Part 6. Thyroid nodules and thyroid cancer Thyroid nodules Patients with a discovered thyroid nodule or one which has increased in size over several months should have a serum TSH measurement, and most can be referred routinely. If any of the following features of concern (Red Flags) are present the patient should be referred under the 2 week rule: painless nodule growth change in voice •Unexplained cervical lymph nodes •Palpable nodule in a or teenager •Thyroid *In the presence of airway obstruction or stridor, referral should be as an emergency* If the patient is hyperthyroid (suppressed TSH), the TSH, FT4 & FT3 should be repeated and referred according to Part 3 (Hyperthyroidism). Patients with a history of sudden onset of painful thyroid nodule are likely to have bled into a thyroid cyst and can be referred routinely. Referral to secondary care may NOT be necessary if there is a clear history of a nodule or goitre that has not changed for several years and there are no other suspicious features (no history of neck irradiation, adult patient, no FH of thyroid cancer, no palpable cervical lymphadenopathy, no stridor). Referral to secondary care is not recommended for incidentally discovered thyroid nodules on CT, MRI or US unless are suspicious features in the report, with the exception of incidentally detected thyroid nodules showing positivity of a PET CT scan. primary investigation of a new thyroid nodule in secondary care is an ultrasound of •The the neck by an experienced operator. Neck ultrasound is not recommended prior to referral, as it does not change initial • management and delays secondary care assessment. is used to triage individuals to different care pathways: those who simply •Ultrasound need observation (benign appearances; U2) or those who need evaluation by aspiration cytology (U3–U5), or diagnostic surgery (U3–U5). the presence of an established multinodular goitre, the same Red Flag features of •In concern growth, voice change, nodes) should initiate referral (with measurement of TSH). Adolescents and older men are relatively more likely to have cancer.
Part 6. Thyroid nodules and thyroid cancer Thyroid nodules Patients with a discovered thyroid nodule or one which has increased in size over several months should have a serum TSH measurement, and most can be referred routinely. If any of the following features of concern (Red Flags) are present the patient should be referred under the 2 week rule: painless nodule growth •Unexplained change in voice •Palpable cervical lymph nodes •Thyroid nodule in a or teenager *In the presence of airway obstruction or stridor, referral should be as an emergency* If the patient is hyperthyroid (suppressed TSH), the TSH, FT4 & FT3 should be repeated and referred according to Part 3 (Hyperthyroidism). Patients with a history of sudden onset of painful thyroid nodule are likely to have bled into a thyroid cyst and can be referred routinely. Referral to secondary care may NOT be necessary if there is a clear history of a nodule or goitre that has not changed for several years and there are no other suspicious features (no history of neck irradiation, adult patient, no FH of thyroid cancer, no palpable cervical lymphadenopathy, no stridor). Referral to secondary care is not recommended for incidentally discovered thyroid nodules on CT, MRI or US unless are suspicious features in the report, with the exception of incidentally detected thyroid nodules showing positivity of a PET CT scan. •The primary investigation of a new thyroid nodule in secondary care is an ultrasound of the neck by an experienced operator. • Neck ultrasound is not recommended prior to referral, as it does not change initial management and delays secondary care assessment. •Ultrasound is used to triage individuals to different care pathways: those who simply need observation (benign appearances; U2) or those who need evaluation by aspiration cytology (U3–U5), or diagnostic surgery (U3–U5). •In the presence of an established multinodular goitre, the same Red Flag features of concern growth, voice change, nodes) should initiate referral (with measurement of TSH). Adolescents and older men are relatively more likely to have cancer.