodule raised suspicions of malignancy but gave low yields at surgery. Without a diagnosis of cancer, or an indeterminate FNA, one cannot justify the extremely aggressive approach of surgery as the next step in management. Switching brands of coffee is not a bad idea, esp. if you are buying “instant”…but it is not relevant to this case. J :rolleyes:
A 34-year-old woman named Jennifer Ashton was applying her make-up while also drinking her morning cup of coffee. She noticed in the mirror that a round, 2-cm mass would move up and down in the lower part of her neck whenever she swallowed.
Her physician confirms that she has a single, firm, thyroid nodule in the right lobe. There are no other abnormalities in the history or physical examination.
Her pulse is 82/min and regular. Thyroid stimulating hormone (TSH) is within normal limits. She calls you day and night for advice. What is required for diagnosis at this time? :(
1-TSH level
2-T4, T3 level
3-Calcium level
4-FNA (fine needle aspiration)
5-Emergent lobectomy
6-Advise patient to switch brands of coffee
Most thyroid nodules are benign, and hey she is young too, and surgery must be reserved for selected candidates with the highest likelihood of malignancy. Fine needle aspiration (FNA) is the best way to make the selection. If read by an experienced pathologist as negative for cancer, patients can be safely followed. If read as either indeterminate or positive for cancer, surgery would be required. Choosing surgical candidates this way, cancer is found at surgery in 20% to 40% of patients operated, a vast improvement over earlier selection methods, where the yield was around 10% to 15%. Hey, what is the most common thyroid neoplasm??? (Ans: Papillary) Clinical observation alone would not be appropriate. Thyroid cancers grow slowly, but they still need to be diagnosed and treated. Incidentally, they typically do not affect thyroid function, so that following the TSH would not alert you to the presence of malignancy. Thyroid nodules can be benign but hyperfunctioning (toxic adenoma), and therefore thyroid function must be determined. But, that has already been done here with the normal TSH. Further pursuit of T3 and T4 is unnecessary in someone with no clinical evidence of hyperfunction (normal pulse). Thyroid scan would have been the answer 10 or 20 years ago, before FNA displaced it as the best way to select surgical candidates. In the old days, a cold nodule raised suspicions of malignancy but gave low yields at surgery. Without a diagnosis of cancer, or an indeterminate FNA, one cannot justify the extremely aggressive approach of surgery as the next step in management. Switching brands of coffee is not a bad idea, esp. if you are buying “instant”…but it is not relevant to this case. J :rolleyes: