This 27-year-old female presents with a 2 cm x 1 cm mass in her left neck found as part of her
routine physical examination. The patient was unaware of the mass at the time of her exam.
She has no difficulty swallowing solids or liquids. She has no voice changes. She has no other
local compressive symptoms related to her thyroid gland. Her health is unremarkable at this
time. An ultrasound of the neck demonstrated appropriate size and shape thyroid gland.
The mass appeared to be superior and lateral to the left lobe of the thyroid gland consistent with an
enlarged lymph node. The patient was seen by ear nose and throat physician and a fine-needle
aspiration biopsy was performed. The biopsy demonstrated Bethesda 6 lesion that was
consistent with follicular thyroid carcinoma. The patient was then referred to Endocrinology.
Patient’s TSH was 2.1. No other lab testing was done. There is no family history of thyroid
cancer that this patient is aware of at this time. There is no history of head or neck irradiation in
this individual.
Is there any further testing you would like at this time?
There is not necessarily any additional testing she needs at this time. She should get an urgent referral to an ENT surgeon. The most important thing is that she should see a surgeon who does a high volume of thyroidectomies. Thyroid surgeries are very complex and carry risks of complications. The parathyroids can often stunned leading to transient low calcium. They can even be accidentally removed. The recurrent laryngeal nerve can also be damaged leading to vocal cord dysfunction.
What type of surgery would you recommend for this case?
I generally leave decision on the surgical approach to the surgeon, but I also take the pathology into account. This patient has follicular thyroid cancer which is somewhat more aggressive than papillary. However assuming her disease is confined to the thyroid she would be low risk under the 2015 ATA guidelines. For that reason I think a lobectomy is a reasonable first step followed by better risk stratification afterwards.
Would your recommended surgery change if the patient had a family history of thyroid cancer?
While thyroid cancer can be familial it is only rarely associated with cancer syndromes. I would still pursue a more conservative approach.
Would your recommendation of surgery change if the patient had a personal history of head or neck irradiation?
That is more concerning as we know this carries a higher risk. Unfortunately we don’t have enough data to best risk stratify these patients, so history of head or neck radiation is not currently used on the ATA risk stratification. I would have a conversation with the patient and discuss the risks and benefits of radioactive iodine ablation. Ablation requires total thyroidectomy to be effective. If the patient felt very strongly about total thyroidectomy I would pursue it alongside an ablation, but i think that a trial of therapy with just lobectomy and close monitoring would be reasonable.
Traditionally endocrinologist have been taught that head or neck radiation would make the patients prognosis much worse. However, there is no current data that actually proves this point. The bigger question is, would this make it more likely to be a multifocal cancer. There is some data to suggest radiation exposure makes multifocal cancer more common. I would discuss with the patient this information and allow the patient and the surgeon to decide about the type of excision that would be necessary. Please recognize that there are new guidelines currently under review, but not yet published. These new guidelines may change all of the advice above.
Sources:
Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. doi: 10.1089/thy.2015.0020. PMID: 26462967; PMCID: PMC4739132.