Approach to the lumpy thyroid katherine a kovacs md msc frcpc
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Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC. Setting of Thyroid Nodule Discovery. Routine neck palpation by physician Self-examination by patient Incidental finding during radiological procedure. Clinical Relevance of Nodule Discovery. Potential malignancy

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Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC

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Approach to the lumpy thyroid katherine a kovacs md msc frcpc

Approach to the Lumpy ThyroidKatherine A. Kovacs, MD MSc FRCPC

Setting of thyroid nodule discovery

Setting of Thyroid Nodule Discovery

  • Routine neck palpation by physician

  • Self-examination by patient

  • Incidental finding during radiological procedure

Clinical relevance of nodule discovery

Clinical Relevance of Nodule Discovery

  • Potential malignancy

  • Clue to underlying thyroid pathology (i.e., Hashimoto’s thyroiditis)

  • Potential for thyroid dysfunction

  • Potential for compressive symptoms

Etiology of thyroid nodules


Colloid nodule

Hashimoto thyroiditis

Simple or hemorrhagic cyst

Follicular adenoma

Subacute thyroiditis


Follicular cell-derived carcinoma




C-cell-derived carcinoma


Thyroid lymphoma

Metastatic carcinoma

Etiology of Thyroid Nodules

Evaluation history


  • Thyroid function status

  • Associated pain

  • Compressive symptoms/Cosmetic

  • Establish risk factors for malignant disease

    • age < 30 or > 60; male sex

    • exposure to ionizing radiation

    • family history

    • rapid growth

Evaluation physical examination

EVALUATIONPhysical Examination

  • Number, size & consistency of lumps

  • Mobility

  • Tenderness

  • Presence of lymphadenopathy

  • Compressive signs

Evaluation tsh


  • Low-normal or suppressed TSH (< 0.5)

    • autonomous nodule(s)

    • overt hyperthyroidism

      indication for radioisotope scan (hot nodule, especially by I123, almost always benign)

  • High-normal or elevated TSH

    • Hashimoto’s thyroiditis

    • Overt hypothyroidism

      higher risk of malignancy

Evaluation ultrasound


  • Most sensitive test to detect thyroid nodules and recommended for all patients identified to have one or more thyroid nodules

  • Assess size & number of nodules

  • Assess for sonographic characteristics that are higher risk for malignancy

  • Select nodule(s) for biopsy

  • Accuracy dependent on expertise

Mng vs solitary nodule

MNG vs Solitary Nodule

  • Risk of cancer is the same in MNGs vs glands with solitary nodule

  • Selection for FNA should be based on U/S features rather than on size or clinically “dominant” nodules

U s features indicating higher risk of malignancy

U/S Features Indicating Higher Risk of Malignancy

Evaluation consider other radiology

EVALUATIONConsider Other Radiology

  • Technetium or I123 scan

    • most nodules are cold; AVOID as a routine

    • useful when suspecting hot nodule (low TSH)

  • CT thyroid/chest

    • useful in assessing retrosternal goitre

Evaluation fna


Evaluation when to perform fna


Indications for u s guided fna

Indications for U/S-guided FNA

  • Palpation-guided FNA non-diagnostic

  • Complex (solid/cystic) nodule

  • Palpable small nodule (< 1.5 cm)

  • Impalpable incidentaloma

  • Abnormal cervical nodes

  • Nodule with suspicious U/S features

Evaluation fna categories


Management treatment surveillance


  • Toxic Adenoma/MNG

    • surgery, high-dose RI or alcohol/laser ablation

  • Follicular Neoplasm

    • surgery for definitive diagnosis or close F/U

  • Carcinoma

    • surgery, RI PRN, & T4 suppress to TSH < 0.1

  • Others

    • palpation, TSH, ?ultrasound, rebiopsy PRN

    • controversial: T4 suppression to TSH 0.1-0.4

Unanswered questions

Unanswered Questions

  • Sufficient length of time to follow a nodule and maximum growth allowed to conclude that it is benign

Case 1 toxic adenoma

Case 1: Toxic Adenoma

  • 32-yr-old female manager of music store

  • c/o 2-3 yrs panic attacks, palpitations; 1 yr goitre, irregular menses, insomnia; 6-8 mo fatigue, muscle weakness; few weeks hand tremor, weight gain

  • medications: none

  • no FH thyroid cancer

Case 1 cont d

Case 1 (cont’d)

  • O/E:

    • normal weight, BP 138/70, HR 110 (regular)

    • easily visible goitre with ovoid mass in L lobe (4x normal size lobe); R lobe slightly palpable with tiny nodule

    • hands warm and sweaty

    • proximal muscle weakness

Case 1 cont d1

Case 1 (cont’d)

  • Investigations:

    • TSH < 0.05, FT4 46 (Jan. 19)

    • Nuclear thyroid scan: 4.3 x 3 cm ovoid mass in L lobe with markedly increased uptake; mostly absent uptake in R lobe; 24 hr thyroid uptake 36 % (Feb. 2)

    • TSH 0.03, FT4 53.3, HCG < 0.5 (when I saw Mar. 19)

Normal thyroid scan

Normal Thyroid Scan

Thyroid scan in toxic adenoma

Thyroid scan in Toxic Adenoma

Case 1 cont d2

Case 1 (cont’d)

  • Treatment:

    • high-dose radioiodine

  • Response:

    • marked shrinkage

    • induction of biochemical hypothyroidism

Case 2 multinodular goitre

Case 2: Multinodular Goitre

  • 34-yr-old taxi driver

  • large goitre x 9 years, gradual enlargement

  • pressure sensation when supine, nocturnal dry cough, frequent choking

  • mild fatigue, tendency to heat intolerance, gaining weight

  • medications: none

  • no FH thyroid disease

Case 2 cont d

Case 2 (cont’d)

  • O/E:

    • moderately overweight, BP 148/92, HR 90 (regular)

    • easily visible irregular goitre, roughly 8x normal size

    • hands very warm

Case 2 cont d1

Case 2 (cont’d)

  • Investigations:

    • TSH 0.2, FT4 15.8

    • U/S: diffusely enlarged heterogeneous thyroid

Ultrasound mng

Ultrasound MNG

Thyroid scan in mng

Thyroid Scan in MNG

Case 2 cont d2

Case 2 (cont’d)

  • Treatment:

    • high-dose radioiodine 29 mC on 3 occasions

  • Response:

    • modest shrinkage

    • induction of biochemical hypothyroidism

Case 3 colloid nodule

Case 3: Colloid Nodule

  • 54-yr-old male chief of security

  • lump in thyroid detected at routine physical

  • no compressive symptoms

  • no symptoms of thyroid dysfunction

  • no hx significant radiation exposure

  • no FH thyroid cancer; mom - goitre

Case 3 cont d

Case 3 (cont’d)

  • O/E:

    • mildly overweight, BP 160/92, HR 75 (regular)

    • easily visible, mobile L thyroid mass

    • no lymphadenopathy

    • clinically euthyroid

Case 3 cont d1

Case 3 (cont’d)

  • Investigations:

    • TSH 1.27

    • U/S: solitary 3.4 cm inferior L thyroid nodule

    • Nuclear thyroid scan: solitary cold nodule

    • FNA x 3: unsatisfactory (cyst contents, inflammatory cells, few epithelial cells)

      • shrunk after procedure

  • U/S-guided FNA: cyst contents, fragment of thyroid tissue with normal-looking follicles

  • repeated after nodule grew - colloid nodule

Ultrasound thyroid nodule

Ultrasound Thyroid Nodule

Fine needle aspiration

Fine Needle Aspiration

Thyroid scan in cold nodule

Thyroid Scan in Cold Nodule

Case 4 follicular neoplasm

Case 4: Follicular Neoplasm

  • 46-yr-old woman on disability

  • incidental thyroid nodule detected during CT pulm/angio for pulmonary emboli

  • dysphagia to liquids & solids

  • irritability, weight gain, fatigue, constipation

  • no history of significant radiation exposure

  • no FH thyroid cancer

Case 4 cont d

Case 4 (cont’d)

  • O/E:

    • moderately overweight, BP 120/68, HR 60 (regular)

    • easily visible, mobile R thyroid mass

    • no lymphadenopathy

    • clinically euthyroid

Case 4 cont d1

Case 4 (cont’d)

  • Investigations:

    • TSH 1.11

    • U/S: solitary 3.8 cm R complex thyroid nodule

    • FNA: few groups of follicular epithelial cells favouring neoplasm or colloid nodule

    • Pathology on resection: follicular adenoma



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