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Clinical Crossroads | Clinician's Corner

A 64-Year-Old Woman With a Thyroid Nodule

Susan J. Mandel, MD, MPH, Discussant
JAMA. 2004;292(21):2632-2642. doi:10.1001/jama.292.21.2632.
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DR REYNOLDS: Mrs G is a 64-year-old woman from Brazil with an incidentally discovered thyroid nodule. On a routine visit for follow-up of her multiple medical problems, Mrs G’s primary care physician palpated a left-sided thyroid abnormality.

Mrs G had a right-sided cold thyroid nodule resected in Brazil several decades ago; she became hypothyroid and has been receiving thyroid replacement therapy. During the past 10 years here in the United States, her thyroid-stimulating hormone (TSH) level has always been within normal limits, and her thyroid exam has been either unremarkable or not documented by her physicians. Then, during a recent annual examination, Mrs G’s doctor felt a left-sided thyroid nodule on the background of an enlarged gland. Mrs G’s thyroid function was normal. A thyroid ultrasound suggested a previous right partial thyroidectomy, a small amount of residual right-sided gland, and a completely calcified node. The left lobe measured 2.3 cm × 2.6 cm in transverse diameter at the level of the isthmus; a large solid heterogeneous nodule arose from the left lobe.

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Figure 1. Initial Laboratory Evaluation of a Patient With a Thyroid Nodule >1 cm Detected by Palpation or Ultrasound
Graphic Jump Location

*Cutpoints for low, normal, and high TSH levels vary according to laboratory.

†Evaluate for hypothyroidism.

‡Evaluate for hyperthyroidism.

§Indications for fine-needle aspiration guided by ultrasound include palpable nodule greater than 50% cystic, difficult to palpate or nonpalpable nodules, and nondiagnostic cytology on previous fine-needle aspiration.

∥Perform diagnostic thyroid ultrasound if not previously performed.

¶Follicular neoplasm, Hürthle cell neoplasm, suspicious for papillary thyroid cancer.

#Insufficient quantity of follicular thyroid cells.

Figure 2. Radioiodine 123 (123I) Scans of Hyperfunctioning Thyroid Nodules With and Without Suppression of Extranodular Thyroid
Graphic Jump Location

Hyperfunctioning thyroid nodules (arrowheads) with homogeneously increased 123I uptake. A, A hyperfunctioning (“hot”) left-sided thyroid nodule suppresses serum thyroid-stimulating hormone (TSH) level, suppressing uptake of 123I in the rest of the thyroid gland. B, A hyperfunctioning right-sided lower-pole thyroid nodule that is not suppressing serum TSH level. 123I uptake is increased in the nodule, but the extranodular uptake is not suppressed.

Figure 3. Radioiodine 123 (123I) Scan of Nonfunctioning Thyroid Nodule and 123I Scan and Ultrasound of “Isofunctioning” Nodule
Graphic Jump Location

A, A nonfunctioning (“cold”) thyroid nodule in the right lower thyroid (arrowhead). B, Images obtained 24 hours after oral administration of 500 μCi of 123I and with ultrasound in a patient with a 3.5-cm left thyroid nodule. On the 123I scan, the area of the nodule appears isofunctioning compared with the surrounding thyroid parenchyma on the 123I scan. However, as depicted on the ultrasound, the nodule (arrowheads) is bordered anteriorly and laterally by normal thyroid parenchyma. This surrounding normal thyroid tissue is what causes the area of the nodule to appear isofunctioning on the 123I thyroid scan; the nodule itself does not produce thyroid hormone.

Figure 4. Transverse Thyroid Ultrasounds With Differences in Thyroid Contour
Graphic Jump Location

A, Normal contour and gland. Note the homogeneous bright appearance of normal thyroid parenchyma. B, A palpable right-sided 1.7-cm solid nodule (arrowheads) causes the abnormal contour. C, An asymmetric isthmus without a discrete nodule causes the abnormal contour. A small nonpalpable subcentimeter cyst is present (arrowheads). D, Hashimoto lymphocytic thyroiditis with asymmetrically enlarged left lobe (arrowhead). Note the heterogeneous echotexture compared with panel A.




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