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Q: " I am a 32 year old thyroid cancer survivor (diagnosed in Dec'99). I am doing well - it seems - however, lately, I do not feel well. My hands and neck hurt and I have a sore throat. I'm not sure but I may have swollen glands. My thyroglobulin levels are less than 1 so I know that is good - but I don't feel quite right and these pains are bothering me. Any suggestions...."

Dr. Keti:

Thyroid nodules are common and although only a small percentage are malignant, you must maintain a high index of suspicion for malignancy. In all cases, immediate consultation or referral is imperative.

Evaluation of Nodules
Most nodules are small (0.5 cm in diameter) and rarely they are malignant (95 % benign). The best way to work up a nodule is with your fingers. Clinical criteria are helpful in establishing the risk of malignancy. Nodules that are large (> 3 cm), fixed, stony hard are more likely to be malignant. The first step in the evaluation of a palpable thyroid nodule is to obtain thyroid function tests. If thyroid function is abnormal, it is very unlikely that a thyroid nodule is cancerous.

Signs of Thyrotoxicosis?
The next step is to inquire about symptoms and signs of thyrotoxicosis, especially if the nodule is 3 cm or greater. Check a thyroid-stimulating hormone (TSH) level to rule out thyrotoxicosis. The current evaluation of a thyroid nodule(swollen glands, lumps) depends on fine-needle aspiration (FNA). Fine-needle aspiration is performed using a 21-22-gauge needle that is attached to a closed suction syringe. A repeat biopsy is indicated if the nodule grows or becomes suspicious in any fashion. Many would repeat an aspiration in 6-24 months as a follow-up. Also, a plain chest film (X-ray) should be obtained in every patient. This film may demonstrate the extent of tracheal compression or deviation and reveal pulmonary(lung) metastases.

The Role of Thyroglobulin(TG)
Although thyroglobulin(TG) is a specific tissue marker for functioning thyroid tissue, because increased levels of TG may be found in multiple thyroid diseases, measurement of serum TG is of limited value in the initial work-up of a single thyroid nodule. Also, the physician should consider hypercalcemia or hypocalcemia (as complications of surgical removal of thyroid gland include damage to the superior laryngeal nerve (1 to 2 percent of cases) and hypocalcemia from inadvertent removal of parathyroid tissue.

In cases of patients with hyperparathyroidism, more than two-thirds show no symptoms; laboratory analysis will reveal elevated serum calcium levels (hypercalcemia).
The remaining patients present with complaints of non-specific symptoms ranging from fatigue, mild "aches and pains" (paresthesias), muscle weakness; or others present with psychiatric illnesses, such as depression or psychoses.

Again, immediate consultation or referral is a must, so all patients with differentiated thyroid carcinoma are followed clinically for: neck palpation(examination), physical examination, chest x-rays and observation for thyrotoxicosis that might indicate functioning metastases.

About 6-12 months after their postoperative scan, patients usually receive another 131I(radioactive iodine) whole body scan and serum thyroglobulin measurement while hypothyroid; these procedures have a combined sensitivity of 95% for metastases. Serum thyroglobulin in a patient receiving thyroxine has a lower sensitivity of 62%.

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