A study guide (2009) presents the multiple choice question:
A 45-year-old female presents to the office complaining of a “ball in my neck.” She noticed a lump in her anterior neck approximately 1 month ago. She is not sure if it has increased in size. She has not noticed any other lumps or masses. She denies dysphagia, odynophagia, neck pain, cough, weight loss, fever, chills, sweats, or a change in bowel habits. She also denies any hyperthyroid or hypothyroid symptoms. She is premenopausal, and her cycles are regular. She has been treated for diabetes for 6 years, which is well controlled with glyburide 5 mg daily. In 1993 she immigrated to the U.S. from Kiev, Ukraine, where she had lived for most of her life. She has no family history of thyroid or other endocrine disorders, but several relatives in Kiev have been diagnosed with various cancers.
According to the same source, the answer should be as follows:
This patient lived in Kiev, near the Chernobyl nuclear power plant, during and after the reactor accident in 1986. She was exposed to radiation and, like her family members, is at significantly increased risk for cancer, especially thyroid malignancies. Other factors from the history and physical that suggest a malignant etiology include: a nodule > 2 cm or increasing in size, dysphagia, hoarseness, regional lymphadenopathy, a fixation to the surrounding tissues, male sex, age less than 40, and family history.
Reference: Harrison’s 16 edition Chapter 320
Such example is inaccurate in many ways;
• In order to be in risk for radiation induced thyroid cancer that patient must be between 37 and 22 years of age at the time of the exam (exposed before birth or aged before 14 at the time of disaster)
• Must play outdoors on May 1st -3rd 1986
• Must drink milk from back yard cow during May – November 2006
• Must eat green leafy vegetables grown locally
Based on her age in 1986, she is unlikely having radiation caused thyroid cancer (but she may have breast cancer)
The patient from the case must be evaluated using standard protocol; if FNA will indicate extensive nuclear bridging this nodule may be cased by radiation exposure.
If she would be my patient I would ask her to prepare for me Ukrainian Borsch or perhaps to sing for me the Ukrainian folk song!
Cnclusion: if your thyroid patient is from Kiev, do not sell her thyroid cancer unless FNA indicates so!
If such question is asked by non-medical people it is a bad joke; if a doctor asks the same question 18 year old child from Ukraine or 50 year old person from the same region, that doctor must be replaced by another one ASAP!
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