#MedicalCase

Goiter in a 27 year old living in an endemic goiter area for the past 8 years, with low consumption of iodized salt. (Endocrinology)

Dr. Isaac Gana., CARDIOLOGY SPECIALITY

 

Medical Case Details:

I have a young 27 years old male patient, with unilateral swelling of thyroid (one-sided).

The patient has no symptoms apart from the swelling, which is not really visible on the outside. It is only enlarged on the ultrasound.

1. I would love to know, how long can surgery be delayed?
2. What is the chance of it been thyroid cancer? There is no lymph node enlargement.

Thanks.

 


    Discussions


    Dr. Haleema Yezdani

    Hello

    I would recommend you to get a FNAC before proceeding any further.It will definitely help you decide your approach

    Hope this helps
    Dr Haleema

    ▲ 2
    03.Jun, 12:56pm

    Dr. Maryum
    General Medicine Physician

    Dr Isaac i would like to advise thyroid function test in this case so that we may know the thyroid status first. if it is not causing any hinderance to breathing then surgery will be required on priority basis otherwise no need of surgery

    ▲ 1
    03.Jun, 01:00pm

    Dr. Marco M Zahedi
    General Medicine Physician

    I have questions to your questions:

    1) What are the TSH, Free T3 and Total T4 levels?
    2) Any Risk factors? Previous history of Radiation Tx to the neck area? Family History?

    Making several assumptions based on your description and assuming the answer to my above questions are within normal limits/negative, a Goiter in an Iodine deficient region can (and should) be worked up with a nuclear scan and possibly a biopsy to rule out occult malignancy. Assuming these are done and wnl, the answer to your question of how long surgery can be delayed is dependent on the patients symptoms. A goiter only needs to be treated surgically if it has become an aesthetic or cosmetic issue for the patient, or more concerning, that it is started to cause compression like symptoms on the nerves, trachea and most commonly the esophagus manifested by difficulty swallowing. So, you should first rule out a cold nodule with a nuclear thyroid scan, then observe for as long as the patient can tolerated. I have had patients with Goiters for over a decade.

    Hope that helps.

    Marco M. Zahedi M.D., M.P.H.
    Family Medicine
    Los Angeles, CA

    ▲ 1
    03.Jun, 01:01pm

    Dr. Maryum
    General Medicine Physician

    FNAC criteria requires nodules on ultrasound which are cold on thyroid scan, if thyroid scan shows poor uptake of contrast then FNAC is compulsory otherwise not needed

    ▲ 1
    03.Jun, 01:08pm

    Dr. Pratik Patil

    If goitre is caused by iodine deficiency, small doses of iodide in the form of Lugol's Iodine or KI solution are given. If the goitre is associated with an underactive thyroid, thyroid supplements are used as treatment. In extreme cases, a partial or complete thyroidectomy is required. Only if multinodular goitre, or malignancy is comtemplated, needs a surgical intervention. Would suggest to get a FNAC done.

    ▲ 1
    03.Jun, 01:45pm

    Dr. Madhumati Varma
    Diabetologist

    Yes as mentioned other doctors
    1 thoiroid function test
    2. Scan to rule out malignancy
    3. FANC or CT scan also can
    4. Any compressive symptoms, hypo or hyper function symptoms of thoiroid etc
    All to gethor make help to discision for surgery. Need more work up.

    ▲ 1
    03.Jun, 02:19pm

    Dr. Arvind Guru
    General Surgeon

    Hi

    I would like to know, what the radiologist exactly reported and why was the USG neck done in the first place? (since the patient does not have any symptoms or visible goiter in the neck.)
    Also, is there any risk factor for Cancer esp. Radiation and Family history of cancer syndromes

    Just get a TSH, and freeT4.

    There is no hard and fast need of a Thyroid scan if there are no nodules in a the gland and the patient is Euthyroid.

    There is no need for an FNAC as well, if there are no nodules. It will not change anything.

    Surgery is the mainstay of treatment. The indications of Surgery in a Nontoxic Goiter :
    1) Local Symptoms - Pain, choking sensation, Compression
    2) Cosmetic issues (usually along with local symptoms)
    3) Large Substernal extension, even without symptoms.

    None of which is met in your patient

    Radio-iodine has its own share of pros and cons.

    ▲ 1
    03.Jun, 03:47pm

    Dr. Isaac Gana
    Cardiologist

    Hello, Thank you all for your numerous contribution. The patient noted slight enlargement after shaving and went for an ultrasound. Ultrasound showed enlargement of the right lobe of the thyroid, no signs of a compressive syndrome, absent lymph enlargement or other symptoms. No history of treatment with radiation or family history of cancer. Patient has been living in endemic goiter region for 7-8 years. Free T3, T4, TSH test result was normal. The test was carried out yesterday. Is there need to proceed with FNAC? I really appreciate all your effort Doctors. Thanks

    04.Jun, 03:28pm

    Dr. Arvind Guru
    General Surgeon

    No FNAC is required. Thyroid scan can be done, though of not much use, in my opinion.

    Reason :
    There is no focus / nodule to sample. So what can/will FNAC assess ?
    Even USG guided procedure needs something to target.

    Regarding thyroid scan,
    1) It is unlikely to show diffuse increased uptake, because the thyroid profile is normal.
    2) Thyroid scan can suggest whether the whole enlarged lobe has decreased uptake, if it is a type of thyroiditis. However, even if it is, what good is a scan doing to do, since the treatment is observation till hypothyroidism develops.
    3) Scan can pick up nodules but it CANNOT differentiate between Benign vs Malignant. Because 80% of ‘cold’ swellings are benign and 5% functioning or ‘warm’ swellings are malignant.

    You have already done USG, hope it does not show any
    Solid / Complex Nodules, MicroCalcifications, Increased Vascularity, Hypoechogenic nodules.

    Just ensure that the USG and thyroid profile is repeated after 6-12 months.

    Some people use LevoThyroxine to regress early stages of endemic goiter.
    Dietary changes to avoid goitrogens and use iodised salt, to prevent progression.

    Hope that helps

    04.Jun, 06:41pm



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