DIAGNOSIS

History Taking
During examination, patients should be asked about a family history of benign or
malignant thyroid disease. Previous disease or treatments involving the neck (head
and neck irradiation during childhood), recent pregnancy, and rapidity of onset and
rate of growth of the neck swelling should be documented. Presence of thyroid
nodules during childhood and adolescence should induce caution because the
malignancy rate is 3- to 4-fold higher than in adult patients. Solitary nodules are most
likely to be malignant in patients older than 60 years and in patients younger than 30
years. The risk of thyroid cancer is also higher in older persons and in men. Most
patients with thyroid nodules have few or no symptoms, and usually no clear
relationship exists between nodule histologic features and the reported symptoms.

In symptomatic patients, a detailed history and a complete physical examination may

guide the selection of appropriate clinical and laboratory investigations. Slow but
progressive growth of the nodule (during weeks or months) is suggestive of malignant
involvement. Sudden pain is commonly due to hemorrhage in a cystic nodule. In
patients with progressive and painful enlargement of a thyroid nodule, however,
anaplastic carcinoma or primary lymphoma of the thyroid should be considered.
Symptoms such as a choking sensation, cervical tenderness or pain, dysphagia, or
hoarseness may be perceived as attributable to thyroid disease, but in most patients,
these symptoms are caused by nonthyroid disorders. Slow-onset cervical symptoms
and signs caused by the compression of vital structures of the neck or upper thoracic
cavity usually occur if thyroid nodules are embedded within large goiters. When
observed in the absence of a multinodular goiter (MNG), the symptoms of tracheal
compression (cough and dysphonia) suggest an underlying malignant lesion..
Differentiated thyroid carcinomas rarely cause airway obstruction, vocal cord
paralysis, or esophageal symptoms at their clinical presentation. Hence, the absence
of local symptoms does not rule out a malignant tumor.

Physical Examination
The general examination for hyperthyroidism, hypothyroidism, and autoimmune
stigmata is followed by systematic examination of the goiter. A retrosternal goiter
may not be evident on physical examination. Examination of the goiter is best
performed with the patient upright, sitting or standing. Inspection from the side may
better outline the thyroid profile, as shown below. Asking the patient to take a sip of
water facilitates inspection. The thyroid should move upon swallowing. See the image
below.

Fig.1 Patient with a goiter. Prominent side-view outline.

Palpation of the goiter is performed either facing the patient or from behind
the patient, with the neck relaxed and not hyperextended. Palpation of the goiter rules
out a pseudogoiter, which is a prominent thyroid seen in individuals who are thin.
Each lobe is palpated for size, consistency, nodules, and tenderness. Cervical lymph
nodes are then palpated. The oropharynx is visualized for the presence of lingular
thyroid tissue.
The size of each lobe is measured in 2 dimensions using a tape measure. Some
examiners make tracings on a sheet of paper, which is placed in the patient's chart.
Suitable landmarks are used and documented to ensure consistent measurement of the
thyroid gland.
The pyramidal lobe often is enlarged in Graves disease. Multiple nodules may
suggest a multinodular goiter or Hashimoto thyroiditis. A solitary hard nodule
suggests malignancy, whereas a solitary firm nodule may be a thyroid cyst. Diffuse
thyroid tenderness suggests subacute thyroiditis, and local thyroid tenderness suggests
intranodal hemorrhage or necrosis. Cervical lymph glands are palpated for signs of
metastatic thyroid cancer. A firm rubbery thyroid gland suggests Hashimoto
thyroiditis, and a hard thyroid gland suggests malignancy or Riedel struma.
The principal sign of thyroid carcinoma is a firm and nontender nodule in the
thyroid area and the mass is painless. Some patients have a tight or full feeling in the
neck, hoarseness, or signs of tracheal or esophageal compression.
Palpable thyroid nodules are usually solitary, with a hard consistency, an average size
of less than 5 cm, and ill-defined borders. This nodule is fixed in respect to
surrounding tissues and moves with the trachea at swallowing.

Laboratory Evaluation
The serum thyroid-stimulating hormone (TSH) concentration is a highly
sensitive measure for hyperthyroidism or hypothyroidism. A sensitive TSH assay is
useful in the evaluation of solitary thyroid nodules. A low serum TSH value suggests
an autonomously functioning nodule, which typically is benign. However, malignant
disease cannot be ruled out on the basis of low or high TSH levels.
Other thyroid function tests are usually not necessary in the initial workup.
Serum thyroglobulin measurements are not helpful diagnostically because they are
elevated in most benign thyroid conditions.
Further laboratory testing is based on presentation and results of screening
studies and may include thyroid antibodies (antithyroid peroxidase formerly the
antimicrosomal antibodies and antithyroglobulin), thyroglobulin, sedimentation rate
and calcitonin in an individual at high risk for medullary carcinoma of the thyroid.

Imaging Studies
High-resolution US is the most sensitive test available to detect thyroid
lesions, measure their dimensions, identify their structure, and evaluate diffuse
changes in the thyroid gland. If results of palpation are normal, US should be
performed when a thyroid disorder is suspected on clinical grounds or if risk factors
have been recognized. The physical finding of suspicious neck adenopathy warrants
US examination of both lymph nodes and thyroid gland because of the risk of a
metastatic lesion from an otherwise unrecognized papillary microcarcinoma.
 In all patients with palpable thyroid nodules or MNGs, US should be
performed to accomplish the following:
 Help with the diagnosis in difficult cases (as in chronic lymphocytic
thyroiditis)
 Look for coincidental thyroid nodules or diffuse thyroid gland changes
 Detect US features suggestive of malignant growth and select the lesions to be
recommended for FNA biopsy
 Choose the gauge and length of the biopsy needle
 Obtain an objective measure of the baseline volume of the thyroid gland and
of lesions that will be assigned to follow-up or medical therapy
Standardized US reporting criteria should be followed, indicating position,
shape, size, margins, content, and echogenic and vascular pattern of the nodule.
Nodules with malignant potential should be carefully described.
The reported specificities for predicting malignancy are marked
hypoechogenicity, microcalcifications (small, intranodular, punctate, hyperechoic
spots with scanty or no posterior acoustic shadowing), irregular or microlobulated
margins, and chaotic arrangement or intranodular vascular images.
Large neoplastic lesions may be characterized by degenerative changes and
multiple fluid-filled areas, findings rarely noted in microcarcinomas. Although most
complex thyroid nodules with a dominant fluid component are benign, ultrasonografy
should always be performed because papillary thyroid carcinoma (PTC) can be
partially cystic. Extension of irregular hypoechoic lesions beyond the thyroid capsule,
invasion of prethyroid muscles, and infiltration of the recurrent laryngeal nerve are
infrequent but threatening US findings that demand immediate cytologic assessment.
The presence of enlarged lymph nodes with no hilum, cystic changes, and
microcalcifications is highly suspicious. Rounded appearance and chaotic
hypervascularity are more common but less specific findings.
Chest radiography, CT scanning, and MRI usually are not used in the initial
workup of a thyroid nodule, except in patients with clear metastatic disease at
presentation. These tests are second-level diagnostic tools and are useful in
preoperative patient assessment.
FNAB
Clinically inapparent thyroid lesions were detected by US in about half of the
women in several studies. The prevalence of cancer reported for nonpalpable thyroid
lesions ranges from 5.4% to 7.7% and appears to be similar to that reported for
palpable lesions (5.0%-6.5%). Clinical criteria for a malignant nodule are lacking for
most nonpalpable lesions. Hence, it is essential to determine which thyroid lesions
have a high malignant potential on the basis of their US features. The US
characteristics suggestive of malignant involvement in impalpable thyroid nodules are
the same as in palpable nodules. The combination of nodule isoechogenicity with a
spongiform appearance, however, has a high predictive value for a benign lesion.
Malignant involvement is not less frequent in nodules smaller than 10 mm in
diameter; thus, an arbitrary diameter cutoff for cancer risk is not justified and
suspicious lesions smaller than 10 mm should be assessed with FNA biopsy.
Furthermore, early diagnosis and treatment of small tumors may be clinically
important, but an aggressive disease course is rare in incidentally discovered
microcarcinomas. Hence, incidental thyroid lesions with a diameter of about 5 mm
should usually be followed up with US.