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Table 26 6 illustrates the approach to the evaluation of thyroid nodules based on the index of suspicion for malignancy
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A Symptoms and Signs
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Most small thyroid nodules cause no symptoms and are easy to miss during routine physical examinations Such small thyroid nodules may sometimes be detected only by having the patient swallow during careful inspection and palpation of the thyroid A thyroid nodule or multinodular goiter can grow to become visible and of concern to the patient Particularly large nodular goiters can become a cosmetic embarrassment Nodules can grow large enough to cause discomfort, hoarseness, or dysphagia Retrosternal large multinodular goiters can cause dyspnea due to tracheal compression Large substernal goiters may cause superior vena cava syndrome, manifested by facial erythema and jugular vein distention that progress to cyanosis and facial edema when both arms are kept raised over the head (Pemberton s sign) Depending on their cause, goiters and thyroid nodules may be associated with hypothyroidism (Hashimoto s thyroiditis, endemic goiter) or hyperthyroidism (Graves disease, toxic nodular goiter, subacute thyroiditis, and thyroid cancer with metastases)
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THYROID NODULES & MULTINODULAR GOITER
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ESSENTIALS OF DIAGNOSIS
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Single or multiple thyroid nodules are commonly found with careful thyroid examinations Thyroid function tests mandatory Thyroid biopsy for single or dominant nodules or for a history of prior head neck or chest shoulder radiation Ultrasound examination useful for biopsy and follow-up Clinical follow-up required
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Nodular enlargement of the thyroid is detectable by palpation in 4 7% of the adult population in areas of the world with sufficient intake of iodine Each year in the United States, about 275,000 thyroid nodules are detected by palpation Palpable thyroid nodules are even more common in iodinedeficient geographic areas (see Endemic Goiter, below) Palpable thyroid nodules are unusual in children but are increasingly prevalent with age A thyroid nodule is four times more likely to develop in women than men On thyroid ultrasound,
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B Laboratory Findings
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Thyroid nodules are an indication for thyroid function testing Serum determinations for TSH (sensitive assay) and FT4 are preferred Tests for antithyroperoxidase antibodies and antithyroglobulin antibodies may also be helpful Very high antibody levels are found in Hashimoto s thyroiditis However, thyroiditis frequently coexists with malignancy, so suspi-
Table 26 6 Clinical evaluation of thyroid nodules1
Clinical Evidence History Physical characteristics Serum factors Fine-needle aspiration biopsy Scanning techniques Uptake of 123I Ultrasonogram Roentgenogram Thyroxine therapy
Low Index of Suspicion Family history of goiter; residence in area of endemic goiter Older women; soft nodule; multinodular goiter High titer of antithyroid antibody; hypothyroidism; hyperthyroidism Colloid nodule or adenoma
High Index of Suspicion Previous therapeutic radiation of head, neck, or chest; hoarseness Young adults, men; solitary, firm nodule; vocal cord paralysis; enlarged lymph nodes; distant metastatic lesions
Papillary carcinoma, follicular neoplasm, medullary or anaplastic carcinoma Cold nodule Solid lesion Punctate calcification Increase in size
Hot nodule Cystic lesion Shell-like calcification Regression after 005 01 mg/d for 6 months or more
Clinically suspicious nodules should be evaluated with fine-needle aspiration biopsy
cious nodules should always be biopsied Serum calcitonin is obtained if a medullary thyroid carcinoma is suspected in a family member with a history of familial medullary thyroid carcinoma or MEN type 2
Neck ultrasonography should be performed on most patients with thyroid nodules to measure the size of a nodule and to determine whether a palpable nodule is part of a multinodular goiter The following ultrasound characteristics of thyroid nodules increase the likelihood of malignancy: irregular or indistinct margins, heterogenous nodule echogenicity, intranodular vascular images, microcalcifications, complex cyst, or diameter over 1 cm FNA biopsy is performed on such nodules even if they are nonpalpable if they are over 8 mm in diameter Ultrasound is also useful for long-term surveillance of thyroid nodules and multinodular goiter Ultrasonography is generally preferred over CT and MRI because of its accuracy, ease of use, and lower cost RAI (123I or 131I) scans have limited usefulness in the evaluation of thyroid nodules Hypofunctioning (cold) nodules have a somewhat increased risk of being malignant but most are benign Hyperfunctioning (hot) nodules are ordinarily benign but may sometimes be malignant RAI uptake and scanning is helpful if a patient is found to have evidence of hyperthyroidism (See Hyperthyroidism, above) CT scanning is helpful for larger thyroid nodules and multinodular goiter; it can determine the degree of tracheal compression and the degree of extension into the mediastinum
emission tomogrpahy (18FDG-PET), 2% When such scanning detects a thyroid nodule, an ultrasound is performed to better determine the nodule s risk for malignancy and the need for FNA biopsy (see above), and to establish a baseline for ultrasound follow-up The malignancy risk is about 17% for nodules discovered incidentally on CT or MRI, and 25 50% for nodules discovered incidentally by 18FDG-PET For incidentally discovered thyroid nodules of borderline concern, followup thyroid ultrasound in 3 6 months may be helpful; growing lesions may be biopsied or resected