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19yr old unmarried female has come to me with history of a slowlygrowing swelling in the neck for 6 months. Clinically it is a thyroid cyst replacing whole of the left lobe. no history in family, exposureto radiation etc. is present. US shows a cyst with size 1.5cmx1.8cm with no wall irregularity, no mixed echogenicity, no solid component orcalcification. other lobe is normal sonologically. neck is negative for nodes clinically. TFTs are normal.FNAC has shown follicular neoplasm. I plan to take her up for hemithyroidectomy proceed sos completionthyroidectomy in case the report of HPE shows a malignancy. 1) should i proceed? 2) should i consider her for a total or near total thyroidectomy atthe primary surgery itself? 3) can i offer her RAI after hemithyroidectomy if the HPE shows malignancy, despite the fact that she is yet to have a family? 4) what is the implication of RAI in case she decides to take it and then plans to have kids, say five yrs after the radio iodine? 5) does she merit suppression therapy with levoT4 if the HPE turns out to be follicular adenoma only, after hemithyroidectomy? thanking you in anticipation.
Sanjay Gandhi
Memorial Hospital
Mangol Puri Delhi, India
Response
General comment: I do not believe that the material recovered from a cystic fluid (if indeed the nodule is entirely fluid) can allow the diagnosis of follicular neoplasm. Thus my answer is: 1) I would not proceed to surgical treatment. I would aspirate all the Fluid and then wait and see. 2) RAI has no indication for total ablation after hemithyroidectomy 3) In any case RAI is not a risk for subsequent pregnancies, even after 6 months. No need to wait 5 years. 4) Just in case that a patient has HemiTx for follicular adenoma there is no reason for suppressive therapy. Replacement therapy is sufficient. Sincerely,
F. Pacini MD