Thyroid nodule

Diagnosis

A suspicious nodule measuring 14 mm in the left lobe of the thyroid gland

Patient's questions:

During the ultrasound examination, a 14 mm hypoechoic nodule of irregular shape was detected in the left lobe of the thyroid gland. The nodule has a mixed vascular structure. No extension beyond the capsule was observed. The appearance of the lesion raises slight concerns. 

Additionally, a small, partially cystic, isoechoic nodule measuring 3 mm was detected in the right lobe of the thyroid gland, which appears to be benign. The rest of the thyroid gland appears normal. The cervical lymph nodes are normal.

I'm now in the fourth month of my pregnancy. My cousin had thyroid cancer and died from the disease. There has also been a history of lung cancer in our family.

I would like your advice on further investigations and treatment options. 

A response from surgeon Professor Henning Dralle:

You are 5 days and 3 months pregnant. Your doctors found a suspicious nodule measuring 14 mm in the upper pole of the left thyroid lobe during a neck ultrasound, but no suspicious nodes in the neck. Your cousin had thyroid cancer and died from the disease. Lung cancer has also been observed in your family. 

Based on this information, I conclude the following:

• Regarding your cousin's thyroid cancer, the criteria for familial thyroid cancer are not met. For a non-medullary differentiated thyroid cancer to be familial, at least three first-degree consanguineous family members must be affected by differentiated papillary or follicular thyroid cancer. This does not seem to be the case in your situation, even if you were to develop differentiated thyroid cancer.
• If thyroid surgery is necessary during pregnancy, it should ideally be performed in the second trimester (fourth to sixth month). This allows enough time for additional diagnostics and decision-making.
• If a biopsy reveals differentiated thyroid cancer, for example if the Bethesda cytology result is 5 or 6, surgery can be postponed until after delivery, provided there is no evidence of lymph node or distant metastases. Based on your ultrasound report, no suspicious neck lymph nodes have been described. 
• Regarding your biopsy, please send me the final report. Ask the pathologist whether BRAF immunocytochemistry or other molecular markers were analysed. If they have done so and the BRAF analysis shows positivity for BRAF, then papillary thyroid cancer is proven. However, some cases of papillary and follicular thyroid cancer are BRAF negative, so papillary and follicular thyroid cancer cannot be excluded in the event of BRAF negativity. 
• To determine the probability of medullary thyroid cancer, the tumour marker calcitonin should be analysed in the blood. 

Once I have received the final biopsy report and the calcitonin value, including the normal range, I will provide further advice.