Thyroid Nodule
Red Flags (Malignancy)
Red Flags (Malignancy)
- History
- Rapid growth
- Dysphonia
- Dysphagia
- Dyspnea
- Hx of radiotherapy (head and neck, total body)
- Familial thyroid carcinoma
- Thyroid cancer syndromes (MEN2, FAP, Cowden)
- Physical Exam
- Larger than 4 cm
- Firmness to palpation
- Fixation of the nodule to surrounding tissue
- Regional lymphadenopathy
- Vocal fold immobility (on flexible laryngoscopy)
Investigations
Investigations
- Thyroid ultrasound
- TSH if nodules >1cm
- If low (< 0.3 mU/L), radionuclide thyroid scan I-123
- Toxic multinodular goiter vs. hyperfunctioning nodule (consider ablation)
- If TSH normal or high, consider FNA if meets criteria as below
- If low (< 0.3 mU/L), radionuclide thyroid scan I-123
Threshold for FNA
Threshold for FNA
- ≥ 1.0 cm solid hypoechoic nodule
- Higher risk of irregular margins, microcalcifications, taller-than-wide, rim calcification, extrathyroidal extension
- ≥ 1.5 cm isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric solid area without any ultrasonographic features
- ≥ 2.0 cm spongiform or partially cystic without any ultrasonographic features
No biopsy required for purely cystic nodules as <1% malignancy
References: