J Korean Med Assoc.  2009 Apr;52(4):405-416. 10.5124/jkma.2009.52.4.405.

Diagnostic Approaches to Patients with Thyroid Nodules

• Kang HC

• KMID: 2137725
• DOI: http://doi.org/10.5124/jkma.2009.52.4.405

Abstract

Thyroid nodules are epidemic with the rising use of high-resolution thyroid ultrasonography for health screening. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. Initial history taking and physical examination should focus on the clinical risk factors associated with thyroid cancer. Measurement of thyroid stimulating hormone (TSH) is the only biochemical test routinely needed to exclude autonomously functioning nodules. Thyroid ultrasonography-guided fine needle aspiration biopsy (US-FNA) is the most accurate standard diagnostic test for most thyroid nodules. Ultrasonographic features of nodules associated with increased risk of thyroid cancers include hypoechogenicity, microcalcification, irregular spiculated margin, taller-than-wide, Doppler signal in the nodules, and suspicious cervical lymphadenopathies. These findings are helpful in risk stratification of the nodules and in deciding which nodule should be sampled in multinodular goiters. The success of the procedure heavily depends on the experience and expertise of the clinicians. Knowledge on basic US-FNA techniques and some tricks is very important to improve overall diagnostic yields. Practically critical issues related to US-FNA are emphasized based on several guidelines and author's experiences.

Keyword

Thyroid nodule; Thyroid cancer; Thyroid ultrasound; Fine-needle aspiration biopsy

MeSH Terms

Biopsy
Biopsy, Fine-Needle
Diagnostic Tests, Routine
Goiter
Humans
Mass Screening
Physical Examination
Risk Factors
Thyroid Gland
Thyroid Neoplasms
Thyroid Nodule
Thyrotropin
Thyrotropin

Figure

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  Figure 1 Diagnostic algorithm for thyroid nodules (modified from Ref. 4).

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  Figure 2 (A) A hypoechoic nodule has multiple internal microcalcifications, which is typical for thyroid papillary carcinoma, (B) 3D-recondtion US image shows solid hypoechoic nature of the tumor with multiple microcalcifications, (C, D) Surgical specimen shows a whitish to yellowish lobular nodule with multiple internal calcifications, (E) Pathologic examination confirms the diagnosis of thyroid papillary carcionoma with mutliple microcalcifications. The tumor has high cellularity and multiple psammoma bodies.

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  Figure 3 (A) A hypoechoic nodule containing multiple internal microcalcifications is shown in right lobe of the thyroid, (B) 3D-image showing the microcalcifications in the nodule, (C) Multiple bilateral lymphadenopathies(LN) are evident in both internal jugular chains.

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  Figure 4 (A) A panoramic thyroid US view of multifocal papillary carcinoma. A hypoechoic nodule is seen in each lobe of the thyroid. Right lobe nodule has central dense calcification and ascoustic shadowing. Both nodules are taller-than-wide and hypoechoic. (B) Schematic drawing of the US clearly shows the taller-than-wide nature of the nodules.

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  Figure 5 A case of mixed solid and cystic nodule with multple risky US features in solid portion. (A) A lump in right side of the neck, (B) A mixed solid-cystic nodule is seen in right lobe of the thyroid. (C) Typical multiple microcalcifications are observed in solid portion of the nodule. (D) Vascular signals are evident in solid portion of the nodule. US-FNA was performed in the solid portion using capillary technique. (E) Cross sectioned specimen of resected mass shows the similar findings between US image and real mass. Cystic papillary was confirmed on pathologic examination.

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  Figure 6 Examples of suspicious lymphadenopathies (LAP) suggesting metastases. (A) Round multiple LAP, (B) Round LAP with internal hyperechogenicity, (C) LAP with cystic change, (D) LAP with multiple microcalcifications.

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  Figure 7 US-FNA equipment is simple and inexpensive. Small needls (25~27 G) are critically important to improve diagnostic yield and to decrease the pain.

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  Figure 8 Non-aspiration US-FNA with 25-or 27-G needle. Angle correction is shown based on the location of the nodule. (A) A more -vertical angle is used for a deep nodule. (B) A less -vertical, more -obtuse angle is used for biopsy of a more superficial nodule.

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  Figure 9 Some tricks for difficut US-FNA. (A) A highly vascular nodule. Dopper vascualr mapping is helpful to avoid the puncture of vessels. (B) A densely calcified nodule. When the calcified nodule cannot be penetrated with the needle, obtain the sample from the interface between the nodule and normal thyroid parenchyme. (C) A nodule with thin eggshell calcification. Multiple breaks were seen after the US-FNA. (D) A mixed solid-cystic nodule. FNA should be done in soloid portion.

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