From the Guidelines
The recommended approach for patients with thyroid nodules begins with a thorough evaluation including medical history, physical examination, thyroid function tests (TSH, free T4), and ultrasound imaging, as the most recent and highest quality study suggests that a coordinated approach is necessary for effective management 1. The evaluation and treatment approach for patients with thyroid nodules should prioritize the identification of potential malignancies while avoiding unnecessary procedures for the majority of thyroid nodules that are benign.
- Fine-needle aspiration (FNA) biopsy should be performed for nodules larger than 1-1.5 cm or those with suspicious ultrasound features such as irregular margins, microcalcifications, hypoechogenicity, or increased vascularity.
- Management depends on FNA results:
- Benign nodules require periodic monitoring with repeat ultrasound every 6-24 months.
- Indeterminate nodules may need molecular testing or surgical consultation.
- Malignant nodules typically require surgical removal.
- Treatment options include:
- Observation for small, asymptomatic benign nodules.
- Levothyroxine suppression therapy (starting at 25-50 mcg daily, titrated to achieve low-normal TSH) for select cases.
- Radioactive iodine for hyperfunctioning nodules.
- Surgery (lobectomy or total thyroidectomy) for suspicious, malignant, or symptomatic nodules. Patients with large nodules causing compressive symptoms may require surgical intervention regardless of cytology, and regular follow-up is essential as nodule characteristics may change over time, requiring adjustment of the management strategy, as suggested by the most recent study 1.
From the Research
Evaluation Approach
- The initial evaluation of thyroid nodules involves clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, and ultrasound 2, 3.
- Thyroid function testing and ultrasonographic characteristics guide the initial management of thyroid nodules 4.
- Certain ultrasound features, such as a cystic or spongiform appearance, suggest a benign process that does not require additional testing 4.
Diagnostic Procedures
- Fine-needle aspiration biopsy (FNAB) is the most efficient diagnostic tool for evaluating thyroid nodules 5, 6.
- FNAB is indicated for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer 2.
- Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management 2.
Treatment Approach
- Management includes simple observation, local treatments, and surgery and should be based on the estimated risk of malignancy and the presence and severity of compressive symptoms 4.
- Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context 2.
- Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis 2.
Follow-up
- The initial risk estimate, derived from ultrasound and, if performed, cytology report, should determine the need for treatment and the type, frequency, and length of subsequent follow-up 4.
- Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival 2.