Updated: 2/22/2018

Thyroid Nodules

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Snapshot
  • A 22-year-old woman presents to her primary care physician after finding a "lump" on her neck. She denies any fever, flu-like symptoms, or sick contacts. She also denies any pain or discomfort in the neck; however, she notes an unintentional 8-pound weight loss. She does not have any significant medical history. Family history is significant for medullary thyroid cancer in her mother and parathyroid hyperplasia in her maternal grandmother. Physical exam is significant for a fixed hard mass in the right-side of the thyroid. A thyroid stimulating hormone level is decreased and thyroid scintigraphy is scheduled to be performed.
Introduction
  • Epidemiology
    • malignant risk factors
      • < 30 or > 70 years of age
      • family history of 
        • medullary thyroid cancer
        • multiple endocrine neoplasia (MEN) 2 
        • Cowden syndrome
        • familial adenomatous polyposis 
      • history of prior radiation to the neck
      • cold nodule on radioactive iodine uptake
      • cervical lymphadenopathy
      • concerning findings on ultrasound
        • hypoechoic
        • irregular borders
        • microcalcifications
        • central vasculature
    • benign risk factors
      • family history of 
        • autoimmune thyroid disease
        • goiter
      • hyper- or hypothyroidism
      • nodular tenderness
Approach to Thyroid Nodules
  • Discovery of a thyroid nodule
    • begin with a thorough history and physical exam
      • this determines the risk factors the patient has for having a malignant or benign nodule
    • thyroid stimulating hormone (TSH) levels should be checked in all patients with a thyroid nodule
      • ↓ TSH
        • perform thyroid scintigraphy (radioactive iodine uptake test) 
          • hot
            • definition
              • there is an increased uptake of iodine compared to the surrounding thyroid tissue
            • suggests an autonomously functioning thyroid
            • likely a benign nodule, thus fine needle aspiration (FNA) is not needed
          • cold
            • definition
              • there is less uptake of iodine compared to the surrounding thyroid tissue
            • perform FNA
          • indeterminate
            • perform FNA
      • ↑ or normal TSH
        • perform FNA if the nodule meets sonographic criteria
    • ultrasonography should be check in all patients with a thyroid nodule
      • sonographic pattern
        • high suspicion
          • a hypoechoic nodule that is > 1 cm and with ≥ 1 suspicious features such as
            • irregular margins
            • microcalcifications
            • rim calcifications
            • extrathyroidal extension
          • perform FNA
        • intermediate suspicion
          • a hypoechoic nodule that is > 1 cm with smooth margins
          • perform FNA
        • low suspicion
          • isoechoic, hyperechoic solid nodule, or partially cystic nodule that has eccentric solid areas and is > 1.5 cm
          • perform FNA
  • FNA findings and management
    • benign
      • periodic ultrasound monitoring
    • indeterminate
      • repeat FNA in 2-3 months
    • suspicious for malignancy
      • thyroidectomy
    • malignant (e.g., papillary cancer, medullary thyroid cancer, and anaplastic cancer)
      • thyroidectomy
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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