This document discusses the evaluation and treatment of solitary thyroid nodules (STN). STNs occur in 1-5% of the population and require evaluation to detect disorders of thyroid function or malignancy. Evaluation includes history, exam, thyroid stimulating hormone levels, ultrasound of the neck, and fine needle aspiration biopsy. Fine needle aspiration biopsy has a 70-97% accuracy rate and can determine if a nodule is benign, malignant, or requires further testing. Treatment options include surgery such as hemithyroidectomy or total thyroidectomy, cyst aspiration, or in rare cases, thyroid hormone suppression.

1. SOLITARY
NODULE
THYROID
Dr Vipin V Nair
Asso Prof Surgery
and Plastic Surgeon

4. Dominant Nodule - discrete swelling in a gland
with clinical evidence of generalised abnormality
in the form of a palpable contra-lateral lobe or
generalised mild nodularity

5. Incidence
1% of male
5% of female
Being discovered more often due to wider availability of
imaging modalities
Frequency rises with age

6. Aim of evaluation
Detect presence of
Disorder of function
Malignancy

7. Careful history and physical examination
Neck swelling, moving with deglutition
Local pressure symptoms- if large sized

8. Pain – thyroiditis / bleeding /
malignant change
Features of toxicity
Features of malignancy
Family history – familial medullary
carcinoma, MEN 2, polyposis coli

13. Investigations
• TSH – if low, less likely to be
malignant
• USG Neck – solid /cystic
/heterogenous
• Size - < 1 cm – no further
evaluation unless indicated on
USG

14. USG findings
suggestive of
malignancy
• Microcalcifications
• Hypervascularity
• Infiltrative margins
• Hypoechoic
• Height >width on
transverse scan

15. TI-RADS

16. Radioisotope Scan
• Assesses function
• Technetium-99m
pertechnetate / I123
• Indicated for patients
with decreased TSH
• Cold nodule – presence of
malignancy in 15 -20%

17. Indication – all nodules > 1cm
Blind / Image (USG) guided for non palpable nodules, heterogenous lesions
Results – malignant/ suspicious/ benign/ non-diagnostic
Unable to diagnose follicular carcinoma, False negative rate – 1 to 6%
FNAC
23 to 27 gauge needle

18. Investigations - FNAC
Benign – monitored by repeat USG after 6
months
Non-diagnostic/ suspicious – repeat FNAC /
proceed with surgery or keep under
observation
Malignant – surgery

19. BETHESDA CRITERIA
 Accuracy of FNAC: 70 – 97 %
 False Negatives: 1 – 6 %
 Chances of malignancy in:
i. FLUS – 10 – 35 %
ii. AUS – 60 – 75 %
 Suspicious for malignancy : 60 %
turn out to be malignant
 Malignant : 97 % are malignant
Despite negative aspirate
thyroidectomy indicated if
large, hard nodule fixed to
surrounding structures
FROZEN SECTION
Lobectomy ???

20. Treatment
Conservative :- for hot nodules.
Thyroxin to suppress TSH & follow-up
after 6 months
Not widely practiced. Only 20 to 30% of
nodules respond and even 13% of
proven papillary cancers showed a
decrease in size

21. Treatment
Cystic lesions – needle
aspiration
Bloody aspirate – send for
cytology
Surgery - if there is a
residual palpable mass after
aspiration or recurrence of
lump

22. Treatment
Surgery :- Hemithyroidectomy / total
thyroidectomy
Pregnant patient – avoid radionuclide scan and
radiographs otherwise work-up remains same
Surgery may be deferred till patient is post
partum

23. Take home message
STN needs evaluation for exclusion of malignancy
15 to 20% of cold nodules likely to be malignant
Treatment – surgery / aspiration
Conservative management is not recommended

24. Thanks