Solitary thyroid nodule

 

Most thyroid nodules that are clinically solitary are a more prominent part of a multinodular goitre. The diagnosis of a multinodular goitre can be confirmed by ultrasound scan and the finding of a free T4 in the upper end of the normal range or even above normal, with a suppressed TSH.

 

A true solitary nodule associated with a high free T4 is a toxic adenoma and is benign, and can be treated by surgery or radioactive iodine.

 

A euthyroid solitary nodule still carries only a low risk of malignancy. Signs of a Horner’s syndrome or a vocal cord paresis would suggest malignancy, particularly in the elderly, in whom anaplastic carcinoma can occur. In younger patients the concern would be whether the swelling could harbour a papillary or follicular carcinoma. Management depends to a degree on the patients preferences and fears. If the patient is very concerned about the swelling and is willing to have surgery, then there is little point in any additional tests. If the patient would prefer to avoid surgery, then further investigations could help to reassure the patient. These tests include:

 

  Ultrasound appearance – as above, the finding of multiple nodules is reassuring

  Cystic appearance – if a cyst is present it can be aspirated and if it does not recur this is reassuring

  Cytology – Dr Grant can aspirate tissue for cytology. The finding of follicular cells always indicates the need for surgery, because the differential between adenoma and carcinoma can only be made on the basis of formal histology.

  Nuclear medicine scans – these are performed at the Royal Sussex County Hospital Nuclear Medicine Department, and have to be arranged through our X ray department. A nodule that is “hot” on technetium scanning is likely to be benign. A nodule which is cold on MIBI scanning is likely to be benign.

 

If there is still doubt then the patient should be advised to have surgery.