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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*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.
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