Clearing the Throat

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The woman sitting on the exam table before me just had her 65th birthday. She came to the office as a new patient for her “Welcome to Medicare” physical; the one time that Medicare allowed some flexibility in allowing physicians’ to do preventative tests, rather than fixing existing health problems. She was extremely pleasant and relaxed, offering a medical history that revealed no surprises. We were just about to start her physical examination when she leaned forward intently and politely asked, “Is there some test you can do for cancer?”

I was just about to explain how many different kinds of cancers, requiring many different types of test and procedures. “We can do specific . . . ,” but she held up her hand and stopped me abruptly. “What do you think this is?” she said, as she rolled down her blue silk turtleneck and pointed a well–manicured index finger to the right side of her neck. “I’m not sure how long its been there. My granddaughter Kristen was hugging me the other day and asked me what it was,” she continued. “It doesn’t hurt or anything, but it seems to move when I swallow. I’ve been self-conscious, so that’s why the turtleneck despite the Summer heat.”

When she drew back her finger I could see the outline of her concern. At the lower right side of her neck was a slight elevation in the skin. A quick check of the other side of her neck was unrevealing. Running my fingers over the surface elevation, I could feel a firm nodule about the size of an almond. Just as she described, when she swallowed it seemed to dip like a fishing bobber attached to an invisible prey.

I finished the rest of her exam before returning to her neck. We try not to get so focused on one area that we miss something else. I also wanted to check her lymph nodes without causing her undue alarm. Satisfied that everything else seemed okay, I probed a little more about her history. She had no changes in her weight, no family history of head and neck cancer, no history of radiation exposure (“unless cell phones count,” she added with a chuckle), and no night sweats. “So what is it?” she asked, as she rolled her turtleneck back up.

The nodule could be felt in the right lobe of her thyroid gland,  a gland sitting at the base of our neck. Thyroid nodules, within the thyroid gland, are quite common in the average population. Many are undetectable due to their small size and frequent lack of symptoms. For the most part they’re of no clinical concern; however, about four to seven percent of the time they may contain thyroid cancer. Certain factors in the history raise our suspicion for thyroid cancer: rapid growth, radiation exposure to the head and neck, or family history of thyroid or endocrine tumors. Thyroid nodules that are firm and unmovable (fixed to the underlying muscle), enlarged lymph nodes or a new onset of speech problems, raise our suspicions of thyroid cancer.

Blood tests are helpful, especially checking thyroid hormone levels. What is really needed is an ultrasound of the nodule; a procedure that’s painless, shows whether the nodule is solid, cystic (fluid–filled) or both, identifies other nodules we can’t feel, and helps predict thyroid cancer. But unlike the TV weatherman predicting a 30 percent chance of rain, when it comes to telling whether a thyroid nodule is cancerous we want to know for sure. One great way to do so is to place a small needle into the nodule and withdraw tissue or fluid, allowing pathologists to decide the possible presence of cancer. Of course, there are other tests, but these are the fundamental and safe procedures to accomplish. I explained this to my patient and she graciously agreed to everything.

Six weeks later, she returned for follow-up having received her diagnosis. “I can’t believe it was just a plain old cyst,” she said. “You were right, the procedures didn’t hurt a bit and I feel like a great weight is off my shoulders. I even gave Kristen a big hug for finding my ‘bump’.” It’s gratifying to give a patient good news, but it’s even better when its great news and I couldn’t help but notice she was no longer wearing a turtleneck sweater. I noticed because over the small biopsy site was a band-aid, adorned with a yellow happy face and signed, “Love, Kristen.”

About Steve P. Sanders

A general internist writing and sharing ideas and art.

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