Practice Rational Imaging

Incidental thyroid nodule

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b611 (Published 04 March 2009) Cite this as: BMJ 2009;338:b611
  1. Chirag N Patel, specialist registrar in radiology 1,
  2. Georgina Gerrard, consultant clinical oncologist2,
  3. Andrew F Scarsbrook, consultant radiologist and nuclear medicine physician1
  1. 1Departments of Radiology and Nuclear Medicine, St James’s University Hospital, Leeds Teaching Hospital, Leeds LS9 7TF
  2. 2Department of Clinical Oncology, St James’s University Hospital, Leeds Teaching Hospital, Leeds LS9 7TF
  1. Correspondence to: A F Scarsbrook andrew.scarsbrook{at}leedsth.nhs.uk

    Thyroid nodules may be coincidentally detected as a result of neck imaging, and most are benign; the authors discuss how best to decide which nodules are most likely to be malignant and require further evaluation

    Learning points

    • Thyroid nodules are very common, and the overwhelming majority are benign

    • Thyroid nodules may be coincidentally detected as a result of the increasing use of neck imaging

    • No imaging modality can reliably differentiate between benign and malignant thyroid nodules, but ultrasonography is the best technique for evaluating nodules and triaging those that require histological evaluation

    • Ultrasound guided fine needle aspiration cytology is accurate, cheap, and safe in most cases, but local resources vary

    • Metabolically active thyroid nodules detected on fused positron emission tomography and computed tomography (PET-CT) are associated with a 1 in 3 chance of malignancy and should be further evaluated

    • PET-CT may have a future role in reducing unnecessary surgery in patients with indeterminate cytology because of its high negative predictive value

    The patient

    A 78 year old man presented with haemoptysis and was found to have a bronchial tumour at bronchoscopy. He was referred for a 18fluorine fluorodeoxyglucose PET-CT scan (which combines positron emission tomography and computed tomography) for accurate staging before surgical treatment; this scan confirmed operable disease. An incidental solitary thyroid nodule was detected, with the scan showing increased uptake of 18fluorine fluorodeoxyglucose within the nodule (fig 1).

    Fig 1 Half body PET-CT scan. The axial CT scan (top left), PET scan (top right), and fused PET-CT scan (bottom left) show abnormal focal uptake of 18fluorine fluorodeoxyglucose in the left lobe of the thyroid gland (indicated by red “crosshairs”). The maximum intensity projection of the PET scan (bottom right) shows abnormal focal uptake of 18fluorine fluorodeoxyglucose in the thyroid gland (long arrow) and two adjacent foci …

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