Thyroid nodule
-History & PE. Palpate neck.
-Patient with palpable nodule (by patient & physician) or incidental nodule discovered on imaging.
-Will order Ultrasonography of the neck and TSH.
-If TSH is low, will get RAIU to r/o a hyperfunctioning nodule.
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AAFP Diagnosis and Treatment Algorithm for Thyroid Nodule Reviewed with the patient.
A 46-year-old female. Mild anterior neck fullness during an annual PE. Neck U/S shows a normal-sized thyroid gland with a 1.2-cm nodule in the right lobe. How do you work her up?
“The first step in the evaluation of a thyroid nodule is to order a TSH level. If the TSH level is suppressed, radionuclide scintigraphy should be ordered to rule out a hyperfunctioning nodule. If the TSH level is either normal or high, the current recommendation is to biopsy only nodules >1 cm. Clinical follow-up is recommended for nodules < 1 cm.”
How do you detect thyroid nodules?
The patient may feel neck pressure. It can be discovered during PE or incidentally on an imaging study.
“They may present with symptoms of pressure in the neck or may be discovered during physical examination. Although the risk of cancer is small, it is the main reason for workup of these lesions. Measurement of thyroid-stimulating hormone can identify conditions that may cause hyperfunctioning of the thyroid. For all other conditions, ultrasonography and fine-needle aspiration are central to the diagnosis. Lesions larger than 1 cm should be biopsied. Lesions with features suggestive of malignancy and those in patients with risk factors for thyroid cancer should be biopsied, regardless of size. Smaller lesions and those with benign histology can be followed and reevaluated if they grow. The evaluation of thyroid nodules in euthyroid and hypothyroid pregnant women is the same as in other adults. Thyroid nodules are uncommon in children, but the malignancy rate is much higher than in adults. Fine-needle aspiration is less accurate in children, so more aggressive surgical excision may be preferable.” ABFM
“Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination.
The American Thyroid Association’s guidelines recommend that TSH be the initial evaluation (SOR A) and that this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended.” ABFM
References
Am Fam Physician. 2013 Aug 1;88(3):193-196. http://www.aafp.org/afp/2013/0801/p193.html
American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al: Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1167-1214