The challenge remains identifying which palpable nodules are malignant

Thyroid nodules are found in 5% of middle aged women and are commoner in women than in men. A nodule raises concerns about malignant disease, but thyroid cancer is rare, accounting for about 1000 new cases in England and Wales each year. The main aim of management is to identify the small proportion of patients with thyroid cancer who require treatment and avoid unnecessary testing and treatment for the majority.

Nodules are more likely to be malignant in men, particularly men aged over 70.1 A history of neck irradiation, rapid tumour growth, or a family history of thyroid cancer increases risk. Physical signs associated with increased risk include firm, non-tender nodules, local lymphadenopathy, and recurrent laryngeal nerve palsy in the absence of previous surgery. The incidence of cancer in those with clinical features strongly suggestive of malignancy is high,2 but most patients do not have these features.

Solitary nodules are more common than multinodular goitres clinically, and solitary nodules used to be considered more likely to harbour malignant disease. This view …