1/1/2010

Management of a Thyroid Nodule

Author: Nanette F. Santoro, MD

Editor: Christy Cooksey, MD

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The prevalence of thyroid nodules varies with the level of iodine sufficiency. Because iodine deficiency is relatively rare in the United States, only about 5% of US women will have a palpable thyroid nodule. In contrast, as many as 67% of women will have a detectable nodule when high resolution ultrasound is randomly used to examine the thyroid gland.

Even though most thyroid cancers are well differentiated, slow growing, and have an overall good prognosis, it is incumbent on the clinician to rule out a thyroid cancer when a palpable nodule is present.

Nodules greater than 1 cm in size merit a diagnostic evaluation. It is also appropriate to investigate nodules smaller than 1cm in patients when such nodules are associated with suspicious symptoms, lymphadenopathy, or clinical risk factors for cancer.

Risk factors for thyroid cancer include:

Head and neck irradiation
Whole body irradiation for bone marrow transplant
First-degree relative with thyroid cancer

Clinical findings concerning for cancer include:

Rapid growth of a nodule
Hoarseness
Vocal cord paralysis
Cervical lymphadenopathy
Fixation to surrounding tissues

After initial history and physical exam, a TSH (thyroid stimulating hormone) and thyroid ultrasound should be obtained.

Hyperfunctioning nodules are unlikely to be malignant, so fine needle aspiration for cytology is unnecessary. Referral to an endocrinologist for further management of the hyperthyroid state may be appropriate.

When the TSH is normal or elevated, ultrasound of the thyroid is used to confirm the presence of the nodule, determine its location, character, and assess for the presence of any suspicious cervical lymph nodes.

FNA (fine needle aspiration) with ultrasound guidance is the procedure of choice for confirming the diagnosis based on ultrasound patterns of suspicion.

Multiple nodules, such as might be found in a woman with a multinodular goiter, does not rule out malignancy. Sampling each nodule with an FNA is not practical, but ultrasound features of the nodules such as size, hypoechogenicity, micro calcifications and hypervascularity can be used to help predict the likelihood for malignancy and target nodules for biopsy.

Further Reading:

Haugen BR, Alexander EK, Bible KC, et al., 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. doi: 10.1089/thy.2015.0020.

Initial Approval January 2010. Revised September 2016. Reaffirmed January 2018. Reaffirmed July 2019. Reaffirmed March 202. Revised September 2022. Revised July 2024.

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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