This document provides information about the assessment and management of solitary thyroid nodules. It defines a solitary thyroid nodule and discusses the epidemiology, factors that suggest malignancy, clinical assessment including history and physical examination, investigations such as blood tests, ultrasound, CT/MRI, FNAC, and limitations of FNAC. It also outlines the respective malignancy risks associated with different FNAC categories and recommendations for when FNAC should be performed.

1. SOLITORY
THYROID
NODULE
CAPE COAST
TEACHING
HOSPITAL
DEPARTMENT
OF SURGERY
PRESENTER:
STEPHEN ADU-
DANQUAH(RESID
ENT)

2. OUTLINE
1. Definition
2. Epidemiology
3. Assessment
4. Investigation
5. Management

3. Definition
• Discrete lesion within thyroid
gland that is radiologically
distinct from Surrounding
parenchyma
• May be palpable or
impassable
• Functioning or non functioning

4. Epidemiology
• Framlingham Study:
• Age 35 – 59
• Women 6.4%
• Men 1.5 %
• Prevalence increases::
• Age
• Exposure to Ionising radiation
• Nodule in radiated patient 35-

5. Epidemiology
• 45 % malignant
• Pregnancy increases risk
• CCTH
 Year 2022 : Total thyroids: 312
 Males 32 :10.3 %
 Females 280: 89.7%

6. CAUSES

7. Factors suggesting Malignancy in a
thyroid Nodule

8. Clinical Assessment
• History:
Younger and older Pateints(M>
40, F >50) more likely to have
malignant thyroid nodule
Children may present with
more advanced disease
Rapid growth in a preexisting or
new thyroid nodule may
indicate Haemorrhage into cyst
or Malignancy

9. History
• Throat or neck pain:
Haemorrhage into benign
nodule thyroid rarely with
Carcinoma
• Compressive or invasive
Symptoms :Voice changes,
Hoarseness , Dysphagia ,
Dyspnoea

10. • Symptoms of hypothyroidism/
Hyperthyroidism
• Family History
• History of previous head and
neck Radiation Exposure
• History of Medullary
Carcinoma

11. • Or hyperparathyroidism (MEN
syndromes

12. Physical Examination
• Careful palpation of thyroid
(solitary nodule or dominant
nodule in multinodular goitre)
• Firm nodule:2-3x increased
risk of Carcinomas
• Substernal extension
Estimated by relationship of
inferior aspect of mass
clavicle

13. • Thoracic inlet Obstruction by
Pemberton manoeuvre
• FINDINGS SUGGESTIVE OF
MALIGNANCY
• Vocal cord paralysis
• Cervical Lymphadenopathy
(also in Hashimoto thyroiditis
,graves disease or infection )

14. • Fixation of nodule to
Surrounding tissues

15. Investigation
• CBC, ESR for inflammatory or
infectious thyroiditis
• TFT most Pateints are
Euthyroid
• TSH is an independent risk
factor for Malignancy
• TPO antibodies inpatients with
high TSH (Hashimoto
thyroiditis)

16. • Serum calcitonin elevated in
Medullary Carcinoma Of
thyroid
• 24 hr urine for Metanephrines
and Catecholamines
• Serum Calcium to exclude
hyperparathyroidism

18. Ultrasound Scan
• Noninvasive and inexpensive
• Detect nonpalpable nodules
• Differentiate between Cystic
and solid nodules.
• Identify Hemiagenesis and
contralateral lobe hypertrophy
misdiagnosed as thyroid
nodule

19. Cont.
• Detect Cervical nodes which
may contain early clinically
occult Metastatic disease.

23. CT and MRI
• Usually unnecessary
• Useful in determining
substernal extension
Identifying Cervical and
Mediastinal Lymphadenopathy
Evaluating Relationship of
thyroid Lesion to adjacent Neck
structures (Trachea and
Esophagus)

24. MRI is more accurate in
distinguishing Recurrent or
Persistent thyroid Tumour from
postoperative Fibrosis.

25. FNAC
• Emerged in 1970
• Procedure of choice in
Evaluating Thyroid nodules
• Minimally invasive
• Improved Diagnostic Accuracy
• Higher malignancy yield at
the time of surgery
• Significant cost reductions

26. Cont.
• Specificity 72 – 100%
• Sensitivity 65 – 98 %

28. RESPECTIVE MALIGNANCY
RISK WITH EACH CATEGORY
(BETHESDA SYSTEM)
1. Non diagnostic
2. Benign < 1%
3. Atypia of undetermined
Significance /Follicular lesion
of undetermined significance
(AUS /FLUS) 5- 10 %
4. Follicular neoplas/ suspicious
20 – 30%

29. Cont
5. Suspicious for Malignancy 50
– 75 %
6. Malignant – 100 %

30. Diagnostic FNAC
recommendation
• Nodules > 1cm in greatest
dimension with high suspicion
sonographic pattern
• Nodules > 1cm in greatest
dimension with intermediate
suspicion Sonographic pattern
• Nodules 1.5cm in greatest
dimension with low Suspicion
sonographic Pattern

31. Cont:
• Nodules >2cm in greatest
dimension with very low
Suspicion sonographic pattern

32. FNAC

37. LIMITATIONS OF FNAC
• False positive results
(Difficulty in interpreting
Cytology)
Hashimoto thyroiditis
Graves Disease
Toxic Nodules
Cannot distinguish Follicular
adenoma from Carcinoma

38. Thyroid Scintigraphy
• Should be performed in
patients with low serum TSH
• Utilises one of iodine
radioisotope (Usually I – 123)
or technetium -99m
Pertechnetate)
• Others Thallidium -201 scan,
Gallium 67 , Tc 99m
Sestamibi

39. • Most benign and virtually all
malignant