Thyroid nodule other diagnostic studies

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Other diagnostic studies which aid in the diagnosis of thyroid nodule include, fine needle aspiration, molecular markers, genetic evaluation and galectin-3 immunohistochemistry

Other Diagnostic Studies

Fine needle aspiration

The most important diagnostic test to differentiate thyroid nodules from each other is fine needle aspiration (FNA). FNA biopsy is sensitive and specific in the diagnosis of childhood thyroid nodules. As FNA is considered as an aggressive procedure, the American Thyroid Association developed the following criteria for FNA indication:[1][2]

  • Nodules ≥ 1 cm with intermediate or high suspicion ultrasound pattern
  • Nodules ≥ 1.5 cm with low suspicion ultrasound pattern
  • Nodules ≥ 2 cm with very low suspicion ultrasound pattern (e.g., spongiform)

For nodules that do not meet the above criteria, FNA is not required, including nodules < 1 cm (with some exceptions) and purely cystic nodules.[3]

Criteria for ultrasound-guided FNA:[3]

  • A higher likelihood of either a nondiagnostic cytology (>25–50% cystic component)
  • A higher likelihood of sampling error:
    • Difficult to palpate nodules
    • Posteriorly located nodules

Molecular marker evaluation

The molecular marker evaluation tests are performed based on samples that are collected during fine needle aspiration using needle washing. The most important indications of the molecular markers study include:[4]

  • Indeterminate cytological diagnosis
  • To assist narrowing disease management options (medical treatment versus surgical treatment)

The molecular tests which have the most available data are Afirma Gene-expression Classifier, seven-gene panel of genetic mutations and rearrangements and galectin-3 immunohistochemistry.[4][5]

Genetic Evaluation

Gene-expression classifier Afirma [6]

A highly sensitive (92%) gene-expression classifier called Afirma evaluates the presence of related gene expression profiles. The low specificity of this technique (a negative predictive value of 93 %, positive predictive value and specificity of 48–53 %) lead to major usage of this technique as a rule out test to identify benign nodules. A benign gene expression classifier result predicts low risk of malignancy but there is still an up to 5% chance of malignancy in the nodules classified as benign.

Gene mutation and rearrangement panel [7]

The seven gene mutation and rearrangement analysis panel evaluates the following genetic mutations:

This technique has a high specificity (86–100 %) and positive predictive value (84–100 %) but poor a sensitivity (reported from 44 to 100 %), thus it is being used to rule in thyroid malignancies, mainly as the second line after gene expression classifier Afirma test.

Galectin-3 immunohistochemistry [8]

Immunohistochemistry evaluation of the marker galectin-3 should be performed on representative histological sections of the thyroid neoplasms that are obtained based on FNA or direct surgical biopsy. The samples should then be stained and then the staining can be graded. Specific cytoplasmic staining of more than 5% of the tumor cells, regardless of the intensity, is scored as positive for galectin-3. It has a high sensitivity especially for papillary thyroid carcinoma.


  1. Chang SH, Joo M, Kim H (2006). "Fine needle aspiration biopsy of thyroid nodules in children and adolescents". J. Korean Med. Sci. 21 (3): 469–73. doi:10.3346/jkms.2006.21.3.469. PMC 2729953. PMID 16778391.
  2. Hung W (1999). "Solitary thyroid nodules in 93 children and adolescents. a 35-years experience". Horm. Res. 52 (1): 15–8. doi:23426 Check |doi= value (help). PMID 10640894.
  3. 3.0 3.1 Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L (2016). "2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer". Thyroid. 26 (1): 1–133. doi:10.1089/thy.2015.0020. PMC 4739132. PMID 26462967.
  4. 4.0 4.1 Bartolazzi A, Orlandi F, Saggiorato E, Volante M, Arecco F, Rossetto R, Palestini N, Ghigo E, Papotti M, Bussolati G, Martegani MP, Pantellini F, Carpi A, Giovagnoli MR, Monti S, Toscano V, Sciacchitano S, Pennelli GM, Mian C, Pelizzo MR, Rugge M, Troncone G, Palombini L, Chiappetta G, Botti G, Vecchione A, Bellocco R (2008). "Galectin-3-expression analysis in the surgical selection of follicular thyroid nodules with indeterminate fine-needle aspiration cytology: a prospective multicentre study". Lancet Oncol. 9 (6): 543–9. doi:10.1016/S1470-2045(08)70132-3. PMID 18495537.
  5. Sapio MR, Posca D, Raggioli A, Guerra A, Marotta V, Deandrea M, Motta M, Limone PP, Troncone G, Caleo A, Rossi G, Fenzi G, Vitale M (2007). "Detection of RET/PTC, TRK and BRAF mutations in preoperative diagnosis of thyroid nodules with indeterminate cytological findings". Clin. Endocrinol. (Oxf). 66 (5): 678–83. doi:10.1111/j.1365-2265.2007.02800.x. PMID 17381488.
  6. Duick DS, Klopper JP, Diggans JC, Friedman L, Kennedy GC, Lanman RB, McIver B (2012). "The impact of benign gene expression classifier test results on the endocrinologist-patient decision to operate on patients with thyroid nodules with indeterminate fine-needle aspiration cytopathology". Thyroid. 22 (10): 996–1001. doi:10.1089/thy.2012.0180. PMC 3464064. PMID 22873825.
  7. Nikiforova MN, Wald AI, Roy S, Durso MB, Nikiforov YE (2013). "Targeted next-generation sequencing panel (ThyroSeq) for detection of mutations in thyroid cancer". J. Clin. Endocrinol. Metab. 98 (11): E1852–60. doi:10.1210/jc.2013-2292. PMC 3816258. PMID 23979959.
  8. Sumana BS, Shashidhar S, Shivarudrappa AS (2015). "Galectin-3 Immunohistochemical Expression in Thyroid Neoplasms". J Clin Diagn Res. 9 (11): EC07–11. doi:10.7860/JCDR/2015/16277.6760. PMC 4668414. PMID 26673516.

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