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A 44-year-old woman is referred to the endocrine clinic after her general practitioner felt a 2 cm left-sided thyroid nodule. She is clinically euthyroid. She had mantle radiotherapy for Hodgkin lymphoma at age 12. Examination reveals a firm, non-tender left thyroid nodule and a palpable 1.5 cm left level-IV cervical lymph node. Serum TSH is 1.8 mU/L (normal). Thyroid ultrasound shows a solid, hypoechoic, taller-than-wide nodule with irregular margins and microcalcifications (TI-RADS 5).
Questions
a) What is the significance of her history and ultrasound findings, and what is the next diagnostic step? (2 marks)
Model answer: Both her history of CHILDHOOD NECK IRRADIATION (a major risk factor for thyroid cancer) and the ultrasound pattern (TI-RADS 5: solid, hypoechoic, taller-than-wide, irregular margins, microcalcifications — high suspicion) markedly raise the risk of malignancy (1 mark). The next step is ULTRASOUND-GUIDED FINE-NEEDLE ASPIRATION with BETHESDA cytology reporting of both the nodule and the suspicious node (1 mark).
b) FNA reports Bethesda category VI (malignant) with nuclear grooves and psammoma bodies. What is the diagnosis and two characteristic features that support it? (2 marks)
Model answer: PAPILLARY thyroid carcinoma (1 mark). Any two of: nuclear grooves and intranuclear pseudoinclusions (optically clear nuclei), PSAMMOMA BODIES, lymphatic spread with cervical nodal involvement, BRAF V600E driver mutation, commonest thyroid malignancy with excellent prognosis (1 mark).
c) Outline the surgical and adjuvant management of her differentiated thyroid cancer. (3 marks)
Model answer: Surgery: TOTAL THYROIDECTOMY with THERAPEUTIC central and lateral neck dissection for the involved node (prophylactic central dissection may be considered) (1 mark). Adjuvant: RADIOACTIVE IODINE ablation for intermediate/high-risk disease (extra-nodal extension, nodal metastases) to destroy residual thyroid and micrometastases (1 mark). Lifelong LEVOTHYROXINE with TSH SUPPRESSION to a risk-adapted target, with SERIAL THYROGLOBULIN (and anti-thyroglobulin antibody) monitoring for recurrence (1 mark).
d) Name two early surgical complications and describe the long-term surveillance strategy. (3 marks)
Model answer: Two of: RECURRENT LARYNGEAL NERVE injury (hoarseness — check vocal cords pre- and post-op), HYPOPARATHYROIDISM (hypocalcaemia — monitor calcium), bleeding or neck haematoma (airway emergency) (1 mark). Surveillance: serial serum THYROGLOBULIN (interpretable only after complete thyroidectomy and if anti-thyroglobulin antibodies are negative), periodic neck ULTRASOUND, and risk-adapted TSH suppression (1 mark); prognostically excellent — 5-year survival over 98 percent for localised papillary cancer (1 mark).