assessment of thyroid nodule
Last edited 01/2020
Clinical evaluation of patients with thyroid nodules
NICE suggest to only consider ultrasound for adults with thyrotoxicosis if they have a palpable thyroid nodule (1)
When considering the symptomatology associated with a thyroid nodule then the onset and rate of progression of symptoms are important in terms of risk of thyroid cancer
- persistent hoarseness and rapidly growing thyroid nodules more likely to indicate a malignant cause
Assessment of symptomatology associated with a thyroid nodule:
Possible symptoms related to thyroid nodules include:
- a palpable neck mass
- anterior neck pain
- globus sensation
- dysphagia
- dyspnoea
- dysphonia/ hoarseness
Swallowing complaints are common but non-specific
- more than 50% associated with laryngopharyngeal reflux (2)
Laboratory testing
TFTs - to rule out hyperthyroidism
- most hyperfunctioning thyroid nodules are benign
Calcitonin
- controversy exists about the benefit of routine measurement of serum calcitonin (2)
- specificity of an elevated serum calcitonin (>100 pg/mL) for diagnosis of medullary thyroid cancer (MTC) is improved with pentagastrin stimulation; however, pentagastrin is no longer available in the US and supply is limited in Europe
- some authors consider routine calcitonin measurement of uncertain benefit during initial thyroid nodule work-up (2)
Assessment of thyroid cancer risk
Need for thyroid biopsy based on clinical, laboratory, and ultrasound findings
The British Thyroid Association categories based on presence of different ultrasound features (composition, vascularity, echogenicity, shape, calcifications, lymph nodes, margins):
| U1- normal | Do not need biopsy, unless patient has statistically high risk of malignancy |
| U2 - benign | Do not need biopsy, unless patient has statistically high risk of malignancy |
| U3 - indeterminate/equivocal | Thyroid biopsy recommended |
| U4 - suspicious | Thyroid biopsy recommended |
| U4 - malignant | Thyroid biopsy recommended |
If biopsy undertaken then next management step (whether surgical intervention or observation) based on
- the FNA result
- molecular markers and/or repeat FNA
- individual patient's preferences and context
Reference:
- NICE (November 2019). Thyroid disease: assessment and management
- Ospina NS et al. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment.BMJ 2020;368:l667.