Thyroid nodules and thyroid cancer: Clinical

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Thyroid nodules and thyroid cancer: Clinical

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A 50-year-old woman comes to the clinic for evaluation of a neck nodule. The patient is asymptomatic and in good health. She feels well and has not experienced palpitations, diaphoresis, hair loss, weight gain, constipation, or insomnia. Her mood is good. Family history is non-contributory. Temperature is 37.0°C (98.6°F), pulse is 80/min, and blood pressure is 116/80 mmHg. On physical examination, a nodule is noted in the right thyroid lobe. Ultrasound is performed and reveals a 2 cm hypoechoic nodule with microcalcifications. Laboratory tests show the following:

Which of the following is the most appropriate next step in the evaluation of this patient?


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Thyroid nodules are lumps on the thyroid gland that represent clusters of abnormally growing thyroid cells. They’re actually fairly common, and they’re often felt on palpation, or they’re discovered incidentally, like during an ultrasound of the thyroid gland.

There may be a single nodule or multiple nodules, and sometimes they form on a pre-existing goiter - which is when the thyroid is enlarged, usually due to an autoimmune attack on the thyroid gland, like with Hashimoto’s thyroiditis, or Graves’ disease.

The key thing to identify is whether or not the nodule is benign or is a thyroid cancer.

The thyroid is sensitive to radiation, so an important risk factor for thyroid cancer is prior radiation in the head or neck region, which might have been given for another malignancy in the area, like lymphoma.

Other risk factors for thyroid cancer include a family history of thyroid cancer or being over age 65, since nodules are more likely to be malignant in older individuals.

Because thyroid nodules are fairly uncommon in young individuals, if they appear in a person below 20 years of age, they’re usually cancerous.

Finally, having symptoms related to the nodule like voice changes or a hoarse voice, and difficulty breathing or swallowing suggest that the nodule is an invading adjacent tissues and structures, a sign of thyroid cancer.

On a physical examination, a nodule is more likely to be thyroid cancer if it’s firm and hard on palpation, or if it’s fixed - meaning, it doesn’t move when the individual swallows.

Another warning sign is the presence of a swollen lymph node in the neck region, especially when the lymph node doesn’t hurt on palpation, and is only on one side.

The next step in evaluating the risk that a thyroid nodule is cancerous, is getting a TSH level and a thyroid ultrasound. Depending on the results of these tests, a fine needle aspiration may or may not be needed.



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