CD2: THYROID CASE: “Honestly and Throat-fully”

Evely is a 36-year-old female who consulted because of an enlarged anterior neck mass.
One week prior to consultation she noted slight discomfort over her anterior neck region and a
few days later, upon waking up she noted a 2 x 2 cm mass on her neck that moves on
swallowing. She denies any fever, dysphagia, palpitations, tremors and weight loss.
She was never hospitalized nor underwent any surgeries before. Both her parents are
diabetic and her mother underwent left thyroid lobectomy for a nodular goiter at age 50 that
turned out to be adenomatous. The patient is a non-smoker with no history of alcohol and drug
use. She maintains a well-balanced diet and has not been taking any medications nor
supplements.

Pertinent physical examination findings:

● Conscious, coherent, ambulatory
● BP 110/80 CR 84/min, regular RR 19/min Temp 36 C BMI 23.9 kg/m2
● Pink palpebral conjunctivae, anicteric sclerae, no exophthalmos, no lid lag
● Supple neck with palpable 2.5 x 2.5 cm fluctuant, movable nodule over the right lobe of
the thyroid.
● No palpable cervical lymph nodes, JVP is not elevated
● Heart: adynamic precordium, AB at 5th LICS MCL, no murmurs
● Lungs: symmetrical chest expansion, normal breath sounds
● Abdomen: flat, normoactive bowel sounds with no organomegaly
● Extremities: no edema, no deformities, no tremors, DTRs: ++

Ultrasound of the Thyroid Gland

● 3.0 x 2.5 cm predominantly anechoic cystic lesion with a thin wall, well-circumscribed
margins, and mild posterior acoustic enhancement.

[just add the picture here]

1. Does Evelyn have a goiter? (Rensters)

Yes. A goiter is defined as an enlargement of the thyroid gland and since the mass
moves with deglutition, the enlarged mass is presumed to be the thyroid.
2. What are the important initial tests in the evaluation of this patient? (​AC​​)

a. Thyroid imaging
● Ultrasound
● Diagnosis and evaluation of patients with nodular thyroid disorder
● Distinguishes solid from cystic lesions and provides information about size and
multicentricity
● Echotexture, shape, borders and presence of calcifications, and vascularity can provide
useful information regarding risk of malignancy
● Useful in monitoring nodule size and for aspiration of nodules or lesions
 ○ Ultrasound-guided fine needle aspiration lowers rate of inadequate sampling and
decreases sample error
b. Measurement of thyroid hormones
● to determine first whether TSH is suppressed, normal or elevated
● (with rare exceptions) normal TSH excludes primary abnormality of thyroid function
● Depends on use of immunochemiluminometric assays (ICMAs)
○ sensitive enough to discriminate lower limit of reference range and suppressed
values that occur with thyrotoxicosis
○ Rendered TRH stimulation test obsolete
● Finding of abnormal TSH
○ Measure of circulating thyroid hormone levels to confirm diagnosis of
hyperthyroidism (suppressed TSH) or hypothyroidism (elevated TSH)
○ Radioimmunoassays for serum total T4 and total T3
○ Most purposes, unbound T4 level is sufficient to confirm thyrotoxicosis.
○ Unbound T3 levels should be measure in patients with suppressed TSH but
normal unbound T4 levels.
○ Source: Harrison’s 19th Edition
● The serum thyroid-stimulating hormone level should be measured during the initial
evaluation of a patient with a thyroid nodule. If it is low, radionuclide scintigraphy should
be performed.
● If TSH is suppressed, radionuclide scintigraphy with technetium 99m or iodine 123 can
determine whether there are hyperfunctioning nodules or whether the entire thyroid
gland is overactive, as it would be in cases of toxic multinodular goiter
● Source: https://www.aafp.org/afp/2013/0801/p193.pdf

c. Biopsy
● Fine-needle aspiration is the procedure of choice for sampling thyroid nodules for biopsy,
except for hyperfunctioning nodules, which do not require biopsy
● Lesions larger than 1 cm should be biopsied.
● Lesions with features suggestive of malignancy and those in patients with risk factors for
thyroid cancer should be biopsied, regardless of size.
● Smaller lesions and those with benign histology can be followed and reevaluated if they
grow.
● Source: https://www.aafp.org/afp/2013/0801/p193.pdf

Additional information:
Some experts advocate the measurement of serum calcitonin levels as part of the workup for
thyroid nodules. Calcitonin levels are elevated in patients with medullary thyroid carcinoma.
However, this disease is rare, and there is no clear threshold that distinguishes between benign
and malignant disease.6 Previous guidelines found insufficient evidence to recommend for or
against this practice,1,14 although more recent guidelines recommend measuring calcitonin in
patients with thyroid nodules and a family history or clinical suspicion of medullary thyroid
carcinoma or MEN type 2.2
3. Interpret the ultrasound result done as to possible diagnosis.

Normal thyroid ultrasound findings

● normal thyroid gland has a homogenous appearance, the capsule may appear as a thin
hyperechoic line
● each lobe normally measures:
○ length: 4-7 cm
○ depth: <2 cm
○ isthmus <0.5 cm deep
 ● volume (excluding isthmus, unless its thickness is >3 mm)
○ 10-15 mL for females
○ 12-18 mL for males

(Karen) Case ultrasound: transverse view. Only right side is seen. Anechoic, cystic, no
calcifications etc. = possible colloid cyst (most likely benign)

4. What is the approach in the diagnosis of solitary thyroid nodules? (janine david)
5.​ What are the possible treatment options available for Evelyn? (Camile, bea)
5.1. If cytology sows that it is a benign lesion?
5.2. If cytology shows that it is malignant?
● 2.5x2.5 cm movable nodule over the right lobe of thyroid
● No palpable cervical lymphnodes
● No fever, dysphagia, palpitations, tremors and weight loss
● FH: mother : lobectomy adenomatous
● UZ: 3.0x2.5cm predominantly anechoic cystic lesion with a thin wall,
well-circumscribed margins, and mild posterior acoustic enhancement
● Management:
○ Do a near total-total thyroidectomy (after a frozen section intra-op for
histological analysis): to prevent recurrence
○ Do post-op radioactive ablation
○ Prior surgery: hold anti-thyroid medication 2 weeks prior and hold thyroid
hormone replacement 6 weeks prior (target euthyroid stage in order to
prevent thyrotoxic crisis)
○ Lugol’s solution (saturated solution of potassium iodide) for 10 days
before surgery to decrease blood flow, rate of blood flow, and
intraoperative blood loss
○ Give thyroid hormone for life to suppress thyroid and to prevent
recurrence (thyroid hormone should be taken 60 mins before breakfast)