Practice Question
A 32-year-old female with no significant past medical history comes to the office after feeling a lump in her neck. She is found to have a thyroid nodule on physical exam. She is asymptomatic. Review of systems is negative for changes in weight, fatigue, and hot or cold intolerance. She takes no medications and has no family history of thyroid disorders. Vital signs are all within normal limits. On physical exam, a 1.5-centimeter, non-tender, firm nodule is palpated in the left thyroid lobe. Her exam is otherwise unremarkable. Thyroid ultrasound reveals a 1.5-centimeter hypoechoic nodule in the left lobe with irregular margins, internal vascularity, and internal microcalcifications.
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Answer:
For this patient with an asymptomatic, 1.5-centimeter thyroid nodule with high-risk sonographic features, the most appropriate next step is (D) fine-needle aspiration (FNA) biopsy. Thyroid nodules should be evaluated with physical examination followed by serum TSH and thyroid ultrasound. Features such as irregular margins, internal microcalcifications, and internal vascularity are associated with a significantly higher risk of malignancy. Risk of malignancy can be classified using the TIRADS score, which utilizes nodule size and ultrasound characteristics to determine whether FNA is recommended. In this case, size >1 centimeter with multiple high-risk features makes this nodule highly suspicious for malignancy and meets criteria for FNA. (A) Close observation with follow up is incorrect because this nodule meets criteria for FNA. (B) Radionuclide thyroid scan may be warranted for thyroid nodules with low TSH, which indicates a hot nodule that is less likely to be a thyroid cancer, but this patient presents with a cold nodule. (C) Serum thyroglobulin is used as a tumor marker to monitor for recurrence after total thyroidectomy, as it is produced by normal thyroid tissue and differentiated thyroid cancer cells. It is not used in the workup of thyroid nodules.