Case 5-2013: A 52-Year-Old Woman with a Mass in the Thyroid
T h e n e w e ngl a nd j o u r na l o f m e dic i n ecase records of the massachusetts general hospitalFounded by Richard C. CabotNancy Lee Harris, m.d., EditorJo-Anne O. Shepard, m.d., Associate EditorSally H. Ebeling, Assistant EditorEric S. Rosenberg, m.d., EditorAlice M. Cort, m.d., Associate EditorEmily K. McDonald, Assistant EditorCase 5-2013: A 52-Year-Old Womanwith a Mass in the ThyroidLori J. Wirth, M.D., Douglas S. Ross, M.D., Gregory W. Randolph, M.D.,Mary Elizabeth Cunnane, M.D., and Peter M. Sadow, M.D., Ph.D.PR ESEN TATION OF C A SEFrom the Departments of Medicine(L.J.W., D.S.R.) and Pathology (P.M.S.),Massachusetts General Hospital; the Departmentsof Otology and Laryngology(G.W.R.) and Radiology (M.E.C.), MassachusettsEye and Ear Infirmary; and theDepartments of Medicine (L.J.W., D.S.R.),Surgery (G.W.R.), Radiology (M.E.C.), andPathology (P.M.S.), Harvard MedicalSchool — all in Boston.N Engl J Med 2013;368:664-73.DOI: 10.1056/NEJMcpc1210080Copyright © 2013 Massachusetts Medical Society.A 52-year-old woman was seen in the thyroid clinic at this hospital because of amass in the neck.The patient had been well until 2.5 months before presentation, when she noteda mass in the right side of her neck and felt a lump in her throat when swallowing.She was seen by her primary care physician. She had a history of myxomatousmitral valve with regurgitation, cardiac arrhythmias (atrial premature complexesand ventricular premature contractions), ovarian cysts, and anxiety; she had had atotal hysterectomy and right salpingo-oophorectomy for uterine fibroids. She drankalcohol in moderation and did not smoke or use illicit drugs. Medications includedatenolol, lisinopril, fluoxetine, calcium carbonate, a multivitamin, and amoxicillinbefore dental work. She had no known allergies. She was married, had no children,and worked in an office. Her father had hypothyroidism, an aunt had a goiter, anda sister had an unspecified thyroid problem; her other siblings were healthy.On examination, the blood pressure was 128/74 mm Hg, the pulse 66 beats perminute, the weight 66.7 kg, and the height 165.1 cm. A nodule was palpable inthe thyroid on the right side; there was no palpable lymphadenopathy. A grade2/6 systolic murmur was heard at the apex. The remainder of the examination wasnormal.The blood level of thyrotropin was 1.74 μU per milliliter (reference range, 0.40 to5.00). Ultrasonography of the thyroid gland revealed a heterogeneous, hypoechoicnodule (42 mm by 32 mm by 26 mm) in the midpole of the right lobe. The nodulehad lobulated margins, scattered central calcification, and mild central blood flow.A solid, hypoechoic nodule (24 mm by 19 mm by 34 mm), posterior and inferiorto the first nodule, contained several foci of punctate calcifications. An enlargedlymph node in the lower cervical region (level 4) on the right side of the neck hadabnormal internal architecture and contained microcalcifications.The patient was referred to the thyroid clinic at this hospital. She reported a mildcough productive of yellow phlegm, occasional palpitations, and a timbre of hervoice that was lower than usual, which she attributed to a recent upper respiratoryinfection. She had no history of radiation to the head or neck. Vital signs were664n engl j med 368;7 nejm.org february 14, 2013The New England Journal of MedicineDownloaded from nejm.org at UNIVERSITAETSBIBLIOTHEK on July 24, 2013. For personal use only. No other uses without permission.Copyright © 2013 Massachusetts Medical Society. All rights reserved.