Mrs L Neck Lump

Question 1

What investigations should be ordered when a patient presents with an apparent thyroid nodule, but appear to be clinically euthyroid

Answer 1

biochemical tests for thyroid function as clinical examination has poor sensitivity

Question 2

what does presence of a goitre tell you about a patient’s thyroid status

Answer 2

hyper, hypo or euthyroid

Question 3

thyroid status of patients with malignant thyroid nodules?

Answer 3

euthyroid often

Question 4

TSH tests have been ordered. 
What test should be ordered if
A) TSH is low
B) TSH is high
What is the thyroid state if 
C) TSH is low
D) TSH is high

Answer 4

A) free triiiodothyronine and free thyroxine
B) thyroid peroxidase antibodies
C) hyperthyroid
D) hypothyroid

Question 5

What condition is indicated by thyroid peroxidase antibodies?

Answer 5

Hashimotos

Question 6

What would be ordered alongside TSH (and subsequent tests in response to TSH results), if the patient has a family hx of thyroid cancer?

Answer 6

serum calcitonin

Question 7

why can calitonin i be used as a serum marker of Medullary thyroid cancer?

Answer 7

MTC is a tumour of the calcitonin-secreting parafollicular cells

Question 8

The GP requests a serum TSH, which is later reported as 3.9 mU/L.
Should the patient be referred to an endocrine surgeon or endocrinologist

Answer 8

• this value is normal
• patient has nodule
• this combination means cancer is more likely: refer to surgery

Question 9

first line test for investigation of thyroid nodules?

Answer 9

fine needle aspiration (US may guide, and also provides info on nodules size and if it’s solid, cystic or mixed -> mixed = higher likelihood malignant)

Question 10

if a radionuclide scan was conducted, would a hot or cold nodule be more concerning

Answer 10

cold (nonfunctional) -> 5-20% are malignant

Question 11

indications for CT or MRI with goitre? (3)

Answer 11

1. retrosternal extension of goitre
2. invasive tumour
3. haemoptysis

Question 12

Potential outcomes for FNA of a thyroid nodule (5)

Answer 12

1. insufficient aspirate for diagnosis (Thy1)
2. Benign e.g. thyroiditis (Thy2)
3. follicular lesion/suspected follicular neoplasm (Thy3)
4. suspicious of malignant (Thy4)
5. diagnostic of malignancy (Thy5)

Question 13

How to manage patient after FNA and can’t tell if follicular adenoma or follicular cancer? (5)

Answer 13

1. surgery - thyroid lobectomy for low risk patient, total thyroidectomy for
2. T3 replacement
3. 131I ablation
4. T4 suppression - this suppresses TSH. If TG lecels rise above 0, suggests return of malignant thyroid cells
5. follow up

Question 14

How to manage patient after FNA and can’t tell if follicular adenoma or follicular cancer? (5)

Answer 14

1. surgery - thyroid lobectomy for low risk patient, total thyroidectomy for
2. T3 replacement
3. 131I ablation
4. T4 suppression - this suppresses TSH. If TG lecels rise above 0, suggests return of malignant thyroid cells
5. follow up