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Chapter 12: Thyroid and Parathyroid

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A 34-year-old woman presents with a large right-sided thyroid nodule seen on ultrasound. What information in her history and workup would make her at higher risk for a differentiated thyroid cancer?

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(A) She underwent radiation treatment after resection of a left lower extremity sarcoma 2 years ago.

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(B) Her thyroid-stimulating hormone (TSH) level is suppressed.

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(C) She grew up in an iodine-deficient area.

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(D) She had acne as a teenager that was treated with radiation.

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(E) She had scoliosis as a teenager requiring frequent spinal x-rays.

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(D) Although thyroid nodules are common within the general population, thyroid malignancy overall is still relatively rare. Approximately 5% of thyroid nodules are eventually found to harbor malignancy; the overwhelming majority of these will be differentiated thyroid cancer (papillary, follicular). Therapeutic doses of radiation to the head/neck region have been shown to increase the risk of thyroid malignancy. Prior to knowing its potential harmful effects, radiation was used for treatment of benign conditions such as acne, recurrent tonsillitis, tinea capitis, and external otitis; therefore, it is important to elicit this information from the patient. Other patients at increased risk of thyroid-related disease secondary to radiation exposure include those exposed to high levels of radiation related to nuclear disasters (e.g., Chernobyl) and patients who have received therapeutic radiation for the treatment of lymphoma or head/neck malignancies. There seems to be a dose-dependent relationship between the amount of radiation and the risk for thyroid malignancy.

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BIBLIOGRAPHY

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Miller BS, Gauger PG. Thyroid gland. In: Mulholland MW, Lillemoe KD, Doherty GM, et al. (eds.), Greenfield’s Surgery: Scientific Principles and Practice, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:Chapter 75.

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Procopiou M, Meier CA. Evaluation of thyroid nodules. In: Oertli D, Udelsman R (eds.), Surgery of the Thyroid and Parathyroid Glands. New York, NY: Springer; 2012:197–205.

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The patient in Question 2 was found to be hyperthyroid on laboratory evaluation. In which situation would antithyroid medication followed by radioactive iodine (RAI) be appropriate?

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(A) Graves disease

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(B) Cold nodule on iodine uptake scan, correlating with the ultrasound finding, with increased uptake in the surrounding parenchyma

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(C) Hot nodule on iodine uptake scan, correlating with ultrasound finding, with suppressed background

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(D) Hashimoto thyroiditis

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(E) If thyroglobulin levels are within normal limits

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(C) The algorithm for evaluation of thyroid nodules includes early measurement ...

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