Question of the Week # 261

261 )  A 30 year old woman presents to your office for a routine physical examination. She feels well and denies any symptoms. Her past medical history is significant for mediastinal Hodgkin’s lymphoma diagnosed at the age of 18 years. She was treated with chemotherapy and involved field radiation therapy at that time. She has a history of hypothyroidism that was diagnosed 8 years ago and has been on levothyroxine therapy. A Thyroid Stimulating Hormone level 2 months ago was within normal limits. Physical examination reveals normal vitals. There is no palpable goiter.  Rest of the physical exam is unremarkable. Routine labortatory investigations and chest x-ray are normal.  Which of the following is the most appropriate recommendation for this patient at this time?

A)   PET/ CT scan

B)    CT scan of Chest, Abdomen and Pelvis

C)     Mammogram

D)     Cardiac catheterization

E)    Anti-microsomal antibodies

14 Responses

  1. b

    • In Long term follow up of Hodgkin’s lymphoma,
      Spiral chest CT scans may be appropriate annually, starting 5 years after therapy, to screen patients at increased risk for lung cancer.
      So, B) CT scan of chest, abdomen, and pelvic.
      http://emedicine.medscape.com/article/201886-treatment#aw2aab6b6c18

      • Mammogram also need to do
        Annually beginning at yr 7 if radiation above the diaphragm began at age
        < 30 yr.
        Annually beginning at age 37 if radiation above the diaphragm began at age ≥ 30 yr.
        Now I am confused. What is the best choice?

      • Mammogram.
        Patient had Mantle field radiation and puts her at increased risk of Breast cancer.
        CT scans are not required for following up Hodgkin lymphoma after 1year of remission. Also, there is no approved screening guideline for lung cancer because of questionable benefit. So, only approved screening is Mammogram

    • I think I got now.
      CT chest need to do whenever Chest Xray is abnormal.
      CT abdomen and pelvic do only upto 5yr.
      Therefore, ans is C) Mammogram

  2. I think B

  3. I think E, we should pay attention to the Lymphoma and hypothyroidism, but we could exclude lymphoma risk considering the rountine lab test is OK and no palpable goiter. More attention should be focused on hypothyroidism

  4. Love these question on this blog! My answer is c.

  5. b . whts d ans ??

  6. Answer: c

    Breast cancer is seen with increased frequency after radiation therapy or combined modality therapy. The risk appears greatest for women treated with radiation before age 30 years, and the incidence increases substantially after 15 years of follow-up.

  7. b is my answer

  8. C

  9. Ans C

    Definitely Mammogram . even i don’t know the protocol for followup after Hodgkin . If you know that Breast cancer is the most common cancer among women . It should lead you to Mammogram.

    Patient’s TSH is normal and asymptomatic . So we can leave thyroid out . Only biopsy is most diagnostic . Other than that , none .

    Chest X ray is normal and no symptoms : we can leave Lung’s out . Why Exposed patient to additional high dose radiation with CT scan . Not necessary .

    Just my 2Cents.

  10. C:)Radiation therapy to the chest area can cause lung damage, increase the risk of heart disease, and increase the risk of lung cancer and breast cancer. It is important that men and women who received radiation to the chest limit other risk factors that may lead to heart damage, such as smoking, obesity, and high cholesterol. It is important that women who received radiation therapy to the chest begin regular breast cancer screening at an early age.
    Radiation therapy to the neck area (specifically, or as part of total body irradiation [TBI] during stem cell transplantation) can cause thyroid problems, most commonly hypothyroidism. Hypothyroidism is when the body produces too little thyroid hormone, which regulates metabolism. This problem can be managed by taking a thyroid hormone supplement pill.

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