Solitary

Thyroid Nodules
Workup and Diagnosis
Ext.
Ext.

Outline

Introduction
Incidence
Initial evaluation
Laboratory evaluation
Thyroid Imaging
FNA
Treatment

Thyroid Gland

http://khalidalomari.weebly.com/nerve-supply.html

Thyroid Nodule
A thyroid nodule is a discrete lesion within
the thyroid gland that is radiologically distinct
from the surrounding thyroid parenchyma

http://www.drdreselsurgery.com/dallas-thyroid-gland.htm

Introduction
Determining the presence or absence of a
disorder of function or malignancy
Most patients with a solitary thyroid nodule
will have a nonfunctioning benign lesion
Deciding between conservative management
and surgical therapy

Incidence
Palpable thyroid nodules are present in
1% of men
5% of women

Ultrasounddetectable thyroid nodules are

present in 19% to 67% of unselected patients
The frequency rises with age
Most of these nodules are benign
5% to 15% are thyroid cancers

INITIAL EVALUATION
History
Physical Examination

Hyperthyroid
Symptoms
Hyperactivity, irritability,
dysphoria
Heat intolerance and
sweating
Palpitation
Fatigue and weakness
Weight loss and
increased appetite
Diarrhea
Oligomenorrhea
Loss of libido

Signs
Tachycardia (AF in elderly
patients)
Fine tremor
Bounding pulse
Goiter
Fine, warm and moist skin
Muscle weakness, proximal
myopathy
Lid lag, lid retraction
Onycholysis
Gynecomastia
Alopecia, fine, thin hair

Hypothyroid
Symptoms

Tiredness,weakness
Dry skin
Feeling cold
Hair loss
Difficulty concentrating & poor
memory
Constipation
Weight gain with poor appetite
Dyspnea
Hoarse voice
Menorrhagia
Paresthesia
Impaired hearing

Signs
Dry coarse skin ; cool
peripheral extremities
Puffy face, hand, and feet
(myxedema)
Diffuse alopecia
Bradycardia
Peripheral edema
Delayed tendon reflex
relaxation
Carpal tunnel syndrome

History and Physical Examination

suggesting Thyroid Carcinoma
Males
Age < 14 or > 70 years
History of head and neck
irradiation in children

Family history of MTC, MEN

type 2, PTC

Rapidly growing nodule

Hoarseness, dysphagia,
difficult breathing

Firm or hard consistency

Irregular margin
Cervical adenopathy
Fixed nodule
Upper airway obstruction
Persistent dysphonia,
dysphagia, dyspnea

Superficial vein dilatation

Signs of inflammation

Family History
Specific endocrine disorder
Familial medullary carcinoma
MEN2
Papillary thyroid cancer

A history of polyposis
Gardners syndrome
Cowdens syndrome

Physical Examination
Palpation of the thyroid, the anterior and
posterior cervical triangles
Associated lymphadenopathy
Multiple nodules or diffuse nodularity --> benign
A firm solitary nodule, particularly in older men
--> malignancy
Rapid growth and clinical indicators of potential
invasion, such as pain or hoarseness, are
suggestive, but not diagnostic of malignancy

LABORATORY EVALUATION
TFT
Serum Tg
Serum calcitonin level

Laboratory Evaluation
Thyroid function test
TSH

Serum Tg
Followup of patients after initial treatment of
thyroid cancer
Should not routinely be checked in the initial
evaluation of a thyroid nodule

Serum calcitonin level

Suspicion of medullary carcinoma

THYROID IMAGING
Ultrasound
Radioisotope Scanning
CT & MRI

Ultrasound
Advantages
Portability
Cost effectiveness
Lack of ionizing radiation

Highly effective in determining location and

characteristics (cystic versus solid)
Limited ability to predict the diagnosis of solid
nodules accurately

Suspicious for malignancy

Microcalcifications
Hypervascularity
Infiltrative margins

Hypoechoic compared
with surrounding
parenchyma
Taller than its width on
transverse view

Two large, hypoechoic nodules associated with poorly defined borders,

the left-sided nodules showing macro- and microcalcifications.

Figure 2 (A, B): Peripheral halo. Transverse USG image (A) of the left lobe
of the thyroid gland shows a hypoechoic nodule (arrows) with poorly
defined margins and absence of a surrounding halo. Transverse USG scan
(B) of the left lobe of the thyroid gland in another patient shows a welldefined isoechoic nodule (arrow) with a surrounding, thin, regular,
complete, hypoechoic halo (arrowheads) in the left lobe of the thyroid gland
http://www.ijri.org/article.asp?issn=0971-3026;year=2012;volume=22;issue=1;spage=63;epage=68;aulast=Popli

Figure 8 (A, B): Shape [solid arrow - transverse diameter (Tr); dashed
arrow - antero-posterior diameter (AP)]. Transverse USG image (A) of the
right lobe of the thyroid gland shows a poorly defined hypoechoic nodule,
which is taller than wide. [AP>Tr] Transverse USG scan (B) shows a
heterogeneous nodule, which is not taller-than-wide [AP

http://www.ijri.org/article.asp?issn=0971-3026;year=2012;volume=22;issue=1;spage=63;epage=68;aulast=Popli

Further workup
of nodules smaller than 1 cm

Suspicious characteristics
Suspicious lymphadenopathy
Family history of papillary thyroid cancer
History of radiation exposure
Prior personal history of thyroid cancer
18F-fluorodeoxyglucose (FDG)/positron
emission tomography (PET)positive lesions

Radioisotope Scanning
Assessment of thyroid function
Using technetium-99m pertechnetate (99mTc)
or 123I to determine whether the nodule is
hyperfunctioning

Technetium-99m pertechnetate
(99mTc)
Taken up rapidly by the normal activity of
follicular cells
Short half-life and low radiation dose
Its rapid absorption
Increased uptake (hot) or hypofunctioning
(cold) areas of the thyroid

123I

and 131I iodine Scintigraphy

Evaluate the functional status of the gland

Trapped by active follicular cells and
organified
Malignancy has been shown to occur in 15%
to 20% of cold nodules and in 5% to 9% of
warm or hot nodules
Malignancy of a nodule can neither be
confirmed nor excluded based on radionuclide
uptake

123I

131I

Low dose of radiation

(100 Ci)
Short half-life (12 to
13 hours)
Evaluating suspected
lingual thyroids or
substernal goiters

Higher levels of radiation

Longer half-life (8
days)
Optimal for imaging
thyroid carcinoma
The screening
modality of choice for
the evaluation of
distant metastasis

PET with 18F-fluorodeoxyglucose

Used to provide three-dimensional
reconstruction images
1% to 2% of PET scans identify so-called
thyroid incidentalomas when evaluating other
solid malignancies
Most PET-avid incidentalomas in the thyroid
are benign, the incidence of malignancy in
those that have progressed to resection has
been reported to be as high as 33%

CT & MRI
Evaluating for local extension in more
advanced stages of thyroid cancer
Appropriate for a suspicious mass (or biopsyproven cancer) with palpable cervical lymph
nodes
Postoperative follow-up for suspicion of
recurrent disease

CT & MRI
Preoperative planning for larger thyroid
masses that show significant tracheal
deviation suggestive of a substernal goiter on
chest radiographs
Both equally sensitive and specific for the
evaluation of thyroid masses

FINE-NEEDLE ASPIRATION
(FNA)

Fine-Needle Aspiration Biopsy

FNA : a cost-effective and valuable tool
All dominant nonfunctioning thyroid nodules should be
evaluated by FNA biopsy
70-90 % of sensitivity and specificity
4% FP and FN

Fine-Needle Aspiration Biopsy

Ultrasound guidance :
- can detect heterogenous lesions
- is recommended for non-palpable, posteriorly located,
or cystic nodules
- results in a lower rate of non-diagnostic cytology and
sampling errors

Fine-Needle Aspiration Biopsy

Accurate diagnosis has significantly decreased rates of surgery
in patients with thyroid nodules
Results of FNA biopsy may be broadly grouped in several
ways, including the following :
(1) malignant
(2) indeterminate or suspicious
(3) benign
(4) nondiagnostic

Fine-Needle Aspiration Biopsy

In cases of nondiagnostic cytology, repeat FNA using
ultrasound guidance is indicated
If FNA is persistently nondiagnostic are known to have a
significant rate of malignancy => must continue to be followed
closely or excised
When FNA results are suspicious but not confirmatory of
malignancy, it appears that more than 50% of such FNA
results are associated with malignancy
If the FNA findings are indeterminate, repeat aspiration,
resection, or close conservative follow-up of the nodule is
suggested

Fine-Needle Aspiration Biopsy

Large series have shown malignancy in 6% to 20% of thyroid
lesions when follicular cells are demonstrated on FNA
The presence of colloid and macrophages in the aspirate
strongly suggests a benign lesion
Tissue immediately adjacent to or contained within another
part of the nodule may harbor malignant cells
Therefore, benign nodules diagnosed by FNA are monitored
sequentially with ultrasound to ensure that their
characteristics do not change

Fine-Needle Aspiration Biopsy

A repeat ultrasound should be performed 6 to 18 months
after the initial FNA
If this shows stable ultrasound findings, further ultrasound
examinations should be performed every 3 to 5 years
if ultrasound shows :
- more than a 50% change in volume
- 20% increase in two dimensions
FNA should be repeated under ultrasound guidance

Fine-Needle Aspiration Biopsy

Cystic lesion by ultrasound :
- aspirate the cystic fluid by a larger bore needle
- mostly was benign cytologic findings
- Papillary carcinoma can also be manifested as a cyst

Fine-Needle Aspiration Biopsy

Cysts that
- have a residual palpable mass after aspiration
- aspirated with benign cytology but then recur
considered for resection

DECISION MAKING &

TREATMENT

Decision Making and Treatment

All patients with a thyroid nodule undergo thyroid function
tests
If the patient is hyperthyroid, a radiouptake scan is used to
confirm a hot nodule
If this is the case, the patient is carefully monitored with
thyroid suppression and seen again after 6 months for
confirmation of successful suppression and reevaluation
If suppressive therapy fails, surgery (usually lobectomy) is
highly effective, but not generally required

Decision Making and Treatment

In a patient with a thyroid nodule and normal thyroid function
test results, ultrasound is performed
Cystic lesions are aspirated; bloody or suspicious aspirates can
be sent for cytologic examination
After aspiration, these patients are seen again in 6 months
Patients with recurrent cysts are considered surgical
candidates

Decision Making and Treatment

Solid or mixed solid-cystic components : depending on the
history, examination, and imaging risk factors for malignancy,
some patients will choose excision, regardless of further
workup
FNA can be used to diagnose papillary cancer and is strongly
suggestive of medullary cancer or anaplastic cancer
It cannot confirm follicular cancer, nor can it confirm a
completely benign diagnosis

Decision Making and Treatment

Therefore, risk assessment is crucial when advising patients
with a solid nodule for whom the diagnosis is not secure with
FNA
Colloid nodules are usually suggested by a mixed solid-cystic
appearance on ultrasound, and FNA shows colloid and
macrophages
If not otherwise suspicious, these lesions can be monitored
closely with serial ultrasonography every 6 months to
establish stability
Alterations in the appearance of the suspicious lesion indicate
a need for surgery

Decision Making and Treatment

Most seem to be asymptomatic papillary carcinomas smaller
than 1 cm
The fact that these lesions are highly curable and associated
with almost nonexistent mortality needs to be taken into
account when deciding whether to perform FNA and proceed
to surgery

Decision Making and Treatment

The practice of using exogenous thyroid replacement to
suppress endogenous TSH to suppress a thyroid nodule is
losing favor
It was believed that nodules that grew on suppressive therapy
were likely malignant, whereas those that shrank were likely
benign
This is neither sensitive nor specific, because only 20% to 30%
of nodules were found to shrink on suppressive therapy and
up to 13% of proven papillary cancers in one series decreased
in size on suppressive therapy

Decision Making and Treatment

The finding of a thyroid nodule in a child or pregnant patient
can be of particular concern to the patient, family, and
referring clinicians
Although the frequency of malignancy may be higher in
children than in adults : evaluation same as adult

Decision Making and Treatment

In pregnant patients :
- the incidence of malignancy compared with nonpregnant patients is not clear
- evaluation same as the nonpregnant patient except that
radionuclide scans are contraindicated

References
Courtney M. Townsend. Sabiston Textbook of
Surgery 19th Edition. Saunders; 2012.
F. Charles Brunicardi, M.D. Schwartz's Principles of
Surgery 9th Edition. McGraw-Hill Professional; 2014.
The American Thyroid Association (ATA). Revised
American Thyroid Association Management
Guidelines for Patients with Thyroid Nodules and
Differentiated Thyroid Cancer. THYROID. Volume 19.
Number 11; 2009.

THANK YOU
For Your Attention