What if My Primary Physician Tells Me I have a Single Thyroid Nodule?

First of all do not panic. 31% of the time the palpation is NOT accurate. 16% of the time there is no nodule at all! The referral to the radiologist for an USGFNA may result in a biopsy even if there is no nodule present, as they are only doing what the physician orders. Ask for a referral to an endocrinologist that does their own high frequency Ultrasound. Check www.thyroidologists.com for a clinical thyroidologist near you. Also, 15% of patients with a worrisome single nodule will actually have a multinodular goiter. The thyroidologist ultrasonographer will confirm if there is a nodule, detect additional nodules, that may need FNA biopsy, and identify the ultrasound characteristics of the nodules. The present guidelines tell us that not all nodules need biopsy, especially <10 mm nodules. If the nodule is <10 mm there must be abnormal lymph nodes found, or radiation history or family history of thyroid cancer.
>10 mm nodules there are solid, hypoechoic or have micro-calcifications, need FNA biopsy. >1.0-1.5cm cm nodules that are solid and either iso,or hypoechoic need FNA biopsy. If they want to biopsy all your nodules or the ones that are not listed here, ask for a second opinion BEFORE you let them do the biopsy. >1.5-2.0 cm complex nodule, with another suspicious feature, such as vascularity, irregular margins,,micro-calcifications need a biopsy.
>2 cm Predominantly cystic without suspicious US features should be biopsied.

What about multiple nodules?
DO NOT allow them to Biopsy all the nodules. Prioritize based of Ultrasound findings. If there are multiple similar, coalescent nodules without suspicious features, they can biopsy the largest one.

Thyroid Ultrasound In summary,
Palpable Nodule
1. Assess if it is the same nodule seen on ultrasound, and look for suspicious findings. Review the ultrasound for other non-palpable nodules and their suspicious findings and select for USGFNA biopsy if indicated.

Non-palpable nodules seen on ultrasound.
1. Assess for need for Biopsy by suspicious findings, or history of radiation or family history.

Multiple Nodules
1. Select the nodules for biopsy based on suspicious findings or size.

All Nodules
1.Assess the lymph nodes for clues to the presence of thyroid cancer.

Always ask to see the actual diagnostic ultrasound and the report before allowing a biopsy to be done.

Good Luck,

Dr.G.

ReferenceFrontiers in Thyroid Cancer
ATA Guidelines in Clinical Practice
July 11-12 2008
Boston Mass.