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.
*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.
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.
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
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.
Thank you for submitting a comment on this article. It will be reviewed by JAMA editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 39
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
NYSORA Textbook of Regional Anesthesia and Acute Pain Management
The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Patient Have Abdominal Aortic Aneurysm?
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.