Thyroid nodule

Question 1

What is your approach in investigating this patient’s thyroid nodules?

Answer 1

Clinical examination, looking for features of hyperthyroidism and goiter, thyroid nodules (not accurate)

Serum TSH + Thyroid USS

• If TSH low → thyroid scan (scint-igraphy - RI or technetium) to assess functional status of nodule (?hyperfunction indicating overt/subclinical hyperthyroidism). If so, these are rarely cancer - does not need FNA (but be aware that nuclear scan is contraindicated in pregnancy)
• If the nodule is cold (non-functioning) → FNA
• TSH normal or High (i.e. unlikely hyperfunctioning), next step depends on what USS shows
  
  • Suspicious features → FNA
    
    • ≥1cm, irregular, hypoechoic, solid, calcificaions
  • Does not meet sonographic criteria → surveillance

Question 2

PET scan detected thyroid nodule - would you biopsy?

Answer 2

Many of the incidentally detected thyroid nodules ≥1cm are thyroid cancers, so should undergo FNA

Reasonable to do thyroid scintigraphy if TSH low and hyperthyroidism/hyperfunctioning nodule is suspected

Question 3

So how would you monitor the thyroid nodules that do not meet the FNA criteria?

Answer 3

6-12 monthly thyroid USS - further frequency determined by the nature of change (or no change)