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A Not-So-Simple Thyroid Nodule

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 50-year-old woman presented with a 2-month history of a neck mass that was associated with hoarseness of voice and globus sensation. Physical examination showed thyromegaly (right greater than left) with an approximately 5-cm palpable nodule in the right lobe. There was no tenderness or cervical lymphadenopathy. There was no prior radiation exposure to the head and neck area. Thyroid function test results were normal, and she did not take thyroid medications. A relative had received a diagnosis of papillary thyroid cancer at age 50 years. There was no other pertinent family history, including a history of multiple endocrine neoplasia. Ultrasonography results showed a multinodular goiter with a dominant 4.6-cm right thyroid nodule, 1.6-cm left-sided thyroid nodule, and suspect left level IV lymph node. Ultrasonography-guided fine-needle aspiration biopsy results showed papillary thyroid carcinoma (PTC) (Bethesda VI) with a BRAFV600E variation in the left nodule and lymph node, and atypia of undetermined significance (Bethesda III) with a suspicious Afirma genomic sequence classifier in the right nodule. She underwent total thyroidectomy with modified left lateral neck dissection. Gross examination of the specimen showed a 2.9-cm pale-tan, partially circumscribed, soft nodule in the right thyroid lobe; a 1.4-cm pale-tan, fibrotic, centrally brown nodule in the left lobe; and a 1.8-cm pale-tan, rubbery, partially circumscribed nodule in the isthmus. Histologic examination of the right thyroid lesion was performed (Figure), with ancillary testing.

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A 50-year-old woman presented with a 2-month history of a neck mass that was associated with hoarseness of voice and globus sensation. Physical examination showed thyromegaly (right greater than left) with an approximately 5-cm palpable nodule in the right lobe. There was no tenderness or cervical lymphadenopathy. There was no prior radiation exposure to the head and neck area. Thyroid function test results were normal, and she did not take thyroid medications. A relative had received a diagnosis of papillary thyroid cancer at age 50 years. There was no other pertinent family history, including a history of multiple endocrine neoplasia. Ultrasonography results showed a multinodular goiter with a dominant 4.6-cm right thyroid nodule, 1.6-cm left-sided thyroid nodule, and suspect left level IV lymph node. Ultrasonography-guided fine-needle aspiration biopsy results showed papillary thyroid carcinoma (PTC) (Bethesda VI) with a BRAFV600E variation in the left nodule and lymph node, and atypia of undetermined significance (Bethesda III) with a suspicious Afirma genomic sequence classifier in the right nodule. She underwent total thyroidectomy with modified left lateral neck dissection. Gross examination of the specimen showed a 2.9-cm pale-tan, partially circumscribed, soft nodule in the right thyroid lobe; a 1.4-cm pale-tan, fibrotic, centrally brown nodule in the left lobe; and a 1.8-cm pale-tan, rubbery, partially circumscribed nodule in the isthmus. Histologic examination of the right thyroid lesion was performed (Figure), with ancillary testing.

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Article Information

Corresponding Author: Liwei Jia, MD, PhD, Department of Pathology, UT Southwestern Medical Center, 6201 Harry Hines Blvd, Room UH04.233, Dallas, TX 75390-9234 (liwei.jia@utsouthwestern.edu).

Published Online: September 2, 2021. doi:10.1001/jamaoto.2021.2155

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information as well as Justin Bishop, MD, University of Texas Southwestern Medical Center, who originally worked up and signed out the pathologic diagnosis on this case.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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