thyroid nodules after initial evaluation by primary health care

Archives of the Balkan Medical Union
Copyright © 2016 CELSIUS
vol. 51, no. 3, pp. 434-438
September 2016
CASE REPORT
THYROID NODULES AFTER INITIAL EVALUATION
BY PRIMARY HEALTH CARE PRACTITIONERS: AN
ULTRASOUND PICTORIAL ESSAY
NICOLETA DUMITRU1, ADINA GHEMIGIAN2, MARA CARSOTE2*, SIMONA ELENA ALBU3,
DANA TERZEA4, ANA VALEA5
1
C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
3
Carol Davila University of Medicine and Pharmacy & University Emergency Hospital, Bucharest, Romania
4
C.I. Parhon National Institute of Endocrinology, Bucharest, Romania & Monza Oncoteam, Bucharest, Romania
5
Iuliu Haåieganu University of Medicine and Pharmacy & Clinical County Hospital, Cluj-Napoca, Romania
2
S UMMARY
Introduction: Thyroid nodules are relatively frequent in general
population. A thyroid mass may be detected by self-palpation or
due to local compressive symptoms or during a routine check-up
of a healthy person. However, the most common scenario
that leads to the identification of a thyroid mass, except for self
palpation, is its discovery to a primary health care control.
Cases report: We aim to introduce a cases series with large
thyroid nodules on patients who were referred to a tertiary
Romanian center of endocrinology from primary health care
centers. Cystic aspects on thyroid may need evacuation
through fine needle aspiration and surgery if some ultrasound
features may suggest a higher oncologic risk or if the cyst
relapses. The youngest female of 28 years had a large thyroid
cyst but its ultrasound aspects as structure and size indicated
thyroidectomy which revealed benign pathological findings.
Thyroid incidentaloma was considered for a man case priory
diagnosed with prostate cancer underlyng a rare first recognition for an adult within his seventh decade of life: accessory
thyroid lobe with adenomatous transformation. Three females
had difficulties of breathing or eating but not all were related
to thyroid.
Conclusion: A good collaboration between family physicians
and endocrinologists improves the outcome of thyroid nodular
conditions.
Key words: thyroid nodule, ultrasound, cyst
Correspondence address:
R ÉSUMÉ
Les nodules thyroïdiens après l’évaluation initiale par les praticiens
de soins de santé primaires : un essai illustré par ultrasons
Introduction: Les nodules thyroïdiens sont relativement fréquents
dans la population générale. Une masse de la thyroïde peut être
détectée par autopalpation ou en raison de symptômes de
compression locaux ou lors d'un contrôle de routine d'une
personne en bonne santé. Cependant, le scénario le plus courant qui
conduit à l'identification d'une masse de la thyroïde, sauf pour
l'auto palpation, est sa découverte à un contrôle de soins de santé
primaires.
Cas présentation: Nous visons à introduire une série de cas avec
de grands nodules thyroïdiens chez les patients qui ont été référés
à un centre tertiaire roumain de l'endocrinologie des centres de
soins de santé primaires. Les aspects kystiques sur la thyroïde
peuvent nécessiter l'évacuation par aspiration à l'aiguille fine
et la chirurgie si certaines caractéristiques ultrasonores peuvent
suggérer un risque oncologique plus élevé ou si le kyste a des
rechutes. Une jeune femme de 28 ans a eu un gros kyste de la
thyroïde, mais ses aspects échographiques comme la structure et la
taille indiquent la thyroïdectomie qui a révélé des résultats
pathologiques bénigns. L’incidentaloma thyroïde a été considéré,
dans le cas d’un homme, diagnostiqué antèrieurement avec un
cancer de la prostate, soulignant une première rare reconnaissance
pour un adulte dans la septième décennie de la vie: un accessoire
du lobe de la thyroïde avec transformation adéno-mateuse. Trois
femmes ont eu des difficultés de respiration ou de manger, mais
pas toutes étaient liées à la thyroïde.
Conclusion: Une bonne collaboration entre les médecins de
famille et d'endocrinologues améliore le résultat des conditions
nodulaires thyroïdiennes.
Mots clés: nodule thyroïdien, échographie, kyste
Mara Carsote, MD
Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology
Aviatorilor Ave 34-38, Bucharest, Romania
e-mail: [email protected]
Archives of the Balkan Medical Union
I NTRODUCTION
hyroid nodules are relatively frequent in
general population, their prevalence increases
with age while the risk of malignancy is higher
in younger patients but more aggressive types of thyroid
cancer are found in older persons. (1,2,3) A thyroid mass
may be detected by self-palpation or due to local compressive symptoms or during a routine check-up of a healthy
person. (4,5,6) Another possibility is the incidental finding
of a thyroid nodule while the patient is investigated for
unrelated signs and symptoms, for instance a non-thyroid
malignancy. (7,8,9) However, the most common scenario
that leads to the identification of a thyroid mass, except for
self palpation, is its discovery to a primary health care
control. (10) We aim to introduce a cases series with large
thyroid nodules on patients who were referred to a tertiary
Romanian center of endocrinology from primary health care
centers.
September 2016, 435
a
T
C ASES
b
REPORT
A 62-year female patient, known with non-autoimmune
hypothyroidism for several years, was referred by her primary
health care physician for an ultrasound evaluation because of
intermittent breathing accuses. She associated menopausal
osteoporosis. On admission, the thyroid ultrasound revealed a
large cyst of 2 centimeters (cm) with inhomogeneous interior
aspect and multiple nodules between 1 and 2.6 cm on both
lobes. (fig. 1) TSH (Thyroid Stimulating Hormone) was of
0.1 μUI/mL, with normal levels between 0.4 and 4.5 μUI/mL,
and normal FreeT4 (Free Levothyroxine) under daily 50
micrograms (μg) of levothyroxine. Substitution therapy was
stopped and thyroidectomy was recommended after TSH
normalization. For the moment, the patient delays surgery
despite intermittent symptoms.
This is another case of a 62-year old non-smoking male,
with a 4 years history of treated prostate cancer and current
remission. Computed tomography was necessary for periodic
assessment and revealed an asymmetrical thyroid in
association with a left cervical mass of unknown origin having
an oval shape and regular margins. After his current physician
sent the patient to endocrinology, the ultrasound confirmed the
nodule of 2 cm. (fig. 2) However, its thyroid origin remained
unconfirmed thus its removal was necessary. Thyroid function
was normal based on a TSH level of 0.9 μUI/mL, (normal
levels between 0.5 and 4.5 μUI/mL), negative thyroid
auto-antibodies and normal parathormone of 24.48 pg/mL
(Normal ranges are between 15 and 65 pg/mL. The postoperatory pathological exam showed an accessory thyroid
lobe with a follicular adenoma.
This is a 59-year old Caucasian female known with goiter
since the last 2 years without mediation who refused other
investigations or therapy. However, her family physician
referred her for another evaluation because it seems that she
has intermittent eating difficulties. On admission, normal
thyroid function associated thyroid ultrasound aspects that
confirm the multinodular goiter with a nodule of maximum 2.8
c
d
Figure 1 - This is the thyroid ultrasound of a 62-year old female
(a) A cyst of 2 cm on the left lobe (sagittal plane)
(b) Thyroid nodule on the left lobe (sagittal plane)
(c) Transversal section of left thyroid nodule
(d) Sagittal section of right thyroid nodule:
multiple nodules of different sizes
THYROID NODULES AFTER INITIAL EVALUATION BY PRIMARY HEALTH CARE PRACTITIONERS - DUMITRU et al
vol. 51, no. 3, 436
a
b
c
Figure 2 - This is the anterior cervical ultrasound of a 62-year
old male: focus on left cervical area at different levels. The
post-operative pathological report after surgery revealed an
accessory thyroid lobe hosting a follicle adenoma
cm. (fig. 3a) Computed tomography was done to reveal the
mass effects on trachea and esophagus but they were intact.
(fig. 3b) However, depression was soon diagnosed as cause of
her accuses.
Figure 3 - These are imagery aspects on 59-year old female
(a) Thyroid ultrasound: a nodule of 2.8 cm
(b) Intravenous contrast cervical computed tomography
shows multinodular goitre
This is a 28-year old female having rare episodes of
dyspnea thus her current primary health care physician
considered necessary a thyroid check-up. A hemorrhagic cyst
of 4.3 by 2.9 by 2.88 cm with hyper-echoic areas causing left
trachea deviation was found in relationship with her accuses.
(fig. 4) The right thyroid lobe was of 3.15 by 3.3 by 5.35 cm
while the left lobe was of 1.92 by 1.53 by 4.82 cm with
Archives of the Balkan Medical Union
September 2016, 437
a
Figure 4 - Large thyroid cyst with heterogeneous structure
on a 28-year old female
relatively homogenous pattern, except for mentioned cystic
mass. Thyroid assays were normal. Total thyroidectomy was
performed and confirmed benign aspects.
This is a 47-year old female, with a longtime history of
Raynaud’s syndrome and Hasmimoto’s thyroiditis with
normal thyroid function who presented herself to her family
doctor because she had difficulties of breathing for the last two
weeks. On admission, the blood thyroid parameters were
normal (like TSH of 1.19 μUI/mL, antithyreoperoxidase antibodies of 143 UI/mL, calcitonin of 1 pg/mL) while ultrasound
profile was hypo-echoic as background with a cyst of 3 by
2.32 by 2.93 cm and negative 131 iodine uptake. Computed
tomography confirmed the well shaped, encapsulated cyst
going through anterior superior mediastinum. (fig. 5) Total
thyroidectomy confirmed benign features based on pathological profile.
D ISCUSSION
As first case did, cystic aspects on thyroid may need
evacuation through fine needle aspiration and surgery if
some ultrasound features may suggest a higher oncologic risk
or if the cyst relapses. (4,5) The youngest female had also a
large thyroid cyst but its ultrasound aspects as structure and
size indicated thyroidectomy which revealed benign pathological findings. Thyroid incidentaloma was considered for
the man case underlyng a rare first recognition for an adult
within his seventh decade of life: accessory thyroid lobe with
adenomatous transformation. (9) Three female cases on
presented series had difficulties of breathing or eating but
not all were related to thyroid.
b
Figure 5 - This is a 47-year female with large cervical cyst
(computed tomography aspect)
(a) Transversal plane; (b) Frontal plane
Conflict of interest: none
R EFERENCES
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C ONCLUSION
A good collaboration between primary health care
physicians and endocrinologists improves the outcome of
thyroid nodular conditions.
4.
Acknowledgment
We thank the patients for signing their consent and
giving us the permission to use the images above.
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