S p e c i a l A r t i c l e • C l i n i c a l Pe r s p e c t i ve

Ahmed et al.
Thyroid Nodules on Chest CT

Special Article
Clinical Perspective
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Incidental Thyroid Nodules on

Chest CT: Review of the Literature
and Management Suggestions
Sameer Ahmed1 OBJECTIVE. This article will review the current literature regarding the detection of thy-
Karen M. Horton2 roid nodules with an emphasis on CT diagnosis. We will also discuss management strategies.
R. Brooke Jeffrey, Jr. 3 CONCLUSION. With advances in cross-sectional imaging, the detection of incidental
Sheila Sheth2 thyroid nodules has increased significantly. Detection of thyroid nodules is common on chest
Elliot K. Fishman 4 CT that is being performed for unrelated reasons. The workup of these nodules can be time-
consuming and expensive.
Ahmed S, Horton KM, Jeffrey RB Jr, Sheth S,
Fishman EK

T
he detection of thyroid nodules
has increased dramatically over
the past 50 years due to rapid ad-
vancements in imaging technolo-
gy, especially CT, MRI, and ultrasound. Giv-
en recent improvements in MDCT, including
improved resolution and thinner slice colli-
mation, thyroid nodules are now commonly
detected on chest and neck CT, typically as in-
cidental, unsuspected findings. There is con-
siderable variability in how radiologists report
incidentally detected thyroid nodules and
what follow-up recommendations, if any, they
make. In addition, the risk of malignancy in
these nodules remains low, yet many cases are
Keywords: MDCT, nodules, thyroid
still followed up with ultrasound and ultimate-
DOI:10.2214/AJR.10.4506 ly ultrasound-guided fine-needle aspiration
(FNA) biopsy, which at our institution aver-
Received February 22, 2010; accepted after revision ages more than $3000 in charges, including
April 28, 2010. radiology and pathology charges.
1
Johns Hopkins University School of Medicine,
This improvement in technology has led
Baltimore, MD. to a particularly dramatic rise in the number
of patients diagnosed with papillary micro-
2
Department of Radiology, Johns Hopkins Medical carcinomas measuring less than 10 mm in
Institutions, 601 N Caroline St., JHOC 3253, Baltimore,
diameter [1]. The recommended treatment of
MD 21287. Address correspondence to K. M. Horton
(kmhorton@jhmi.edu). even small papillary thyroid carcinomas is
thyroidectomy [1], which carries a small but
3
Department of Radiology, Stanford University Medical significant risk of complications. After sur-
Center, Stanford, CA. gery, patients receive lifelong thyroid hor-
4
The Russell H. Morgan Department of Radiology and
mone therapy. Despite an increase in surger-
Radiological Science, Johns Hopkins University School ies to treat these small carcinomas, thyroid
of Medicine, Baltimore, MD. cancer–specific mortality has not improved
[1]. Ito et al. [2] showed that of 162 patients
AJR 2010; 195:1066–1071
with papillary microcarcinomas followed
0361–803X/10/1955–1066 without surgery, more than 70% of tumors
either remained stable or decreased in size,
© American Roentgen Ray Society even after 5 years or more, suggesting that
overdiagnosis and overtreatment of thyroid
disease is a significant concern, as noted by
Black and Welch [3].
This article will review the current litera-
ture regarding the detection of thyroid nod-
ules, with an emphasis on CT diagnosis. We
will review case examples and discuss sug-
gested guidelines for management of thyroid
nodules detected on CT.
Literature Review
Thyroid carcinoma is the most frequent
type of endocrine cancer in the United States,
with 33,500 new cases diagnosed each year
but only 1,500 deaths annually, mainly due to
uncommon, aggressive forms of the disease
[4]. The yearly incidence of differentiated thy-
roid cancers is increasing due, in part, to more
frequent detection of small nonpalpable nod-
ules on cross-sectional imaging examinations
performed for unrelated indications [5]. The
incidence and prevalence of unsuspected thy-
roid nodules varies with the population stud-
ied and the methods used for detection. The
frequency of these incidentalomas has ranged
from as low as 2% to as high as 67% [6–8].
The vast majority of cases are ultimately diag-
nosed as benign colloid nodules, cysts, or ade-
nomas, whereas approximately 5% of nodules
are malignant [9].
Autopsy series report the highest prevalence
of thyroid nodularity [10]. Mortensen et al. [11]
examined 821 patients with no history of thy-
roid disease and reported nodules in 50% of
thyroid glands. Nodules as small as 2 mm in di-
ameter were detected, but it is unclear whether
these are clinically relevant. This study showed

1066 AJR:195, November 2010


an equal frequency of benign and malignant
nodules, but most were asymptomatic micro-
carcinomas unrelated to the cause of death.
Several ultrasound-based studies have re-
ported on the frequency of incidental thyroid
nodules. Steele et al. [12] retrospectively re-
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viewed 2,004 bilateral carotid duplex sonog-
raphy scans and reported thyroid nodules in
9% of patients (approximately 60% of nod-
ules were detected in women). These patients
did not have a history of thyroid nodules or
known thyroid disease. In another study using
this method of detection, Carroll [13] report-
ed a 13% incidence (three men and six wom-
en) of asymptomatic thyroid nodules in a total
of 67 patients without history of thyroid dis-
ease or head and neck radiation. Woestyn et
al. [14] performed ultrasound examinations on
300 patients without any signs or symptoms of
thyroid disease, asymmetry, or enlargement.
Small, incidental echoic nodules were seen
in 19% of patients (17% of men and 20% of
women). A study by Bartolotta et al. [15] in
Italy examined 704 patients with high-reso-
lution sonography and real-time spatial com-
pound sonography. They reported an overall
prevalence of 33%, with 60% of incidental
nodules found in women. The highest reported
frequency also was from an ultrasound-based
study by Ezzat et al. [8] that detected unsus-
pected nodules in 67% of a total of 100 healthy
patients. This is likely an overestimation of the
prevalence because 84% of the subjects were
women. These studies show that thyroid nod-
ules are detected by ultrasound in a large pro-
portion of patients, but the malignancy rates
are still around 5% and the vast majority of
these malignancies (75–80%) represent small
papillary carcinomas [9].
A limited number of CT- and MRI-based
studies have examined the prevalence of in-
cidental thyroid nodules. Yoon et al. [16] ex-
amined 734 patients without known thyroid
disease using 16-MDCT contrast-enhanced
scans of the neck and found thyroid nodules
in 16% of the subjects. They also found that
9% of these incidentalomas were malignant,
with some diagnostic CT features, such as
nodular or rim calcifications, anteroposte-
rior to transverse diameter ratio above 1.0,
and mean attenuation value on contrast-en-
hanced scans greater than 130 HU. Anoth-
er study by Youserm et al. [17] analyzed 123
CT scans of the head and neck and 108 MRI
examinations and reported the prevalence of
incidental thyroid nodules at 16%. Of the 14
patients evaluated for malignancy, none de-
veloped thyroid carcinoma by 24–32 months
AJR:195, November 2010 1067
Thyroid Nodules on Chest CT
of follow-up. Neither of these studies exclud-
ed patients with a history of neck radiation.
Incidental thyroid nodules are detected least
frequently in PET scans. Cohen et al. [6] re-
viewed all patients who underwent PET with
use of 18F-FDG at their institution and report-
ed unsuspected nodules in 2% of patients. This
large study of 4,525 subjects also included thy-
roid biopsy results for 15 patients with newly
discovered nodules and 47% were found to be
malignant. However, these patients were un-
dergoing FDG PET for cancer staging, which
introduces a potential selection and population
bias. Patients with a history of neck radiation
were not excluded, which likely contributed to
a high rate of thyroid cancer. In addition, be-
cause PET is best at detecting active nodules,
it is certainly more likely that nodules detect-
ed on PET will be malignant. Kang et al. [7]
used FDG PET to examine 1,330 subjects and
also identified thyroid incidentalomas in 2% of
glands. Histologic diagnoses of PET-positive
nodules were available for 15 glands by either
sonography-guided core needle biopsy or sur-
gical resection of the tumor, and approximate-
ly 26% tested positive for thyroid cancer. In
both studies, the number of patients evaluated
for malignancy was quite low compared with
the total number of cases. FDG PET is a useful
tool for detecting thyroid malignancies, with
reported sensitivity of 75–90% and specificity
of 90% [18, 19]. However, small nodules may
be below the threshold for accurate detection.
In summary, thyroid nodules are common-
ly detected as incidental findings on all im-
aging techniques including CT, sonography,
MRI, and PET/CT. The chance of malignan-
cy in these nodules is relatively low, depend-
ing on other risk factors and imaging char-
acteristics. Also, most of these malignancies
will be small papillary cancers [1].
Management Guidelines
Incidentally detected thyroid nodules are a
common clinical problem, and their manage-
ment remains controversial. The majority of
these nodules are either benign or small as-
ymptomatic papillary cancers of question-
able clinical significance. The challenge then
becomes determining which nodules can be
ignored, which should undergo biopsy, and
which require surgical intervention. We will
review major sets of guidelines established
by the American Thyroid Association (ATA),
the National Comprehensive Cancer Network
(NCCN), and the British Thyroid Association
(BTA). Please note that there are many other
guidelines available, such as guidelines by the
Society of Radiologists in Ultrasound [20].
However, they are beyond the scope of this
article but may be of interest to the reader.
In 2006, ATA established guidelines for ap-
propriate evaluation of incidentally discovered
thyroid nodules [21]. They recommend that, in
general, thyroid nodules 1 cm or larger should
be further evaluated for malignancy. Nodules
that are smaller than 1 cm may be considered
for evaluation if a sonogram contains features
indicative of malignancy, the patient has a his-
tory of head and neck radiation, or there is a
family history of thyroid carcinoma. Thyroid
nodules also require further evaluation in pa-
tients with regional lymphadenopathy, vocal
cord paralysis, and physical interference with
neck structures. Patients who fit the aforemen-
tioned criteria require an initial evaluation of
serum thyroid-stimulating hormone (TSH). If
TSH levels are not suppressed, then an ultra-
sound examination is recommended. FNA bi-
opsy, preferentially with ultrasound guidance,
is a cost-effective procedure that should be used
to test for malignancy; however, cystic nodules
that yield nondiagnostic cytology should be fol-
lowed through imaging or, in the case of firm
nodules, surgery. If thyroid nodules are found
to be malignant, the ATA strongly recommends
surgery, but benign cytology does not require
further diagnostic study or treatment. However,
it is recommended that benign nodules be fol-
lowed at 6- to 18-month intervals for evidence
of growth. Thyroid glands with multiple nod-
ules larger than 1.0–1.5 cm require aspiration,
but there are no specific recommendations re-
garding the number of nodules to be evaluated.
According to the most recent guidelines
established by the NCCN in 2009 [22], sol-
itary nodules measuring greater than 1 cm
in diameter in patients with certain risk fac-
tors should be further evaluated with mea-
surement of TSH levels, neck ultrasound,
and FNA of nodules and clinically suspi-
cious lymph nodes. Risk factors include age
below 15 years and above 60 years, male sex,
history of head and neck radiation, history
of diseases associated with thyroid cancer
(e.g., Gardner syndrome, Cowden syndrome,
and Carney complex), and family history of
thyroid cancer. Intranodular hypervascular-
ity, irregular borders, and microcalcification
seen on ultrasound are also important factors
associated with malignancy [20]. Nodules
that are very firm, have exhibited a pattern
of rapid growth, or are invading other neck
structures should be considered for surgery
after FNA. The NCCN also recommends
that unsuspected nodules that measure less
 Ahmed et al.

than 1 cm in patients without the aforemen-
tioned risk factors should be monitored and
followed-up clinically as indicated and a
neck ultrasound may be considered.
The BTA, in collaboration with the Royal
College of Physicians, updated management
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but the ATA does recommend its use for inde-
terminate cytology and suspicious lesions. Sur-
gical intervention may be considered for malig-
nant nodules. If a lesion is initially determined
to be benign, FNA biopsy should be repeated
3–6 months later to exclude the finite possibil-
cal correlation with physical examination and
an assessment of risk factors. In high-risk pa-
tients, even nodules smaller than 1 cm in size
may need biopsy.
Multinodular thyroid glands present an-
other topic of controversy, and the current

guidelines in 2007 [23]. They did not recom-
mend urgent referral to secondary care for the
vast majority of incidental thyroid nodules. As-
ymptomatic nodules measuring less than 1 cm
in unsuspected patients should be managed in
primary care. If nodules are detected in a pa-
tient with a family history of thyroid cancer,
history of neck irradiation, unexplained vocal
abnormalities, painless growth of a palpable
thyroid mass, cervical lymphadenopathy, or
persistent neck pain, then it is necessary to fur-
ther evaluate the condition. Initially, a thyroid
function test should be performed, followed by
FNA biopsy. If aspiration does not yield a di-
agnosis after two attempts, core biopsy or sur-
gical excision are suggested. In contrast to the
ATA guidelines, the BTA does not recommend
sonography for all patients under suspicion for
thyroid cancer. However, ultrasound is recom-
mended for biopsy and multinodular glands.
Radioiodine isotope scanning is also not sup-
ported for diagnostic evaluation by the BTA,
ity of a false-negative diagnosis.
All of the aforementioned management
guidelines include a size threshold of about 1
cm, above which a thyroid nodule requires clin-
ical and usually imaging evaluation and like-
ly biopsy. However, it is still unclear whether
nodule size is predictive of malignancy. In one
study, Papini et al. [24] correlated sonographic
findings with the results of ultrasound-guided
FNA biopsy and pathologic staging of resect-
ed carcinomas. They examined 494 patients
and showed that the prevalence of malignan-
cy was not significantly different between nod-
ules greater or smaller than 1 cm (9% vs 7%).
Sahin et al. [25] examined 207 patients with
nodular goiter and showed that 21% of nodules
smaller than 1 cm and 17% of nodules larg-
er than 1 cm were malignant. These studies
suggest that nodules smaller than 1 cm, many
of which are detected on CT, MRI, and ultra-
sound, should not be dismissed clinically due
to size alone. Even small nodules need clini-
guidelines are not explicitly clear in their
recommendations for dealing with these
entities. However, several studies have ex-
amined malignancy in glands with mul-
tiple nodules. Sippel et al. [26] retrospec-
tively reviewed the records of 325 patients
who underwent thyroidectomy with an FNA
diagnosis of either follicular neoplasm,
Hürthle cell neoplasm, or indeterminate.
They showed that the risk of malignancy
was lower in patients with multiple nodules
compared with those with a solitary nod-
ule (16% vs 28%). Frates et al. [27] showed
that solitary nodules have a higher per-nod-
ule likelihood of malignancy; however,
this study only considered nodules larger
than 1 cm in diameter. Other studies have
shown that although solitary nodules are
more likely to be malignant, multinodular
glands still harbor a significant portion of
thyroid carcinomas [24, 28]. Approximate-
ly two thirds of thyroid cancers are found in

Fig. 1—70 year-old man who presented with

shortness of breath and chest pain. Chest CT was
ordered to evaluate for possible pulmonary embolism.
Contrast-enhanced MDCT of chest was performed.
Official CT report does not describe any thyroid nodules.
A and B, Axial (A) and coronal reformation (B) scans
were reviewed as part of another study to determine
prevalence of thyroid nodules on chest CT. Multiple
nodules were noted (arrows); largest was described
on left lobe, measuring 5 × 10 mm. When CT is
performed for another indication, thyroid nodules can
sometimes be overlooked by busy radiologists.
A B

Fig. 2—46 year-old man who was a smoker and

presented with cough. Chest CT was ordered for
suspected pneumonia. Official CT report does not
describe any thyroid nodules but does note that
thyroid is enlarged. This scan was reviewed as part
of another study to determine prevalence of thyroid
nodules on chest CT.
A and B, Axial images on repeat review show 2 × 1 cm
nodule described in left lower pole. No nodules were
seen at ultrasound. Clinical workup revealed top
normal thyroid function tests. Due to artifact through
thyroid from clavicles and from dense IV contrast
material in subclavian veins, pseudolesions can be
created.
A B

1068 AJR:195, November 2010


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A B
the dominant nodule in patients with mul-
tiple nodules [20]. In general, the ATA and
BTA suggest that sonographic features that
are indicative of malignancy should be used
to select nodules for biopsy from a multi-
nodular gland. If suspicious features are not
present, the larger nodules should be prefer-
entially evaluated for malignancy.
Incidental detection of nodules in patients
with another known malignancy is also a
clinical problem. In a study by Wilhelm et
al. [29], 41 patients with a history of another
AJR:195, November 2010 1069
Thyroid Nodules on Chest CT
C D
E F
known malignancy and an incidental thyroid
nodule were evaluated. Thirty-five of the 41
patients met the criterion for biopsy, which
was a nodule of 1 cm or greater. Twenty of
these 35 had atypical biopsy results warrant-
ing surgical resection. Sixteen of these 20
underwent surgery. Pathology revealed four
papillary thyroid cancers, four micropapil-
lary thyroid cancers, two metastatic cancers,
and seven benign nodules. One patient who
did not fit their criteria of an abnormal bi-
opsy also underwent surgical resection and
Fig. 3—62-year-old man with history of lymphoma
involving parotid gland. CT was ordered to evaluate
for other sites of disease.
A and B, Contrast-enhanced axial (A) and coronal
reformation (B) images from MDCT of chest. Report
described 1.9-cm nodule (arrows) in left thyroid lobe.
C, Follow-up sonogram shows 2.1 × 1.8 × 1.6 cm
complex nodule (cursors) with cystic and solid
components as well as increased vascularity. Biopsy
was recommended, but has not yet been performed.
D–F, Ultrasound also shows multiple other nodules
(cursors) not reported on CT. Ultrasound is the
technique of choice to characterize and measure
thyroid nodules. Guidelines from various societies
base biopsy recommendations on size and
appearance of nodules on ultrasound as well as
clinical history and risk factors.
was found to have an incidental micropapil-
lary cancer.
Thus, there is still controversy regarding the
management guidelines for thyroid nodules.
However, the guidelines stress that clinical his-
tory is important (age, radiation, endocrine
syndromes), laboratory analysis (TSH) is help-
ful, and the size and sonographic appearance
of the nodule are important and help determine
which nodules should be biopsied or followed.
The guidelines do not directly address what to
do with nodules detected on CT.

Fig. 4—28 year-old woman undergoing chest CT for
evaluation of thoracic outlet syndrome.
A and B, Contrast-enhanced axial with 5-mm slice
thickness (A) and coronal reformation with 0.75-
mm slice thickness (B) images show 7-mm nodule
in left lobe of thyroid (arrows) and sonography was
recommended.
C and D, Sonograms show 1.0 × 0.6 mm × 0.8 m cystic
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nodule with soft-tissue nodule (cursors). Biopsy was
performed and pathology revealed adenomatoid
nodule. In retrospect, small solid nodule within
cystic lesion can be seen on CT using thin slices.
Characterizing incidentally detected thyroid nodule
on routine chest CT using 3– to 5–mm slices can be
difficult.
Pitfalls in CT Detection of
Thyroid Nodules
Advancement in MDCT scanner technol-
ogy has resulted in significant improvements
in CT image resolution, now allowing sub-
millimeter collimation. Small nodules are
now commonly detected in the thyroid on
examinations performed for other indica-
tions. As noted previously, on neck CT and
MRI examinations, 16% of patients had un-
suspected thyroid nodules [16, 17].
The value of ultrasound characterization
of thyroid nodules is well accepted and yields
useful information that may help guide biop-
sy. However, the value of CT characterization
is less well studied. There may be some diag-
nostic features, as noted by Yoon et al. [16]
that suggest malignancy, such as nodular or
rim calcifications, anteroposterior to trans-
verse diameter ratio above 1.0, and mean at-
tenuation value on contrast-enhanced scans
greater than 130 HU. However, in a study by
Shetty et al. [30] of nodules detected on CT
with follow-up ultrasound, the authors found
no reliable CT feature to help distinguish be-
nign from malignant nodules.
As noted in the article by Shetty et al. [30],
thyroid nodules detected on chest CT are typi-
cally small and often too small to characterize
accurately. Even larger incidental nodules de-
tected on CT may be difficult to characterize
1070 AJR:195, November 2010
Ahmed et al.
A B
C D
because the CT was not performed specifical-
ly to address the thyroid and the entire gland
may not be imaged. For example, on chest
CT, the patient’s arms are positioned over the
head, which often results in beam harden-
ing artifact through the thyroid as a result of
high-density IV contrast material in the sub-
clavian veins. The clavicle can also cause arti-
fact through the thyroid gland. These artifacts
can obscure nodules or create pseudolesions.
In addition, small nodules would be difficult
to characterize on CT unless thin collimation
and multiplanar reconstruction were avail-
able. Routine chest CT is usually performed
with 3- to 5-mm slice thickness, not ideal for
characterizing nodules less than 1 cm in size.
In the study by Shetty et al. [30], 230 pa-
tients with abnormal findings in the thyroid on
CT underwent ultrasound, and 118 ultimate-
ly underwent biopsy or resection. The CT and
sonography images were reviewed and corre-
lated. CT matched the sonography findings in
53% of patients. CT correctly identified the
dominant nodule but missed the multinodu-
larity in 30% of patients. CT overestimated
the number of nodules in 2.2% and was false-
positive for lesions in 4.3%. The prevalence
of malignancy in these incidentally detected
nodules was 3.9%, with a 7.4% rate of malig-
nant potential [30]. The authors also report
that although nodules may appear homoge-
neously cystic on CT, on sonography the same
nodules may appear as complex cystic or sol-
id nodules of varying echogenicity. No sim-
ple density threshold on CT could distinguish
simple cysts from complex cystic or solid nod-
ules. The authors do not address whether the
size reported on the CT correlated with the
size reported on sonography. Because CT un-
derestimated the number of nodules relative
to sonography in several cases, the authors
suggested that sonography is a useful follow-
up study after incidental detection of a thyroid
nodule on CT. The authors state “Our results
suggest that every incidental abnormality of
the thyroid detected on CT deserves addition-
al clinical or imaging evaluation to exclude
the possibility of malignancy” [30].
In our experience the significance of in-
cidentally detected thyroid nodules differs
depending on the appearance of the nodule
as well as patient medical history and demo-
graphics (Figs. 1–4).
Conclusions
Thyroid nodules are being detected with
increased frequency on contrast-enhanced
MDCT examinations of the chest performed
for unrelated reasons. However, there is con-
siderable variability in how radiologists re-
port incidentally detected thyroid nodules and
what follow-up recommendation they make.

This variability in part is related to the fact
that there are no well-established criteria on
CT to help distinguish benign from malignant
nodules, especially when nodules measure
less than 1 cm in size. Most of the guidelines
established by various societies rely on clin-
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ical history, ultrasound features, and biopsy
for cytopathology to determine which nodules
should be left alone, followed, or resected.
According to the literature, nodules mea-
suring 1 cm or greater detected on CT or
smaller nodules with worrisome CT features,
such as calcifications or invasion of surround-
ing structures, should probably be referred for
ultrasound evaluation and ultimately FNA bi-
opsy. Detailed clinical correlation is also im-
portant to identify risk factors such as age,
history of head and neck radiation, endocrine
syndromes, family history of thyroid cancer,
cervical adenopathy, and so on. In patients
with multiple nodules, clearly dominant nod-
ules should probably be handled the same be-
cause CT gives limited information about the
internal characteristics of nodules.
However, there is still uncertainly in how to
handle a small nodule of less than 1 cm detect-
ed incidentally on chest CT. Should all patients
be referred for follow-up ultrasound evaluation?
That seems excessive and expensive, especial-
ly because small nodules are common and the
vast majority of the nodules smaller than 1
cm are benign. However, the studies summa-
rized in this article suggest that CT character-
ization of nodules does not correlate well with
the number of nodules or nodule characteris-
tics found on ultrasound. It is also debatable
whether the measurements of nodules detect-
ed on CT actually correlate with lesion mea-
surements on sonography. For example, if CT
shows a 7-mm nodule, will sonography show
the same nodule to measure 1 cm?
At this point, given the limitations of CT,
it is probably prudent to report all thyroid
nodules detected on CT. However, it is prob-
ably not reasonable to advise a follow-up ul-
trasound examination in every patient. In
addition, it should be noted that radiologists
typically have limited access to clinical infor-
mation and the medical history of these pa-
tients. It is really the clinicians who should
decide which patient needs to undergo ultra-
sound evaluation once a clinical examination
and assessment of risk factors is considered.
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