From the Guidelines
The management of thyroid cysts should prioritize a conservative approach, with observation and periodic ultrasound monitoring every 6-12 months for most benign and asymptomatic cases, as recommended by recent guidelines 1. The management of thyroid cysts typically begins with assessment of their size, symptoms, and malignancy risk. Most thyroid cysts are benign and asymptomatic, requiring only observation with periodic ultrasound monitoring.
- For symptomatic or cosmetically concerning cysts, fine-needle aspiration (FNA) serves both diagnostic and therapeutic purposes by removing fluid and reducing cyst size.
- Large cysts (>4 cm) or those causing compressive symptoms may require repeated aspirations.
- If cytology from FNA reveals suspicious cells, further evaluation is necessary, considering the latest recommendations for thyroid nodule management 1.
- Recurrent cysts after multiple aspirations may require surgical intervention, typically hemithyroidectomy or thyroid lobectomy.
- Ethanol ablation is an alternative minimally invasive option for benign recurrent cysts, involving injection of 95-99% ethanol into the cyst cavity after fluid aspiration, as supported by recent studies 1.
- Radiofrequency ablation may also be considered for selected cases.
- Thyroid hormone suppression therapy is generally not recommended for simple cysts, according to the guidelines 1. Regular follow-up is essential regardless of the management approach chosen, as some cysts may recur or change characteristics over time, emphasizing the need for coordinated recommendations for "small" lesions 1.
From the Research
Management Approach for Patients with Thyroid Cysts
The management of thyroid cysts involves a combination of diagnostic procedures and treatment options.
- The initial evaluation of thyroid cysts typically involves ultrasound assessment and fine-needle aspiration biopsy to determine the nature of the cyst and to rule out malignancy 2, 3, 4.
- The presence of follicular cells on initial aspiration cytology is a significant factor in predicting cyst recurrence, with the absence of follicular cells indicating a higher likelihood of recurrence 2.
- Ultrasound-guided fine-needle aspiration biopsy (UG-FNAB) is a reliable method for evaluating cystic thyroid nodules, with a low rate of nondiagnostic smears and a high overall accuracy 3.
- The Thy1c cytology category is a reliable method for excluding significant malignancy in dominant cystic nodules, and can guide the clinician in deciding whether to treat with ablation or resection 5.
- The management of thyroid cysts may involve simple observation, local treatments, or surgery, and should be based on the estimated risk of malignancy and the presence and severity of compressive symptoms 4.
Diagnostic Procedures
- Fine-needle aspiration biopsy is a crucial diagnostic procedure for evaluating thyroid cysts, and can be performed with or without ultrasound guidance 2, 3, 6.
- Ultrasound-guided fine-needle aspiration biopsy is particularly useful for nonpalpable, predominantly cystic, or previously nondiagnostic nodules 6.
- Molecular testing may be indicated in selected cases, such as indeterminate cytology 4.
Treatment Options
- Surgery may be necessary for patients with recurrent cysts, compressive symptoms, or suspected malignancy 2, 5, 3.
- Ablation therapy may be an alternative to surgery for some patients with symptomatic cysts 5.
- Simple observation may be appropriate for patients with benign cysts and no compressive symptoms 4.