Med|ca| Gu|de||nes for C||n|ca| ract|ce for

the D|agnos|s and Management of 1hyro|d

Nodu|es
nossein 6horib Mu M4cP M4c
LNDCCkINL kAC1ICL Vo| 16 (Supp| 1) May]Iune
2010Mu
ln18CuuC1lCn
W 1hyrold nodules are a common cllnlcal flndlng
W 1he esLlmaLed prevalence on Lhe basls of palpaLlon
LhaL ranges from 3 Lo 7
W 1he prevalence of cllnlcally ln apparenL Lhyrold
nodules ls esLlmaLed wlLh uS aL 20 Lo 76
key kecommeoJotloos
W nlstoty
8ecord Lhe followlng lnformaLlon
W Age
W lamlly hlsLory of Lhyrold dlsease or cancer
W revlous head or neck lrradlaLlon
W 8aLe of growLh of Lhe neck mass
W uysphonla dysphagla or dyspnea
W SympLoms of hyperLhyroldlsm or hypoLhyroldlsm
W use of lodlneconLalnlng drugs or supplemenLs
9yslcol xomlootloo
W A careful physlcal examlnaLlon of Lhe Lhyrold gland
and cervlcal lymph nodes ls mandaLory
8ecord
W LocaLlon conslsLency and slze of Lhe nodule
W neck Lenderness or paln
W Cervlcal adenopaLhy
ymptoms ooJ lqos
W SympLoms such as a choklng sensaLlon cervlcal
Lenderness or paln dysphagladysphonla or
hoarseness of volce
W Sudden paln ls commonly due Lo hemorrhage ln
cysLlc nodule
W rogresslve and palnful enlargemenL of a Lhyrold
susplclon of anaplasLlc carclnoma or prlmary
lymphoma
ooses of 1ytolJ NoJoles
W enlgn nodular golLer
W Chronlc lymphocyLlc LhyroldlLls
W Sub acuLe LhyroldlLls
W rlmary Lhyrold lymphoma
W Slmple or hemorrhaglc cysLs
W lolllcular adenomas
W aplllary carclnoma
W lolllcular carclnoma
W PurLhle cell carclnoma
W oorly dlfferenLlaLed carclnoma
W Medullary carclnoma
W AnaplasLlc carclnoma
W Sarcoma LeraLoma and mlscellaneous Lumors
octots oqqestloq locteoseJ klsk of Mollqooot
9oteotlol
W PlsLory of head and neck lrradlaLlon
W lamlly hlsLory of M1C MLn 2 or 1C
W Age 14 or 70 years
W Male sex
W Crowlng nodule
W llrm or hard conslsLency
W Cervlcal adenopaLhy
W llxed nodule
W erslsLenL dysphonla dysphagla or dyspnea
Dlttosoooqtopy
uS evaluaLlon ls noL recommended as a screenlng
LesL lL ls recommended for
W aLlenLs aL rlsk for Lhyrold mallgnancy
W aLlenLs wlLh palpable Lhyrold nodules or MnCs
W aLlenLs wlLh lymphadenopaLhy suggesLlve of
mallgnanL leslon
loJlcotloos fot NA 8lopsy
lnA blopsy ls recommended for
nodule(s)
W 10 cm ln dlameLer solld and hypoecholc on uS
W Cf any slze wlLh exLra capsular growLh or meLasLaLlc
cervlcal lymph nodes
W Cf any slze wlLh h/o neck lrradlaLlon or 1C M1C or
MLn 2 ln flrsLdegree relaLlves prevlous Lhyrold
surgery lncreased calclLonln levels
W nodules LhaL are hoL on sclnLlgraphy should be
excluded from lnA blopsy
NA 8lopsy of MoltlooJolot ClooJs
W lL ls rarely necessary Lo blopsy more Lhan 2 nodules
- lf a radlolsoLope scan ls avallable do noL blopsy
hoL areas
- ln Lhe presence of susplclous cervlcal
lymphadenopaLhy lnA blopsy of boLh Lhe lymph
node and susplclous nodule(s) ls essenLlal
tet uloqoostlc lmoqloq 1ecolpoes
W M8l and C1 are noL lndlcaLed for rouLlne
Lhyrold nodule evaluaLlon
W M8l and C1 are lndlcaLed
W assessmenL of slze
W alrway compresslon or
W subsLernal exLenslon of a nodular golLer
oteNeeJle 8lopsy
W Cn performed under uS guldance may offer
addlLlonal lnformaLlon ln selecLed cases wlLh
Lhyrold or neck masses and lnadequaLe lnA
blopsy cyLologlc resulLs
ytoloqlc uloqoosls
CyLologlc dlagnoses should be organlzed lnLo 3 classes
loss 1 NooJloqoostlc (looJepoote ot losofflcleot)
samples wlLh processlng errors or an lnsufflclenL
number of folllcular cells
W loss 2 8eolqo (ot oeqotlve fot mollqooocy)
locloJes collold or hyper plasLlc nodules PashlmoLo
or granulomaLous LhyroldlLls and cysLs
W loss J olllcolot lesloos all folllcularpaLLerned
leslons lncludlng folllcular neoplasm PurLhle cell
leslons and Lhe folllcular varlanL of 1C
W C|oss 4 osplcloos samples LhaL suggesL a mallgnanL
leslon buL do noL compleLely fulflll Lhe
crlLerla for a deflnlLe dlagnosls
W loss 5 Mollqooot (ot posltlve) samples
characLerlzed by mallgnanL cyLologlc feaLures LhaL are
rellably ldenLlfled by Lhe cyLopaLhologlsL
kesolts of NA 8lopsy
W enlgn 6080
W lolllcular leslon/neoplasm 10 Lo 20
W MallgnanL 33 Lo 10
W Susplclous 23 Lo 10
W nondlagnosLlc 10 Lo 13
obotototy volootloo lo 9otleots wlt 1ytolJ
NoJoles
W Always measure serum 1SP no furLher LesLlng for
normal llmlLs
W lncreased serum 1SP LesL free Lhyroxlne and 1CAb Lo
evaluaLe for hypoLhyroldlsm
W uecreased serum 1SP LesL free Lhyroxlne and
LrllodoLhyronlne Lo evaluaLe for hyperLhyroldlsm
AotlboJy Assoys
W Plgh serum 1CAb values auLolmmune or PashlmoLo
LhyroldlLls
W AnLlLhyroglobulln anLlbody chronlc lymphocyLlc
LhyroldlLls
W 18Ab deLermlnaLlon should be performed ln paLlenLs
wlLh hyperLhyroldlsm
kAulNDlu ANNlNC
1ytolJ clotlqtopy
W 1hyrold sclnLlgraphy ls Lhe only Lechnlque LhaL allows
for assessmenL of Lhyrold reglonal funcLlon
W nodules may be classlfled on Lhe basls of
radlo nucleoLlde upLake
W hyper funcLlonlng (hoL")
W hypo funcLlonlng(cold") or
W lndeLermlnaLe (100)
MANACMN1 ANu 1nkA9
W Cllnlcal managemenL of Lhyrold nodules should be
gulded by Lhe resulLs of uS evaluaLlon and lnA
blopsy
-odu/es -ondioqnostic by l-4 8iopsy
W nondlagnosLlc repeaLed wlLh uS guldance
W erslsLenLly non dlagnosLlc solld nodules
surglcally exclsed
NoJoles 8eolqo by NA 8lopsy
W lollowup
W 8epeaLed cllnlcal and uS examlnaLlon and 1SP
measuremenL ln 6 Lo 18 monLhs
W 8epeaLed uClnA blopsy
otqlcol loJlcotloos fot 8eolqo NoJoles
W resence of local pressure sympLoms
W revlous exLernal lrradlaLlon
W progresslve nodule growLh
W susplclous uS feaLures or
W cosmeLlc lssues
DColJeJ 9l
W Ll ls effecLlve ln Lhe LreaLmenL of benlgn
Lhyrold cysLs and complex nodules
W Ll should noL be performed ln sollLary solld
nodules
W Laser ablaLlon may be consldered for Lhe
LreaLmenL of Lhyrold nodules causlng pressure
sympLoms or cosmeLlc lssues
koJloloJloe 1etopy fot 8eolqo NoJolot Coltet
lndlcaLlons are
W hyper funcLlonlng nodule
W sympLomaLlc golLer
W prevlous Lhyrold surgery or surglcal rlsk
olllcolot esloos
ManagemenL
W 8epeaLed lnA blopsy of folllcular leslons ls noL
recommended because lL does noL provlde addlLlonal
lnformaLlon
W Surglcal exclslon ls recommended for mosL folllcular
Lhyrold leslons
W lnLraoperaLlve frozen secLlon ls noL recommended as
a rouLlne procedure
Moooqemeot of NA 8lopsyosplcloos NoJoles
W Surgery
W lnLraoperaLlve frozen secLlon ls useful
NoJoles Mollqooot by NA 8lopsy
ManagemenL
W ulfferenLlaLed Lhyrold carclnoma surglcal
LreaLmenL ls recommended
W AnaplasLlc carclnoma meLasLaLlc leslons and
lymphoma dlagnosLlc workup ls
recommended before surgery
Moooqemeot of 1ytolJ NoJoles uotloq
9teqooocy
W 1hyrold nodules ln pregnanL women should be
managed ln Lhe same way as ln non pregnanL
women
W Avold use of radloacLlve agenLs for boLh
dlagnosLlc and LherapeuLlc purposes
W lor a growlng Lhyrold nodule durlng pregnancy
followup should lnclude uS and lnA blopsy
W lf lnA blopsy shows a folllcular leslon surgery
may be deferred unLll afLer dellvery
Moooqemeot of 1ytolJ NoJoles lo
llJteo
W LvaluaLlon of nodular dlsease ln chlldren ls
slmllar Lo LhaL ln adulLs
W ecause of a hlgher prevalence of mallgnancy
ln chlldren surgery ls ofLen necessary for cold
as well as hoL nodules