Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

FNA or surgery?

A 37-year-old woman was referred for evaluation and management of a thyroid cyst. During the past year she had noted a swelling in her neck but was otherwise well and symptom free. The swelling was clearly visible but was not tender and did not move on swallowing. Her thyroid function studies were normal and thyroid antibodies were also normal.

Ultrasound was reported as “Vascular nodule centrally at the isthmus, slightly more to the left side, measuring 3.1x2.2x2.5 cm.” There was also a sub-centimeter hypoechoic cyst in the left lobe and smaller 3x2x5 mm solid lesion in that lobe.

The large “vascular” nodule gave me cause for concern and my surgical colleague agreed that fine needle aspiration might not be appropriate. At surgery the cyst was enucleated and there remained some “very soft” isthmus and left lobe tissue. The cyst itself was very firm.

Pathology received the excised tissue in two fragments, with the larger one being “remarkable for areas that are well circumscribed, and the cut surfaces are slightly papillary in appearance.” The pathologic diagnosis was papillary carcinoma that was partially encapsulated.

Papillary carcinoma of the thyroid is not uncommon, but I don’t recall seeing any previous ultrasound reports of a vascular solid nodule in the thyroid.

Before composing this blog, I did a PubMed search trying to find citations concerning vascular solid nodules as a presentation of papillary carcinoma of the thyroid and found only two I thought relevant. I am hopeful that my thyroid savvy colleagues will give me more insight into what I currently think is an unusual and reportable case.

For more information:
  • Lyshchik A, et al.  Quantitative analysis of tumor vascularity in benign and malignant solid thyroid nodules J Ultrasound Med. 2007 Jun;26(6):837-46. PMID: 17526616 
  • Cappelli C, et al. The predictive value of ultrasound findings in the management of thyroid nodules. QJM. 2007 Jan;100(1):29-35. PMID: 17178736