From the Guidelines
The patient with an enlarged left thyroid lobe, bilateral thyroid nodules with a score of F2 on elastography, and a lesion in the left submandibular region suspected to be an ectopic thyroid nodule should undergo fine needle aspiration (FNA) biopsy of the thyroid nodules and a technetium-99m or I-123 thyroid scan to evaluate the submandibular lesion, as the prognosis is generally favorable with a low risk of malignancy, according to the most recent guidelines 1.
Diagnosis and Prognosis
The patient's condition is characterized by an enlarged left thyroid lobe, bilateral thyroid nodules with F2 elastography scores, and a suspected ectopic thyroid nodule in the left submandibular region. The F2 elastography score suggests intermediate stiffness, which is associated with a low to moderate risk of malignancy. According to the NCCN guidelines, the prognosis for differentiated thyroid carcinoma (DTC) is generally excellent, with 10-year survival rates exceeding 90% to 95% 1.
Recommended Approach
The recommended approach for this patient includes:
- Fine needle aspiration (FNA) biopsy of the thyroid nodules, particularly those that are suspicious or have a high risk of malignancy, to rule out malignancy 1.
- A technetium-99m or I-123 thyroid scan to evaluate the submandibular lesion and determine if it represents functioning ectopic thyroid tissue 1.
- Complete thyroid function tests (TSH, free T4, free T3) should be performed if not already done to assess current thyroid status 1.
- Follow-up ultrasound in 6-12 months is appropriate to monitor for changes in the nodules and the retrosternal extension 1.
Considerations
The patient's age, sex, and medical history should be taken into account when evaluating the risk of malignancy. The presence of suspicious ultrasound characteristics, such as hypoechogenicity, microcalcifications, or irregular borders, should also be considered when determining the need for FNA biopsy 1. Additionally, the patient's symptoms, such as difficulty swallowing, breathing, or voice changes, should be monitored and addressed accordingly.
From the Research
Prognosis and Next Steps
The patient's condition involves an enlarged left thyroid lobe, bilateral thyroid nodules with a score of F2 on elastography, and a lesion in the left submandibular region suspected to be an ectopic thyroid nodule. Considering the evidence from various studies:
- The size of the thyroid nodule is inversely related to the risk of malignancy, with larger nodules having lower malignancy rates 2.
- Fine-needle aspiration (FNA) biopsy is a crucial tool for diagnosing thyroid nodules, with an accuracy of cytologic diagnosis approaching 95% 3.
- Ultrasound elastography can help reduce nondiagnostic results in FNA biopsy by targeting the optimal area of the nodule 4.
- The initial management of thyroid nodules should be guided by thyroid function testing and ultrasonographic characteristics, with suspicious sonographic patterns prompting cytological evaluation 5.
Recommended Course of Action
Based on the provided evidence:
- FNA biopsy is recommended for the diagnosis and treatment of thyroid nodular disease, particularly for nodules with suspicious sonographic patterns 6, 3.
- Ultrasound elastography-guided FNA biopsy may be beneficial in reducing nondiagnostic results 4.
- The patient's bilateral thyroid nodules and suspected ectopic thyroid nodule should be evaluated using a combination of ultrasound, FNA biopsy, and possibly molecular testing to determine the risk of malignancy and guide further management 5.
- The patient's condition should be managed based on the estimated risk of malignancy, presence and severity of compressive symptoms, and results of diagnostic tests, with options including simple observation, local treatments, and surgery 5.