TSH alone is not sufficient to exclude all patients with a functioning thyroid nodule from undergoing testing to exclude thyroid cancer

  • Luis-Mauricio Hurtado-López
  • Blanca-Estela Monroy-Lozano
  • Carlos Martínez-DunckerEmail author
Original Article



The purpose of the study was to analyze whether the thyroid-stimulating hormone (TSH) alone avoids tests to exclude malignancy in all patients with functional thyroid nodules (FTN).


Sixty-nine patients with FTN on 99mTc scintigraphy, radioiodine uptake test (RIU), 99mTc thyroid uptake, TSH assay, T3, and T4 obtained within 48 h were retrospectively identified out of 2,356 thyroid scans performed from January 2000 to April 2007. FTNs were classified as causing total, partial, or no inhibition of the thyroid as group 1, 2, or 3, respectively.


TSH was subnormal in 21 of 69 (30.43%) patients. In group 1 (N = 23, 33.3%), TSH was subnormal, normal, and high in eight, nine, and six patients; in group 2 (N = 17, 24.6%), TSH was subnormal, normal, and high in four, six, and seven patients, and in group 3 (N = 29, 42%), TSH was subnormal, normal, and high in 9, 13, and 7 patients, respectively. TSH was significantly lower in group 1. In T3, T4, 99mTc thyroid uptake, and RIU, there were no differences between the three groups.


Only 30.43% of patients had subnormal TSH. TSH alone cannot avoid tests to exclude malignancy in all patients with FTN. FTN existence can only be accurately assessed by thyroid scintigraphy. The current incidence of FTN may be unknown because scintigraphy is not routinely performed in all patients with thyroid nodules. Thyroid scintigraphy of patients with high TSH can detect diseases such as Hashimoto’s thyroiditis and identify patients with FTN in whom no further diagnostic procedures would be needed in patients with normal TSH levels with nondiagnostic fine-needle aspiration results.


Thyroid gland Thyroid nodule Thyrotropin Radionuclide imaging 99mTc-Pertechnetate 



We are grateful to Febe-Griselda Mayén-Pérez, our Senior Nuclear Medicine Technician, for her unconditional daily assistance and help in the attention of all our thyroid patients.


  1. 1.
    Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993;328:553–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Vander JB, Gaston EA, Dawber TR. The significance of nontoxic thyroid nodules. Final report of a 15-year study of the incidence of thyroid malignancy. Ann Intern Med 1968;69:537–40.PubMedGoogle Scholar
  3. 3.
    Castro MR, Gharib H. Continuing Controversies in the Management of Thyroid Nodules. Ann Intern Med 2005;142:926–31.PubMedGoogle Scholar
  4. 4.
    Ross DS. Evaluation of the Thyroid Nodule. J NucI Med 1991;32:2181–92.Google Scholar
  5. 5.
    Bennedbaek FN, Hegedus L. Management of the solitary thyroid nodule: Results of a North American survey. J Clin Endocrinol Metab 2000;85:2493–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Bennedbaek FN, Perrild H, Hegedus L. Diagnosis and treatment of the solitary thyroid nodule: result of a European survey. Clin Endocrinol (Oxf) 1999;50:357–63.CrossRefGoogle Scholar
  7. 7.
    American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi. Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules, AACE/AME Task Force on Thyroid Nodules. Endocrine Practice 2006;12:63–102.Google Scholar
  8. 8.
    Cooper DS, Doherty GM, Haugen BR, et al. Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Taskforce. Thyroid 2006;16:109–42.PubMedCrossRefGoogle Scholar
  9. 9.
    Garber JR. Thyroid nodules: managing what has been known for over 50 years. Hormones (Athens) 2006;5:179–86.Google Scholar
  10. 10.
    Welker MJ, Orlov D. Thyroid nodules. Am Fam Physician 2003;67:559–66.PubMedGoogle Scholar
  11. 11.
    McCaffrey TV. Evaluation of the thyroid nodule. Cancer Control 2000;7:223–8.PubMedGoogle Scholar
  12. 12.
    Hamburger JI. Evolution of toxicity in solitary non-toxic autonomously functioning thyroid nodules. J Clin Endocrinol Metab 1980;50:1089–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Thomas CG, Croom RD. Current management of the patient with autonomously functioning nodular goiter. Surg Clin North Am 1987;67:315.PubMedGoogle Scholar
  14. 14.
    Bransom CJ, Talbot CH, Henry L, Elemenoglou J. Solitary toxic adenoma of the thyroid gland. Br J Surg 1979;66:590–5.CrossRefGoogle Scholar
  15. 15.
    Wang HH. Reporting thyroid fine-needle aspiration: literature review and a proposal. Diagn Cytopathol 2006;34:67–76.PubMedCrossRefGoogle Scholar
  16. 16.
    Hurtado-López LM, Arellano-Montaño S, Torres-Acosta EM, et al. Combined use of fine needle aspiration biopsy, MIBI scans and frozen section biopsy offers the best diagnostic accuracy in the assessment of the hypofunctioning solitary thyroid nodule. Eur J Nucl Med Mol Imaging 2004;31:1273–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Meller J, Becker W. The continuing importance of thyroid scintigraphy in the era of high-resolution ultrasound. Eur J Nucl Med 2002;29:S425–38.CrossRefGoogle Scholar
  18. 18.
    Cases JA, Surks MI. The changing role of scintigraphy in the evaluation of thyroid nodules. Semin Nucl Med 2000;30:81–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Lennard TW, Proud G. Thyroid aspiration cytology in Newcastle: a six year cytology/histology correlation study. Hot nodules have a very low incidence of malignancy. Ann R Coll Surg Eng 2000;82:149–55.Google Scholar
  20. 20.
    Niepomniszcze H, Suarez H, Pitoia F, et al. Follicular carcinoma presenting as autonomous functioning thyroid nodule and containing an activating mutation of the TSH receptor (T620I) and a mutation of the Ki-RAS (G12C) genes. Thyroid 2006;16:497–503.PubMedCrossRefGoogle Scholar
  21. 21.
    Mackenzie EJ, Mortimer RH. Thyroid nodules and thyroid cancer. Med J Aust 2004;180:242–7.PubMedGoogle Scholar
  22. 22.
    Ravetto C, Colombo L, Dottorini ME. Usefulness of fine-needle aspiration in the diagnosis of thyroid carcinoma: A retrospective study in 37,895 patients. Cancer Cytopathol 2000;90:357–63.Google Scholar
  23. 23.
    Hooft L, Hoekstra OS, Boers M, Van Tulder MW, Van Diest P, Lips P. Practice, efficacy, and costs of thyroid nodule evaluation: a retrospective study in a Dutch University Hospital. Thyroid 2004;14:287–93.PubMedCrossRefGoogle Scholar
  24. 24.
    Lansfird CD, Teknos TN. Evaluation of the thyroid nodule. Cancer Control 2006;13:89–98.Google Scholar
  25. 25.
    Becker D, Bair HJ, Becker W, et al. Thyroid autonomy with color-coded image-directed Doppler sonography: internal hypervascularization for the recognition of autonomous adenomas. J Clin Ultrasound 1997;25:63–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Asociación Mexicana De Cirugía General. Nódulo tiroideo, 2001. Consenso. Cir Gen 2002;24:76–83.Google Scholar
  27. 27.
    Vela-Amieva M, Hernández-Osorio C, Gamboa-Cardiel S, et al. Hyperthyrotropinemia in Mexican Newborns. Salud Publica Mex. 2003;45(4):269–75.PubMedGoogle Scholar
  28. 28.
    Vásquez-Garibay EM, Romero-Velarde E, Nápoles-Rodríguez F, Nuño-Cosío ME, Trujillo-Contreras F, Sánchez-Mercado O. Prevalence of iron and iodine deficiency and parasitosis in children from Arandas, Jalisco, Mexico. Salud Publica Mex 2002;44:195–200.PubMedGoogle Scholar
  29. 29.
    Hurtado-Lopez LM, Martinez-Duncker C. Negative MIBI thyroid scans exclude differentiated and medullary thyroid cancer in 100% of patients with hypofunctioninal thyroid nodules. Eur J Nucl Med Mol Imaging 2007;34(10):1701–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Kaplan MM. Clinical Perspectives in the Diagnosis of Thyroid Disease. Clin Chem 1999;45:1377–83.PubMedGoogle Scholar
  31. 31.
    Castro MR, Gharib H. Thyroid nodules and cancer: when to wait and watch, when to refer. Postgrad Med 2000;107:113–24.PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Luis-Mauricio Hurtado-López
    • 1
  • Blanca-Estela Monroy-Lozano
    • 1
  • Carlos Martínez-Duncker
    • 2
    Email author
  1. 1.General Hospital of MexicoMexico CityMexico
  2. 2.Medicina Nuclear MolecularHospital Infantil de México Federico GómezMexico CityMexico

Personalised recommendations