View source for WBR0395

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Obstetrics & Gynecology
|Prompt=A 32 year old Caucasian woman comes to the physicians office.  She is 20 weeks pregnant and has been referred by her obstetrician following her complaint of increase in the size of her isolated right thyroid mass recently.  She had this mass before her pregnancy.  Thyroid scans and neck ultrasound then revealed a cold and solid mass respectively.  Fine needle aspiration was consistent with papillary carcinoma.  Further examination and scans did not reveal any lymph node metastasis.  Physical examination now reveals a 2 cm mass that was previously 1.5 cm in size, without any palpable lymph nodes.  Which of the following is the next best step in the management?
|Explanation=[[Thyroid cancer|Papillary carcinoma]] is relatively a nonaggressive lesion with long-term survival (>20 years) of more than 90%.  The lesion is frequently multicentric and rarely an isolated lesion as described above, which argues for more complete resection.  Removal of the involved lobe, and possibly the entire thyroid gland, is appropriate.  Bilateral disease mandates total [[thyroidectomy]].  Metastases, when they occur, are usually responsive to surgical resection or radioablation therapy.  Central and lateral lymph node dissection is performed for clinically suspect lymph nodes along with thyroidectomy.  Considering the indolent nature of thyroid cancer, thyroidectomy is usually delayed until the postpartum period to minimize maternal and fetal complications.  This approach does not have a negative impact on prognosis.  When surgery for thyroid cancer is deferred, the patient should be monitored with thyroid ultrasound during each trimester and thyroid hormone suppressive therapy with a goal of maintaining the TSH in the range of 0.1 to 1.5 mU/L.

'''Educational Objective:'''
Thyroid cancers which are indolent and without any metastasis in pregnancy are managed by deferring the surgery after pregnancy with thyroid hormone suppressive therapy and ultrasound monitoring of thyroid gland during each trimester.  However by 24 weeks, if there is a significant increase in thyroid cancer size (50 percent in volume and 20 percent in diameter in two dimensions) or in the presence of larger and more aggressive thyroid cancer or in the presence of extensive nodal or distant metastasis, surgery should be performed during the second trimester.


|AnswerA=Right thyroid lobectomy

|AnswerAExp='''Incorrect'''-Removal of the involved lobe alone can be appropriate after delivery.  But total thyroidectomy is always the most preferred procedure.
|AnswerB=Thyroid hormone suppressive therapy followed by total thyroidectomy before 24 weeks of pregnancy
|AnswerBExp='''Incorrect'''-By 24 weeks only if there is a significant increase in thyroid cancer size (50 percent in volume and 20 percent in diameter in two dimensions) or in the presence of larger and more aggressive thyroid cancer or in the presence of extensive nodal or distant metastasis, surgery should be performed during the second trimester.  However, if the size remains stable or if it is diagnosed in the second half of pregnancy, surgery may be performed after delivery. 
|AnswerC=131I radioactive ablation of the thyroid gland
|AnswerCExp='''Incorrect'''-The use of radioactive 131I is contraindicated in pregnancy and should be used with caution in women of childbearing age.
|AnswerD=Deferring the surgery after pregnancy with ultrasound monitoring of thyroid gland during each trimester
|AnswerDExp='''Incorrect'''-Deferring the surgery after pregnancy along with both thyroid hormone suppressive therapy and ultrasound monitoring of thyroid gland during each trimester is preferred. 
|AnswerE=Deferring the surgery after pregnancy with thyroid hormone suppressive therapy and ultrasound monitoring of thyroid gland during each trimester

|AnswerEExp='''Correct'''-Papillary carcinoma is relatively a nonaggressive lesion with long-term survival (>20 years) of more than 90%. The lesion is frequently multicentric and rarely an isolated lesion as described above, which argues for more complete resection.  Removal of the involved lobe, and possibly the entire thyroid gland, is appropriate.  Bilateral disease mandates total thyroidectomy.  Metastases, when they occur, are usually responsive to surgical resection or radioablation therapy.  Central and lateral lymph node dissection is performed for clinically suspect lymph nodes along with thyroidectomy.  Considering the indolent nature of thyroid cancer, thyroidectomy is usually delayed until the postpartum period to minimize maternal and fetal complications.  This approach does not have a negative impact on prognosis.  When surgery for thyroid cancer is deferred, the patient should be monitored with thyroid ultrasound during each trimester and thyroid hormone suppressive therapy with a goal of maintaining the TSH in the range of 0.1 to 1.5 mU/L.
|RightAnswer=E
|Approved=Yes
}}