How Do You Evaluate and Treat a Thyroid Nodule?

Patient Presentation
A 15-year-old female came to clinic after she noted a mass in her neck while studying a few days ago. She reported that it was painless and causing no problems breathing or swallowing. She also reported normal energy and sleeping and eating patterns, no changes in weight, hair, palpitations, bleeding or bruising problems, change in voice, coughing, muscle twitchiness or weakness, or other masses. The past medical history was negative. The family history showed an elderly grandmother with hypothyroidism and diabetes. There was no cancer in the family. The review of systems was otherwise negative.

The pertinent physical exam showed a healthy appearing female with a height and weight in the 25-50% that were stable from a previous visit 10 months earlier. Vital signs were normal. HEENT showed a perceptibly but mildly enlarged thyroid on the left. Palpation revealed a diffusely enlarged left hemithyroid without discrete nodules. It moved appropriately with swallowing and no pain was elicited. There was no perceptible enlargement on the right side of the thyroid. A 0.5 cm cervical node at the angle of the mandible was noted and was freely mobile. No other adenopathy was palpable bilaterally.

The laboratory evaluation of a T4 and TSH were normal. The radiologic evaluation of an ultrasound of the thyroid showed 3 nodules on the left, with the largest ones 2 cm and 3 cm in size, plus one small nodule on the right. The patient and family consented to fine needle biopsy at the time of the ultrasound as they had been told by their physician that this was usually the next step in the process. The biopsy showed histology consistent with follicular adenoma, hyperplasia and much less likely follicular carcinoma. After consultation with the primary care provider, the patient was referred to a surgeon who after discussion with the family elected to have a total thyroidectomy performed. The surgery went well and the final pathology report made the diagnosis of follicular cell carcinoma in one nodule that was totally contained within the thyroid, with no local metastasis. The patient did not undergo radioablation per low-risk cancer staging, and has been followed closely for 4 years currently with no signs of recurrence.

Case Image

Figure 84- Transverse  ultrasound image of the thyroid gland (above) shows the single nodule in the right lobe of the thyroid and the largest nodule in the left lobe of the thyroid. Longitudinal ultrasound image of the left lobe of the thyroid (below) shows the three nodules in the left lobe of the thyroid.

Endemic goiter is not a common problem in the U.S. with the addition of iodine to food particularly salt. Thyroid nodules are relatively unusual for children (solitary nodules 0.22-1.35%) compared with adults (4%). Malignancy unfortunately is more common in children than adults; for solitary nodules 15-25% compared to 4% in adults. During adolescence the rate of malignancy decreases to adult levels in late adolescence/early adulthood.

Learning Point
Most single and multiple thyroid nodules are benign but not all and this makes treatment decisions more difficult. Nodules which have obvious malignant changes require surgical treatment and medical followup. It is the nodules which show indeterminant pathology that can be associated with increased malignancy risk which are particularly frustrating for patients and health care providers. Thyroid nodules’ evaluation and treatment has improved with the more consistent availability of ultrasound evaluation and fine needle aspiration biopsy (FNAB) with appropriate pathological consultation. These are particularly helpful for diagnosing benign cystic nodules which may require aspiration but are benign and monitored.

The American Thyroid Association has published an extensive guideline which outlines the recommended evaluation and treatment of thyroid nodules and differentiated thyroid cancer. See To Learn More below. All patients with an enlarged thyroid should have a thyroxine (T4) and thyroid stimulating hormone (TSH) measured (parathyroid hormone is not indicated usually as part of the initial evaluation). This helps to understand the patient’s thyroid state and in planning evaluation and treatment. Patients with hypothyroidism are recommended to have a diagnostic iodine or technetium scan to determine if the nodule is hot or cold. Cold nodules are more consistent with malignancy. Euthyroid or hyperthyroid patients are recommended to be referred for ultrasound and if a nodule is found, then FNAB is performed.

  • If the biopsy is non-diagnostic then another FNAB is performed.
  • If frankly malignant or suspicious for malignancy, surgery is recommended. Radiofrequency ablation is often used post-thyroidectomy to irradicate residual thyroid tissue left in-situ to spare the recurrent laryngeal nerve, parathyroid glands and other adjacent structures.
  • Intermediate pathology (Hurtle cell or follicular neoplasm) is also recommended to have surgical consultation because of the increased risk of malignancy for these usually benign nodules (~20% for Hürtle cell and ~5-10% for follicular neoplasms).
    Follicular neoplasms such as the one above are particularly vexing for pathologists to rule out malignancy because the capsule of the nodule needs to be examined in great detail which is not truly an option without removal of the entire nodule.
    Genetic markers appear to be promising for future determination of indeterminant pathology.

Increased risks for malignancy include:

  • Age 70 years
  • Male gender
  • Prior head and neck radiation
  • Prior thyroid cancer
  • Family history of thyroid disease (benign or malignant0
  • Recurrent laryngeal nerve or other nerve involvement (i.e. dysphonia, dysphagia)
  • Hard, firm or immobile thyroid nodule
  • Cervical lymphadenopathy

Questions for Further Discussion
1. What is the differential diagnosis of an enlarged thyroid gland?
2. What is the role of an endocrinologist in the evaluation and management of thyroid nodules?
3. How is hypothyroidism managed post-operatively with patients who underwent thyroidectomy?
4. What are the potential complications of thyroidectomy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Thyroid Diseases

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Niedziela M. Pathogenesis, diagnosis and management of thyroid nodules in children.
Endocr. Relat. Cancer. 2006;13(2):427-453.

Hebra A, Miller M, Thomas PB. Solitary Thyroid Nodule. eMedicine.
Available from the Internet at (rev. 11/26/2008, cited 5/14/2010).

Dankle SK. Thyroid Nodule. eMedicine.
Available from the Internet at (rev. 3/9/10, cited 5/14/10).

American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM.
Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214.

Freitas BC, Cerutti JM. Genetic markers differentiating follicular thyroid carcinoma from benign lesions.
Mol Cell Endocrinol. 2010 May 28;321(1):77-85.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital