Diagnosis
Papillary thyroid carcinoma, identified in an isthmus nodule (Bethesda VI / TBSRTC 6 confirmed via fine-needle aspiration biopsy).
Patient:
Female, 44 years old, Latvia
Physician:
Prof. Dr. med. Stefan Kersting, Director of the Department of General, Visceral, Thoracic, and Vascular Surgery at the University Medicine Greifswald
Primary Medical Information
Diagnosis: Papillary thyroid carcinoma, identified in an isthmus nodule (Bethesda VI / TBSRTC 6 confirmed via fine-needle aspiration biopsy).
Ultrasound Findings:
- Suspicious nodule in the isthmus measuring ~4.3 × 6.4 × 6.7 mm, presenting as hypoechoic with irregular margins and microcalcifications (classified as TIRADS 4b/c).
- Background of chronic autoimmune thyroiditis (elevated Anti-TPO antibodies at 593.9 IU/mL; normal TSH, Free T3, and Free T4 levels).
- Additional small, benign-appearing cystic nodules in the left thyroid lobe (TIRADS 3).
- No pathologically enlarged cervical lymph nodes detected.
Patient Inquiries
- Surgery Recommendation: Based on my medical records, is surgery recommended in my case?
- Surgical Scope: If surgery is necessary, what is more appropriate—total thyroidectomy or partial thyroidectomy (e.g., lobectomy / isthmusectomy)—given the nodule size and location?
- Urgency: How urgent is the surgery?
- Surgical Delay: Would it be medically safe to postpone the procedure by approximately two months due to a planned family vacation?
Surgical Evaluation & Expert Opinion by Prof. Dr. Stefan Kersting
According to the information available, this is a very small, cytologically confirmed papillary thyroid carcinoma in the isthmus region with a maximum diameter of approximately 7 mm, with no sonographic evidence of abnormal cervical lymph nodes. Provided there is no evidence of extrathyroidal extension or other risk factors, this initially represents a papillary microcarcinoma with a very favourable prognosis.
Surgery is not immediately necessary in this constellation. In the case of an isolated, unifocal papillary microcarcinoma without additional risk factors, active ultrasound monitoring may, in general, also be considered. However, in the case of a 44-year-old female patient with a carcinoma already definitively confirmed cytologically, I consider surgical treatment to be a very reasonable strategy.
The extent of the surgery should be discussed individually with the patient. In the case of a tumour of this size that is definitely solitary and without lymph node metastases, an organ-preserving approach involving a hemithyroidectomy and resection of the isthmus would, in general, be sufficient. If, on the other hand, there are indications of multifocality – particularly in the contralateral thyroid lobe – this would, in my view, be a significant argument in favour of a total thyroidectomy. The small nodules described in the left lobe should therefore be evaluated again by targeted ultrasound before a final decision is made.
I would discuss the advantages and disadvantages of both surgical strategies in detail with patient and determine the definitive course of action together with her. In doing so, in addition to the ultrasound findings, the consequences of a possible second operation must be considered, as well as, conversely, the risks and the need for lifelong hormone replacement following a total thyroidectomy.
With regard to the urgency of the situation, based on the circumstances described, I see no reason for surgery to be carried out at short notice within a few days or weeks. In my view, a delay of around two months is oncologically justifiable provided the findings remain unchanged.
We would be happy to refer the patient to our hospital. Following our own high-resolution ultrasound examination, we can discuss the various options with her and jointly determine the appropriate extent of resection. If she decides to undergo surgical treatment, we can, of course, perform the procedure here.
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