Thyroid Nodules and Neck Masses Missed on Imaging in Oregon

A CT scan that includes the neck is ordered after a car accident. A neck MRI is done for a disc problem. The report mentions, in a line near the end, a small nodule in the thyroid or an enlarged lymph node in the neck. Then the visit moves on. If nobody comes back to that line, the first sign of trouble may be a cancer found later.

This article explains what medical sources say about evaluating thyroid nodules and neck masses seen on imaging, and how Oregon law frames a claim when follow-up did not happen. It does not assess any particular case.

Why thyroid nodules show up on scans meant for something else

A committee of the American College of Radiology (ACR) has written that "[t]he incidental thyroid nodule (ITN) is one of the most common incidental findings on imaging studies that include the neck."¹ The committee defines an incidental thyroid nodule as "a nodule not previously detected or suspected clinically, but identified by an imaging study."¹

MedlinePlus, the National Library of Medicine's consumer site, describes the same setting in plainer terms: "Health care providers often find thyroid nodules during a routine physical exam or imaging tests that are done for another reason."² It also notes that "[m]ost thyroid nodules do not cause symptoms."²

So the patient may have come in for something else and never felt the nodule at all.

Most nodules are benign, which is why evaluation matters

The American Thyroid Association (ATA) states: "Although the vast majority of thyroid nodules are benign (noncancerous), a small proportion of thyroid nodules do contain thyroid cancer."³ The next sentence explains why that small proportion matters: "In order to diagnose and treat thyroid cancer at the earliest stage, most thyroid nodules need some type of evaluation."³

The National Cancer Institute (NCI) agrees that "[t]hyroid nodules are common but usually are not cancer."⁴ It describes what that evaluation can involve: "When a thyroid nodule is found, an ultrasound of the thyroid and a fine-needle aspiration biopsy are often done to check for signs of cancer."⁴ A fine-needle aspiration removes tissue with a thin needle so a pathologist can look for cancer cells under a microscope.⁴ The ATA adds that "[s]ince it’s usually not possible to determine whether a thyroid nodule is cancerous by physical examination and blood tests alone, the evaluation of the thyroid nodules often includes specialized tests such as thyroid ultrasonography and fine needle biopsy."³

The ACR committee also cautions in the other direction. Its white paper says the workup of incidental nodules "has led to increased costs from additional procedures, and in some cases, to increased risk to the patient …"¹ It adds that "the majority of ITNs are benign, and small, incidental thyroid malignancies typically have indolent behavior."¹ Indolent means slow-growing. So the medical question is not whether every nodule needs a biopsy. It is which nodules warrant further steps.⁵

Ultrasound risk systems: TI-RADS

To sort nodules, radiologists use ultrasound-based scoring systems. The ACR's version is called TI-RADS (Thyroid Imaging, Reporting and Data System). Its white paper explains that professional societies and investigators have proposed ultrasound-based risk systems "to identify nodules that warrant biopsy or sonographic follow-up."⁵ The ACR TI-RADS Committee's recommendations "provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance."⁵

Under a system like this, an ultrasound result can point toward a biopsy or toward follow-up ultrasound.⁵ MedlinePlus says that for noncancerous nodules that do not cause symptoms and are not growing, the best treatment may be careful follow-up with a physical exam and ultrasound, or a thyroid biopsy repeated 6 to 12 months after diagnosis, especially if the nodule has grown.² Whether a next step was recommended, and what happened to that recommendation, is a question the records can answer. The general problem of a correct report that never reached anyone is covered in our article on abnormal results that never reached the patient.

Enlarged neck lymph nodes and neck masses

A lump in the neck is a different starting point. NCI explains that head and neck cancers usually begin in the squamous cells that line surfaces such as the inside of the mouth, throat and voice box, and that cancers of the thyroid gland, along with several other sites, "are not usually classified as head and neck cancers."⁶ It explains that "[i]f a squamous cell carcinoma of the head and neck is going to spread, it almost always does so locally and/or to the lymph nodes in the neck."⁶

A clinical practice guideline on evaluating a neck mass in adults was published in 2017 in the journal Otolaryngology–Head and Neck Surgery. Its authors write: "Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise."⁷ They add that "[t]imely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis."⁷ (HNSCC is head and neck squamous cell carcinoma.) They also state that "despite substantial advances in testing modalities over the last few decades, diagnostic delays are common."⁷

The guideline's recommendations include identifying patients at increased risk for malignancy when the patient lacks a history of infectious cause and the mass has been present for two weeks or more without significant fluctuation, or is of uncertain duration.⁷ It lists physical features that raise risk, such as fixation to nearby tissue, firm consistency, size over 1.5 cm, or ulceration of the overlying skin.⁷ For a patient with a neck mass deemed at increased risk, the guideline group made a strong recommendation that clinicians order a neck CT (or MRI) with contrast.⁷ For patients not at increased risk, it recommends that clinicians or their designees "document a plan for follow-up to assess resolution or final diagnosis."⁷ For a cystic neck mass in a patient at increased risk, it recommends continuing evaluation until a diagnosis is obtained, and not assuming the mass is benign.⁷

Two points about the guideline's scope matter. Its target clinicians include those in primary care, dentistry and emergency medicine, as well as pathologists and radiologists.⁷ And it states that its intention "is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology …" because recommendations for those already exist.⁷ Swollen neck nodes from lymphoma raise their own questions, which are discussed in our article on missed lymphoma symptoms.

How Oregon measures the follow-up

Medical guidelines are written by professional groups. They are not Oregon statutes. The legal standard for an Oregon physician is set by ORS 677.095(1): a physician licensed to practice medicine or podiatry by the Oregon Medical Board "has the duty to use that degree of care, skill and diligence that is used by ordinarily careful physicians in the same or similar circumstances in the community of the physician or a similar community."⁸ Subsection (2) sets a parallel duty for physician associates.⁸

In a thyroid or neck case where the providers are physicians, that standard can be applied at several points: whether the radiologist described the finding and recommended a next step, what the ordering physician did with the report, and whether the physician saw to it that a recommended ultrasound, biopsy or referral was arranged. The duty-of-care provisions of ORS 677.095, subsections (1) and (2), cover physicians and physician associates, not other clinicians or the clinic's scheduling systems.⁸ The differences between a misread scan and a report that was correct but not acted on are explained in our article on radiology misreads in Oregon. Questions about whether a delay changed the course of the disease are discussed on our failure-to-diagnose cancer page.

The deadlines when a finding sat in a report

Incidental findings raise a timing problem, because the patient may not know a nodule was ever seen. Under ORS 12.110(4), a medical-malpractice action "shall be commenced within two years from the date when the injury is first discovered or in the exercise of reasonable care should have been discovered."⁹ The Oregon Supreme Court has held that this period "begins to run when the plaintiff knows or in the exercise of reasonable care should have known facts which would make a reasonable person aware of a substantial possibility that each of the three elements (harm, causation, and tortious conduct) exists."¹⁰ The court described those three elements together as "legally cognizable harm."¹⁰ It added that "a mere suspicion is insufficient to begin the statute of limitations to run."¹⁰

The same subsection sets an outer limit that does not wait for discovery: "However, notwithstanding the provisions of ORS 12.160, every such action shall be commenced within five years from the date of the treatment, omission or operation upon which the action is based …"⁹ If no action was commenced within five years because of fraud, deceit or misleading representation, the subsection allows two years from when that conduct is discovered or in the exercise of reasonable care should have been discovered.⁹ So the five-year period runs from the date of the treatment or omission itself, not from the date the cancer is diagnosed.⁹

This article is educational

This article describes Oregon law in general terms. It is not legal advice and does not create an attorney-client relationship.

Time limits matter. Most Oregon personal-injury and auto-accident claims must be filed within two years of the injury or accident. Medical malpractice claims must be filed within two years of when you knew or reasonably should have known of the negligence, with an outer limit of five years from the act itself (with a fraud exception). Wrongful death claims must be filed within three years of the date of death. Claims against public bodies (cities, counties, state agencies, public hospitals) require a notice of claim within 180 days. Missing these deadlines typically ends a case.

If you think you may have a claim, call Huegli Law at 971-317-6436 for a free case review. Todd Huegli is licensed in Oregon and consults on cases in Oregon only.

Footnotes

1. Hoang JK et al., Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee, J Am Coll Radiol 2015;12(2):143-50 (abstract). PubMed, National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/25456025/ ↩ ↩² ↩³ ↩⁴

2. Thyroid nodule. MedlinePlus Medical Encyclopedia, National Library of Medicine. https://medlineplus.gov/ency/article/007265.htm ↩ ↩² ↩³

3. Thyroid Nodules. American Thyroid Association. https://www.thyroid.org/thyroid-nodules/ ↩ ↩² ↩³

4. Thyroid Cancer Treatment (PDQ®)–Patient Version. National Cancer Institute. https://www.cancer.gov/types/thyroid/patient/thyroid-treatment-pdq ↩ ↩² ↩³

5. Tessler FN et al., ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee, J Am Coll Radiol 2017;14(5):587-595 (abstract). PubMed, National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/28372962/ ↩ ↩² ↩³ ↩⁴

6. Head and Neck Cancers fact sheet. National Cancer Institute. https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet ↩ ↩²

7. Pynnonen MA et al., Clinical Practice Guideline: Evaluation of the Neck Mass in Adults, Otolaryngol Head Neck Surg 2017;157(2_suppl):S1-S30 (abstract). PubMed, National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/28891406/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

8. ORS 677.095 — Duty of care. Oregon State Legislature. https://www.oregonlegislature.gov/bills_laws/ors/ors677.html ↩ ↩² ↩³

9. ORS 12.110 and ORS 12.160 (ORS chapter 12 — limitations of actions). Oregon State Legislature. https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩² ↩³ ↩⁴

10. Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994). Caselaw Access Project. https://static.case.law/or/318/cases/0247-01.json ↩ ↩² ↩³