What is the role of the physical exam in the evaluation of a solitary thyroid nodule?

Updated: Aug 19, 2020
  • Author: Daniel J Kelley, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Physical characteristics of a thyroid nodule are poor predictors of malignancy; both malignant and benign solitary thyroid nodules can be soft or firm, smooth or irregular upon examination (although in contrast, a study by Uyar et al indicated that characteristics such as irregular borders, microcalcification, increased vascularity, and cervical lymphadenopathy are malignancy risk factors for solitary thyroid nodules [5] ). However, increased size of a thyroid nodule correlates with increased risk of malignancy. Moreover, size is used in tumor staging and is highly predictive of outcome.

Nonetheless, a study by Valderrabano et al indicated that regardless of size, most solitary cytologically indeterminate thyroid nodules can be successfully treated with thyroid lobectomy. Comparing indeterminate tumors of less than 4 cm with those 4 cm or greater, size was not seen as a categorical or continuous variable in relation to cancer rate. Moreover, the prevalence of extrathyroidal extension, positive margins, lymphovascular invasion, lymph node metastasis, and distant metastasis did not differ by size. The investigators also found the majority of malignant tumors in both size groups to be low-risk lesions. [6]

Fixation to or invasion of surrounding structures by thyroid nodules and the presence of palpable lymph nodes in the neck are highly suggestive of malignancy. Vocal cord paralysis is not a reliable indicator of malignancy because it can also occur in benign disorders.

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