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  #1  
Old 06-30-2012
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Thyroid Thyroid Nodule with indeterminate FNAC!

Excerpt from Kaplan CK Qbank

Quote:
In patients with a solitary nodule and a normal TSH level, fine-needle aspiration (FNA) should be done next to exclude thyroid cancer. If the FNA report is indeterminate, a RAIU scan is indicated to determine whether the nodule is "hot' or "cold."
I guess this is wrong.

I think then answer to indeterminate FNAC should be to repeat FNAC . RAIU scan should be done when patient presents with thyroid nodule and function tests are normal.

thoughts ?
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Old 06-30-2012
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You are talking about this right?

I think this is a controversial topic since UTD does not even mention radioiodine scans after indeterminate FNA. But I think kaplan qbank is wrong too.
<50 macrofollicular ➡ re-FNA
>50 macrofollicular ➡ ff-up
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Old 06-30-2012
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According to UW and NEJM, Radioiodine scan is done just after Sr. TSH showing Low levels in the nodule and you go for FNA if the scan shows non-functioning nodule.


The New England Journal of Medicine

Quote:
In the case of a strong clinical suspicion of cancer, surgery is recommended, regardless of the results of fine-needle aspiration biopsy (FNAB).
In the case of a suppressed level of serum thyrotropin, thyroid scintigraphy should be performed, since a functioning nodule almost invariably rules out cancer.
In the case of a nondiagnostic FNAB, a repeated biopsy yields a satisfactory aspirate in 50 percent of cases. If ultrasonography reveals additional nodules that are more than 10 mm in diameter, FNAB could be performed on one other nodule, in addition to the one that is clinically detectable. The therapeutic options shown cover both solid and cystic nodules.
In the case of a recurrent cyst, the possibilities of treatment are repeated FNAB, surgery, and ethanol injection. I do not recommend levothyroxine therapy for the thyroid nodule.

Last edited by Novobiocin; 06-30-2012 at 05:37 PM.
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Quote:
Originally Posted by Novobiocin View Post
According to UW and NEJM, Radioiodine scan is done just after Sr. TSH showing Low levels in the nodule and you go for FNA if the scan shows non-functioning nodule
As well as Kaplan Qbank and UTD

So UTD and NEJM agrees with Repeat FNAB for indeterminate FNAB(after N/⬆TSH). I guess Kaplan Qbank is totally wrong.
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I don't know where does the USG fits into this scenario since NEJM recommend US guided biopsy (FNA) but UW (Q ID: 3484) recommend USG only for a nodule with normal or high TSH ?
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Quote:
Originally Posted by neoeinstein View Post
As well as Kaplan Qbank and UTD

So UTD and NEJM agrees with Repeat FNAB for indeterminate FNAB(after N/⬆TSH). I guess Kaplan Qbank is totally wrong.
But NEJM recommends Surgery if the second FNA (US guided) is again non-diagnostic.
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Quote:
Originally Posted by Novobiocin View Post
But NEJM recommends Surgery if the second FNA (US guided) is again non-diagnostic.
UTD too!
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Quote:
Originally Posted by neoeinstein View Post
UTD too!
I think we are talking about different categories here. I am talking about NonDiagnostic results and you are talking about Indeterminate/Suspicious results on FNA?
According to NEJM if the FNA shows Suspicious results then Surgery is the next step. But if it shows NonDiagnostic results then only you do a repeat FNA (US guided). There is no recommendation for a RadioIodine Scan for a Suspicious (Indeterminate) result but they straightaway recommend Surgery.
Hope I am making some sense. :sorry:
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I think tyagee and I are talking about the Indeterminate FNAB results (after N/⬆TSH). The algorithm above is from Kaplan Qbank which we think is wrong.

Quote:
Originally Posted by tyagee View Post
In patients with a solitary nodule and a normal TSH level, fine-needle aspiration (FNA) should be done next to exclude thyroid cancer. If the FNA report is indeterminate, a RAIU scan is indicated to determine whether the nodule is "hot' or "cold."
BTW, UTD cited your NEJM's article. It explains why they have the same recommendations
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Quote:
Originally Posted by neoeinstein View Post
I think tyagee and I are talking about the Indeterminate FNAB results (after N/⬆TSH). The algorithm above is from Kaplan Qbank which we think is wrong.
Yes, it is wrong since you go straight to Surgery if the FNA shows "indeterminate" results
Also, according to Goljan NEJM is the "horse's mouth" ............NEJM recommendations are followed by the "question writers" and sometimes they are the same people. That's the reason I always check out NEJM whenever in doubt.

Last edited by Novobiocin; 06-30-2012 at 06:46 PM.
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