1. Approach
to
Prepared by:
Amro Adawi
6th year medical student

2. Approach to
Preface
Thyroid nodules come to clinical attention when noted by the patient, or as an incidental
finding during routine physical examination, or during a radiologic procedure.
Thyroid incidentalomas
Nonpalpable thyroid nodules that are detected during other imaging procedures.
Have approximately the same risk of malignancy as palpable nodules .
The prevalence of cancer is high in :
Children Adults less than 30 or over 60 years old
history of head and neck irradiation Patients with a family history of thyroid cancer

3. Approach to
How ?
History
Rapid growth of a neck mass,
Childhood head and neck irradiation,
Total body irradiation for bone marrow transplantation,
Family history of thyroid cancer, or thyroid cancer syndromes (eg, MEN2)

4. Approach to
How ?
Physical examination
A fixed hard mass,
obstructive symptoms,
cervical lymphadenopathy,
or vocal cord paralysis all suggest the possibility of cancer.

5. Approach to
History and physical examination lack the
sensitivity and specificity sufficient to
diagnose thyroid cancer

6. Approach to
How ?
Now WHAT are the next steps to evaluate a thyroid
nodule

7. Approach to
First step
DoSerum TSH
Thyroid function should be assessed in all patients with thyroid nodules.

8. Approach to
First step
Low TSH level is a way to screen for hyperfunctioning nodules

9. Approach to
How ?
BUT, 95% of nodules are hypofunctioning (cold)

10. Approach to
How ?
Low TSH may be associated with functioning nodules, very unlikely to be malignant.
TSH has a trophic effect on thyroid cancer growth mediated by TSH receptors on
tumor cells.
Higher TSH is associated with more advanced stage of thyroid cancer.

11. Approach to
How ?
Check TSH
Low Normal or
high
Radioisotope scan
+
US
What to do ??
Hot Cold
Observation

12. Approach to
Why US?
Conformation of a sonographically identifiable nodule corresponding to the palpable
abnormality.
Detection of additional non-palpable nodules for which FNA may be indicated.
Identification of the sonographic characteristics of the thyroid nodule.

13. Approach to
Why US?
Characteristics of thyroid nodule on US:
1. Echogenicity (hypo-hyper-iso)
2. Calcifications (micro-dense)
3. Margins (infiltrative-regular well defined)
4. Vascularity (intranodular-peripheral-absent)
5. Shape
High risk
Hypoechoic ,solid
Low risk
Spongiform
Peripheral vascularity

14. Approach to
How ?
If TSH is normal or high ……. WHAT is the next step ?
Do
Ultrasound
FNA
if the criteria was
met
Monitor
if criteria for FNA
not met

15. Approach to
How ?
Recommendations to do FNA

16. Approach to
How ?
Palpation VS US-guided FNA
If what you feel is what you see on US and it is predominantly solid
Go for
Palpation FNA

17. Approach to
How ?
US-guided FNA for nodules
ATA guidelines 2009
1.Nonpalpable and difficult to palpate nodules
2.Predominantly cystic nodules
3.Nodules with a nondiagnostic cytology from palpation or US FNA
-nondiagnostic rate 50% lower than palpation FNA
4.Nodules with a prior benign cytology that have grown
-false negative rate lower than palpation FNA

18. Approach to
How ?
Serum thyroglobulin
Can be elevated in many thyroid diseases.
An elevated level does not help discriminate benign from malignant thyroid nodules.
So, we do not measure serum thyroglobulin levels as part of the evaluation of
patients with a thyroid nodule.

19. Approach to
Special
Pregnancy
Thyroid radionuclide scanning is contraindicated during pregnancy.
A pregnant woman found to have a thyroid nodule should be evaluated in the
same way as if she were not pregnant.
So, fine-needle-aspiration biopsy of the nodule should be done (as it would be for most
nonpregnant patients)

20. Approach to
Summary
The initial evaluation in all patients with a thyroid nodule (discovered either by palpation or
incidentally noted on a radiologic procedure, includes:
a history, physical examination, neck ultrasonography, and measurement of serum thyroid
stimulating hormone (TSH).
Thyroid scintigraphy should be performed in patients with a low serum TSH concentration.
Fine-needle aspiration (FNA) biopsy is the most accurate method for evaluating thyroid
nodules and selecting patients for thyroid surgery.

21. THANK YOU