Approach to a thyroid nodule

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Approach to a thyroid nodule

• Andy Sher
• PGY-2 Family Medicine

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Case

• 44 y.o. woman, 2 cm nodule palpable in left lobe
  of thyroid gland at annual exam smooth,
  non-tender. No lymphadenopathy
• No symptoms of hyper/hypo thyroid. No
  compressive symptoms
• Past Med Hx HTN
• Meds HCTZ
• Fam Hx no hx of thyroid disease

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Epidemiology

• Palpable thyroid nodules 4-7 of population
• Prevalence 19-67 - based on nodules found
  incidentally on ultrasound
• 41 womenmen

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Epidemiology

• Geographic areas with iodine deficiency
• Thyroid carcinoma in 5-10 of palpable nodules
• Following ionizing radiation, nodules develop at
  a rate of 2 annually

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Presentation

• Majority are asymptomatic
• lt1 cause hyperthyroidism
• Neck pressure or pain if spontaneous hemorrhage

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History

• Symptoms of hyper or hypothyroidism
• Previous nodules, goiters, family history of
  autoimmune thyroid disease, thyroid carcinoma, or
  familial polyposis
• Hashimotos thyroiditis association with
  thyroid lymphoma

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History Red Flags

• Male
• lt 20 years, gt 65 years
• Rapid growth of nodule
• Symptoms of local invasion (dysphagia, neck pain,
  hoarseness)
• Hx of radiation to head or neck
• Family hx of thyroid CA or polyposis

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Physical Exam

• Less than 1 cm usually not palpable
• ½ of all nodules detected by ultrasonography not
  detected by physical exam
• Should also examine for lymphadenopathy

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Physical Exam

• Smooth or nodular
• Diffuse or localized
• Soft or hard
• Mobile or fixed
• Painful or non-tender

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Laboratory

• TSH
• Serum calcitonin if family hx of medullary
  thyroid carcinoma
• Do not use thyroid function tests to
  differentiate benign from malignant

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Radiology

• Ultrasound
• to document size, location, and character of
  nodule
• To determine changes in size of nodules over time
  or to detect recurrent lesions
• U/S guided biopsy decreases the incidence of
  indeterminate specimens

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Radiology

• Thyroid scan
• Can not reliably distinguish benign from
  malignant nodules
• Cold nodules 5-15 are malignant
• Hot nodules almost always benign

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Fine Needle Aspiration

• Should be 1st test in the euthyroid patient
• Sensitivity 68-98
• Specificity 72-100
• False negative rate 1-11
• False positive rate 1-8
• Sampling errors in very large and very small
  nodules minimized by u/s guided biopsy

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Treatment

• Surgical treatment indications
• Malignancy
• Indeterminate cytology and suspicious HP
• Indeterminate cytology and cold nodule
• Toxic nodules (suppression of TSH, symptoms
  a-fib) can use radioactive iodine or surgery
• Repeated recurrence of cystic lesions

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Treatment

• Benign biopsies can be followed without surgery
  and monitored q 6 months by physical exam, u/s
• Surveillance change in nodule size and symptoms
  repeat FNA if nodule grows.

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Suppression treatment

• Post-operative suppression treatment following
  resection of cancer
• TSH should be maintained for target of 0.5 mU per
  L
• Greater suppression for high risk patients,
  metastatic or locally invasive not completely
  removed

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Suppression treatment

• For benign solitary nodule controversial
• Follow at 6 month intervals
• Thyroxine to suppress TSH to 0.1 to 0.5 mU per L
  for 6-12 months
• After 12 months, maintain TSH in low normal range

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Incidental Nodule on U/S

• Most are benign and can be monitored without
  further testing
• FNA if
• nodule becomes palpable
• findings suggestive of malignancy on u/s
• larger than 1.5 cm
• Hx of head or neck irradiation
• Strong family hx of thyroid cancer

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Case

• 44 y.o. woman, 2 cm nodule palpable in left lobe
  of thyroid gland at annual exam smooth,
  non-tender. No lymphadenopathy
• TSH ordered normal
• Thyroid u/s confirms 2 cm nodule, solid
• FNA - benign

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Case

• Repeat U/S at 1 year nodule now 2.5 cm in size
• Repeat FNA benign
• Could consider suppression therapy, or continue
  to follow.