Thyroid nodule differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Thyroid nodule differential diagnosis

In rare cases, a thyroid nodule may reflect one of the hereditary nonmedullary thyroid cancer syndromes such as familial adenomatous polyposis, Werner’s syndrome, Carney complex type 1, or Gardner’s syndrome

		Nodule property	Spread			Sudden growth of neck mass	Laboratory		Thyroid scintigraphy				Biopsy result if indicated
			LN	Vessle	Metastasis		TSH	FT4/T3	Hot	Cold	US finding	FNA finding		Associated mutation	special consideration
Benign	Colloid adenoma		-	-	-		NL	NL
	Hashimoto's thyroiditis	Rarely painful	-	-	-		↓↓	↓	+
	Cysts nodules	Most common cause of painful neck lesion	-	-	-	May happen as a result of sudden hemorrhage	NL	NL	-	+	cystic non-calcified nodules	Follicular cells Macrophages RBC Colloid	-	-	Mostly due to degenerating thyroid adenomas
	Follicular adenomas		-	-	-		↑↑↑	↑						PAX8-PPAR gamma 1
	Hyperplastic nodules		-	-	-		↑↑↑	↑
	Macrofollicular adenomas		-	-	-		↑↑	↑
	Microfollicular or cellular adenomas		-	-	-		↑↑	↑
	Hürthle cell adenomas		-	-	-		↑↓	↑↓
Malignant	Papillary carcinoma	Fixed Painless	↑↑↑	↑↑↑	Pulmonary Skeletal metastases		NL	NL		+	multifocal	unencapsulated and may be partially cystic	papillae consisting of one or two layers of tumor cells surrounding a well-defined fibrovascular core; follicles and colloid are typically absent The nuclei are large, oval, and appear crowded and overlapping on microscopic sections. They may contain hypodense powdery chromatin, cytoplasmic pseudoinclusions due to a redundant nuclear membrane, or nuclear grooves.	RET/PTC NTRK1 RAS BRAF
	Follicular carcinoma	Fix Painless		↑↑↑	Bone Lung		↑↓	↑↓			Unifocal	FLUS	Tumor capsule Vascular invasion	RAS mutations PAX8-PPAR gamma 1	Most common thyroid cancer in iodine deficient areas
	Oxyphilic (Hürthle cell) type carcinoma
	Medullary carcinoma		↑↑↑		Locally to neck all body organ systems						Unifocal May present as multifocal	hypoechoic, microcalcifications			May be associated with other co-existing diseases Associated with high levels of calcitonin
	Anaplastic carcinoma						↑
	Primary thyroid lymphoma
	Metastatic carcinoma
	Thyroglossal duct cysts	Mostly midline Can be painful if get infected
	Parathyroid cysts