Is a hemodynamically stable patient with hyperthyroidism on methimazole 5 mg daily and propranolol 10 mg daily, suppressed TSH, low free thyroxine (FT4) but asymptomatic, and a 2 × 4 cm anterior neck mass cleared for a neck‑mass biopsy?

Clearance for Neck Mass Biopsy in a Hemodynamically Stable Patient with Hyperthyroidism

Yes, this patient can be cleared for neck mass biopsy. The patient is hemodynamically stable, asymptomatic from a cardiovascular standpoint, and the hyperthyroidism is adequately controlled on current medical therapy, making the procedural risk acceptable.

Risk Assessment for Procedural Clearance

Thyroid Function Status

• The patient's suppressed TSH (0.01) with low FT4 (0.41) indicates the hyperthyroidism is biochemically controlled, though the patient may be trending toward iatrogenic hypothyroidism from methimazole therapy 1.
• Current symptoms are minimal: heat intolerance and palpitations are present but the patient demonstrates normal vital signs (HR 74, BP 130/70) and is not in distress, indicating adequate beta-blockade with propranolol 2.
• The combination of methimazole and propranolol has been shown to effectively control heart rate and reduce hyperadrenergic symptoms in hyperthyroid patients, making them suitable candidates for procedures 2.

Cardiovascular Stability

• Heart rate of 74 bpm with propranolol 10 mg daily demonstrates adequate rate control 2.
• Blood pressure 130/70 mmHg is within normal limits with no evidence of hemodynamic instability 1.
• The patient shows no chest pain, dyspnea, or signs of heart failure, which are critical exclusion criteria for procedural clearance 3.

Procedural Considerations for the Neck Mass

Diagnostic Priority

• This patient has a 2×4 cm anterior neck mass present for an extended duration (since the initial presentation years ago), which meets high-risk criteria for malignancy requiring urgent tissue diagnosis 1.
• Prior cytology showed "suspicious for follicular neoplasm, Hurthle cell type," which is an indeterminate diagnosis that requires definitive surgical management rather than repeat FNA 4.
• The mass characteristics—smooth, well-defined margins, nontender, firm, moves with swallowing—are consistent with a thyroid nodule, and the prior cytology result mandates surgical intervention 1.

Appropriate Biopsy Approach

• Given the prior FNA showing follicular neoplasm, the planned "neck mass biopsy" should ideally be a surgical excision (lobectomy or total thyroidectomy) rather than a repeat needle biopsy, as follicular neoplasms cannot be definitively diagnosed as benign versus malignant without examining capsular and vascular invasion on permanent histology 4.
• If the referring team is planning an open surgical biopsy or thyroidectomy, this is the appropriate next step given the indeterminate cytology and the patient's prolonged follow-up 4.
• Repeat FNA would not be beneficial in this case, as follicular neoplasms require surgical excision for definitive diagnosis 4.

Pre-Procedural Optimization

Thyroid Hormone Management

• The low FT4 (0.41) suggests the patient may be over-treated with methimazole, but this actually reduces procedural risk by preventing thyroid storm 5, 3.
• Continue current methimazole and propranolol through the day of surgery; do not discontinue these medications, as abrupt cessation can precipitate thyroid storm 3.
• The anesthesia team should be informed of the hyperthyroid history and current medications 3.

Monitoring Requirements

• Intraoperative monitoring should include continuous cardiac monitoring given the history of hyperthyroidism and palpitations 6.
• Postoperative thyroid function testing should be performed 6-8 weeks after surgery if thyroidectomy is performed, as the patient will require levothyroxine replacement 7.

Critical Pitfalls to Avoid

Do Not Delay Surgery for "Perfect" Thyroid Function

• The patient's current thyroid status is acceptable for surgery; waiting to achieve completely normal thyroid function tests would unnecessarily delay diagnosis of a potentially malignant lesion 1.
• The risk of delaying diagnosis outweighs the minimal additional risk from mild residual hyperthyroid symptoms in a hemodynamically stable patient 4.

Do Not Perform Isolated Biopsy Without Surgical Planning

• If the procedure is truly just a "biopsy" rather than definitive surgical excision, clarify with the surgical team whether this is appropriate given the prior follicular neoplasm cytology 4.
• Open biopsy alone (without definitive resection) is generally inappropriate for thyroid nodules with indeterminate cytology, as it does not provide definitive treatment and may complicate subsequent surgery 4.

Ensure Appropriate Surgical Extent

• Given the follicular neoplasm cytology, the patient will likely require at minimum a thyroid lobectomy (possibly total thyroidectomy depending on intraoperative findings and patient factors) 8.
• Bilateral nodularity or suspicious contralateral findings on imaging would mandate total thyroidectomy rather than lobectomy 8.

Documentation for Clearance

The clearance note should state:

• Patient is hemodynamically stable with controlled hyperthyroidism on methimazole 5 mg daily and propranolol 10 mg daily 1.
• Vital signs are stable (HR 74, BP 130/70) with no signs of thyroid storm or cardiovascular decompensation 2.
• Patient is cleared for neck mass biopsy/surgical excision with the understanding that anesthesia will be informed of hyperthyroid history 3.
• Continue current medications through the day of surgery 3.
• Recommend postoperative thyroid function monitoring if thyroidectomy is performed 7.