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Assessment of thyroid nodules

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Clinical evaluation of patients with thyroid nodules

NICE suggest to only consider ultrasound for adults with thyrotoxicosis if they have a palpable thyroid nodule (1)

When considering the symptomatology associated with a thyroid nodule then the onset and rate of progression of symptoms are important in terms of risk of thyroid cancer

  • persistent hoarseness and rapidly growing thyroid nodules more likely to indicate a malignant cause

Assessment of symptomatology associated with a thyroid nodule:

Possible symptoms related to thyroid nodules include:

  • a palpable neck mass
  • anterior neck pain
  • globus sensation
  • dysphagia
  • dyspnoea
  • dysphonia/ hoarseness

Swallowing complaints are common but non-specific

  • more than 50% associated with laryngopharyngeal reflux (2)

Laboratory testing

TFTs - to rule out hyperthyroidism

  • most hyperfunctioning thyroid nodules are benign


  • controversy exists about the benefit of routine measurement of serum calcitonin (2)
    • specificity of an elevated serum calcitonin (>100 pg/mL) for diagnosis of medullary thyroid cancer (MTC) is improved with pentagastrin stimulation; however, pentagastrin is no longer available in the US and supply is limited in Europe
    • some authors consider routine calcitonin measurement of uncertain benefit during initial thyroid nodule work-up (2)

Assessment of thyroid cancer risk

Need for thyroid biopsy based on clinical, laboratory, and ultrasound findings

The British Thyroid Association categories based on presence of different ultrasound features (composition, vascularity, echogenicity, shape, calcifications, lymph nodes, margins):

U1- normal

Do not need biopsy, unless patient has statistically high risk of malignancy

U2 - benign

Do not need biopsy, unless patient has statistically high risk of malignancy

U3 - indeterminate/equivocal

Thyroid biopsy recommended

U4 - suspicious

Thyroid biopsy recommended

U4 - malignant

Thyroid biopsy recommended

If biopsy undertaken then next management step (whether surgical intervention or observation) based on

  • the FNA result
  • molecular markers and/or repeat FNA
  • individual patient's preferences and context


  • NICE (November 2019). Thyroid disease: assessment and management
  • Ospina NS et al. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment.BMJ 2020;368:l667.

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