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Hot Nodule with Indeterminate Histology

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Question

A 45 years lady presented with STN.TSH-0.1,Tc uptake at 20 min-39%.FNAC-? follicular neoplasm. She was managed with carbimazole for 2 months.now her TSH is 10.8,Tc uptake is still 31%.FNAC -colloid with sheets of follicular cells.Is she a candidate for surgery?

Regards,

Dr. Sailesh Lodha
759 Ganeshpath, Mahaveernagar, Tonkroad
Jaipur 302004

Response

I presume that the Tc uptake was restricted to the “hot” nodule, and that it probably would be the same if you had used 131-I or 123-I.. Presumably this type of hyperthyroidism could not be permanently cured by Antithyroid drugs, so you are left with RAI, or surgery, or some kind of nodule injection therapy (which is still an unusual treatment). The risk of cancer must be very low in such a toxic nodule, but is not zero. I think, in fact, that this histology may be common in such nodules, but since they are usually not biopsied, cytology is not a factor in deciding treatment. If you give RAI you will probably easily cure the hyperthyroidism, probably destroy a low grade malignancy if present, but you will be left with a firm nodule in the gland that you will need to watch “forever” and a significant (10-30%) incidence of hypothyroidism..Operation could in theory be a unilateral resection (assuming the rest of the gland is normal on US) and thus low risk, would cure the hyperthyroidism, remove a malignancy if present, reduce the need for future surveillance, and avoid hypothyroidism. I believe that many thyroidologists would give RAI in this situation.. If I had a good surgeon available, I would prefer surgical resection.

L De Groot, MD