• To establish a definitive diagnosis in cases
where clinical examination gives
• To differentiate between malignant and
• Treatment(conservative or surgical line of
• Serum TSH, T3 and T4 levels:
If a 1 cm or larger nodule is identified.
Denotes subclinical hyperthyroidism;
radioisotope scan is indicated.
Correlates with a lower likelihood of malignancy.
Suggests hypothyroidism(Hashimoto’s thyroiditis)
• Serum calcitonin levels: High in Medullary
Male: >13.8 ng/L
Female: >6.4 ng/L
• Detection of Thyroid antibodies in patients
with toxic features(anti-thyroglobulin
All nonthyrotoxic nodules should be evaluated.
Determines the location and
characteristics(cystic versus solid)
Useful in patients who are being managed
conservatively to detect increased volume of a
Detect Lymph nodes.
Limited ability to predict the diagnosis of solid
Being hypo-echoic compared to the surrounding
Having a shape that is taller than its width on
The size of the nodule on ultrasound determines the
need for further evaluation.
A nodule <1 cm in size is not further evaluated unless
it is associated with:
suspicious characteristics or
Family history of papillary carcinoma of thyroid
Prior personal history of thyroid cancer
PET positive lesions
Assessment of thyroid function.
Dominant thyroid nodule larger than 1cm in size
with low TSH using technetium-99m
pertechnetate or 123I
is trapped by follicular cells and its rapid
absorption allows quick evaluation of increased
uptake or cold nodule
and 131I iodine scintigraphy is also used to
evaluate the functional status of the gland.
is a good choice for imaging thyroid
carcinoma and is the screening modality of
choice for the evaluation of distant metastasis.
Categorized as Hot, Warm or Cold nodule
Malignancy has known to occur in 15-20% of
cold nodules and 5-9% of hot nodules.
FINE NEEDLE ASPIRATION BIOPSY
• KEY MODALITY for evaluation(86% sensitivity)
• ‘Fine or thin’ gauge needle(23 to 27 gauge)
• All dominant non functioning thyroid nodules
that are 1 cm or larger should be evaluated.
Results of FNA biopsy can be grouped into:
Malignant, indeterminate or suspicious, benign
Cellular changes include:
Ground glass cytoplasmic inclusions(‘Orphan
Presence of Psammoma bodies.
Typically, aspirates are hypercellular,
composed of large, poorly cohesive cells,
Amyloid is often, but not invariably, present, and
there is no colloid
Demonstration of capsular or vascular invasion by
follicular cells not by cellular cytology alone but on
complete histological examination of the resected
Repeat aspiration,resection,or close
conservative follow-up of the nodule
The tissue immediately adjacent to or
contained within another part of the nodule
may harbour malignant cells(false negetive
Monitor with ultrasound.
In cases of non-diagnostic cytology, repeat FNA
under ultrasound guidance
Lesions in which FNA is found to be persistently
non-diagnostic is associated with a high risk of
malignancy and must be followed up closely or
FNA can also be done for lesions that appear
cystic on ultrasound: occasionally papillary
carcinoma may manifest as a cyst.
COMPUTED TOMOGRAPHY AND MAGNETIC
Both are equally sensitive and specific for
evaluating local extension in more advanced
stages of thyroid cancer.
It is appropriate for a suspicious mass with
palpable cervical lymph nodes
CT or MRI is advisable in pre-operative planning
for large thyroid masses that show tracheal
deviation suggestive of a substernal goiter on
History and physical