Monday, May 13, 2019

Work up of thyroid nodule


Here is the shorter version of this post: Investigating thyroid nodule for Step 2 CK (link:

So - if you find a thyroid nodule on physical examination - what do you do next?

If TSH is normal or elevated, thyroid USG is done to determine if the nodule meets the sonographic criteria for FNA.

If TSH is subnormal, a radionuclide thyroid scan is done to determine if the nodule is hyperfunctioning (“hot,” i.e., tracer uptake is greater than the surrounding normal thyroid), or nonfunctioning (“cold,” i.e., has uptake less than the surrounding thyroid tissue).

Since hyperfunctioning nodules rarely harbor malignancy, no further cytologic evaluation is necessary.

If the nodule is nonfunctioning, it is determined if the nodule meets the sonographic criteria for FNA by doing thyroid USG.

If the nodule is functional, free T4 (FT4) and T3 levels are measured. If FT4 and T3 levels are normal, the diagnosis of subclinical hypothyroidism is made.

If FT4 and/or T3 levels are high, the diagnosis of overt hyperthyroidism is made.

FNA is recommended in nodules with these sonographic criteria:

1. Any hypoechoic nodule with one or more of the following features:
a) Subcapsular location adjacent to the recurrent laryngeal nerve or trachea.
b) Extrathyroidal extension.
c) Extrusion through rim calcifications.
d) Associated with abnormal cervical lymph node.

2. Nodules >/= 1 cm if they are solid and hypoechoic or have any of the following characteristics:
a) Irregular margins.
b) Microcalcifications.
c) Taller than wide shape.
d) Rim calcifications.

3. Any nodule >/= 1.5 to 2 cm.

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