Assessing Thyroid Nodules: A Clinician's Guide

Mark A. Lupo, MD; Zsofia Geck, MD


December 11, 2020

Editorial Collaboration

Medscape &

The intermediate-suspicion category consists of hypoechoic solid nodules without high-suspicion features (Figure 4). These carry a cancer risk of 10%-20% and should be biopsied if they are larger than 1 cm.

Figure 4. An intermediate-risk hypoechoic solid nodule.

The high-suspicion category consists of solid or partially cystic hypoechoic nodules with irregular margins, microcalcifications, taller-than-wide shape, rim calcifications with small extrusions, or evidence of extrathyroidal extension (Figures 5, 6). These carry a cancer risk of 70%-90% and should be biopsied at or over 1 cm. Of note, this category includes sonographically suspicious cervical lymph nodes (Figures 7, 8), highlighting the critical role of assessing anterior neck lymph nodes as part of every thyroid nodule evaluation.

Figure 5. High-suspicion, taller-than-wide solid hypoechoic nodule with microcalcifications.

Figure 6. High-suspicion hypoechoic nodule with microcalcifications and probably invasion into strap muscles.

Figure 7. Right lateral neck cystic lymph node (LN).

CCA = common carotid artery; IJV = internal jugular vein

Figure 8. Left lymph node with microcalcifications and compression of jugular vein seen in transverse (left panel) and longitudinal (right panel) views.

Our patient's ultrasound notes a spongiform nodule (Figure 9). This places her in the very–low suspicion category, making it appropriate to monitor this nodule with ultrasound only.

Figure 9. This static image of a 2.5-cm nodule has nonspecific echogenic foci (arrows) that are commonly interpreted as microcalcifications (high suspicion). Real-time imaging, however, showed that these are bright spots behind small cystic spaces in a spongiform/hyperplastic nodule.

A Palpable Nodule

About a week later, a 58-year-old woman comes in as a new patient with a record of a recent carotid ultrasound that noted a thyroid nodule. This is palpable on physical exam, although she denies any previous awareness of the nodule. She denies any compressive symptoms. She has not been on thyroid medications. She grew up in Romania and was there during the time of the Chernobyl nuclear accident. Her mother has hypothyroidism.

Her ultrasound notes a hypoechoic nodule (Figure 10).

Figure 10. A mildly hypoechoic solid nodule without suspicious features, measuring 3.1 cm.

The nodule measures 3.1 cm and is hypoechoic, with regular borders and no calcifications. No suspicious lymph nodes are seen.

These characteristics place this nodule in the intermediate-suspicion category, which carries a cancer risk of 10%-20%. Because of its size and characteristics, we proceed with a fine-needle aspiration to rule out thyroid cancer. Her cytology results from the biopsy are indeterminate.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.