What is the management for a heterogeneous thyroid gland with a mildly enlarged right lobe and nodules showing intra-nodular flow?

From the Guidelines

The management for a heterogeneous thyroid gland with a mildly enlarged right lobe and nodules showing intra-nodular flow should begin with a comprehensive thyroid ultrasound followed by fine-needle aspiration (FNA) biopsy of any suspicious nodules, particularly those with intra-nodular flow as this can indicate increased vascularity potentially associated with malignancy. The presence of intra-nodular flow on Doppler ultrasound raises concern for hyperfunction or potential malignancy, which is why thorough evaluation rather than simple observation is necessary 1. Some key points to consider in the management of thyroid nodules include:

• Laboratory tests including TSH, free T4, and possibly thyroid antibodies should be ordered to assess thyroid function.
• If the FNA results are benign and thyroid function is normal, observation with repeat ultrasound in 6-12 months is appropriate.
• For nodules with indeterminate cytology, molecular testing may be helpful.
• If malignancy is detected or strongly suspected, surgical consultation for possible thyroidectomy is warranted.
• Hyperfunctioning nodules may require radioactive iodine therapy or anti-thyroid medications such as methimazole (starting at 5-10 mg daily) or propylthiouracil (50-150 mg twice daily). Regular follow-up is essential regardless of initial findings, as thyroid nodules can change in size and character over time 1. It is also important to note that the management of "small" thyroid nodules (less than 1 cm) can be challenging due to conflicting guidelines, and coordinated recommendations are needed 1.

From the Research

Thyroid Gland Heterogeneous with Mildly Enlarged Right Lobe and Nodules

• The thyroid gland is described as heterogeneous with a mildly enlarged right lobe and nodules showing intra-nodular flow, which may indicate the presence of thyroid nodules that require further evaluation 2, 3, 4.
• The management of thyroid nodules typically involves fine-needle aspiration biopsy (FNAB) under ultrasound guidance to assess the risk of malignancy, as recommended by various studies 2, 3, 4, 5, 6.
• The presence of intra-nodular flow demonstrated at study with color Doppler in the nodule at the right lobe may suggest a higher risk of malignancy, and FNAB under ultrasound guidance can help confirm the diagnosis 3, 6.

Diagnostic Criteria for Thyroid Nodules

• Various international society guidelines, such as the American Thyroid Association (ATA), American Association of Clinical Endocrinologists (AACE), and Society of Radiologists in Ultrasound (SRU), provide diagnostic criteria for thyroid nodules, including size, composition, and ultrasound features 5, 6.
• The diagnostic performance of these guidelines varies, with some being more sensitive and others being more specific, and clinicians should be aware of the strengths and weaknesses of each guideline in the management of thyroid nodules 6.
• The use of ultrasound-guided FNAB allows for real-time visualization of the needle and can increase the diagnostic accuracy of thyroid nodule evaluation 3, 4.

Management of Thyroid Nodules

• The management of thyroid nodules depends on the results of FNAB and other diagnostic tests, and may involve surgical removal of the nodule or nodules, or observation with regular follow-up examinations 2, 4, 5.
• The presence of micro or macro intra-nodular calcification, which is not present in this case, may increase the risk of malignancy and influence the management of the thyroid nodule 5, 6.
• The smooth borders of the nodules described in this case may suggest a lower risk of malignancy, but further evaluation with FNAB under ultrasound guidance is still necessary to confirm the diagnosis 3, 4.