From the Guidelines
The recommended management for a patient with bilateral solid thyroid nodules and a solid nodule in the left submandibular gland involves a comprehensive diagnostic approach followed by targeted treatment, prioritizing fine-needle aspiration (FNA) biopsy of the thyroid nodules and separate evaluation of the submandibular gland nodule, as suggested by the most recent guidelines 1. The patient's condition, with bilateral solid thyroid nodules and a solid nodule in the left submandibular gland, necessitates a thorough diagnostic workup to determine the nature of these nodules and to guide appropriate management.
- Key considerations include:
- The size and characteristics of the thyroid nodules, with particular attention to those larger than 1 cm or exhibiting suspicious ultrasound features, as outlined in the guidelines for thyroid disease management 1.
- The presence of a solid nodule in the left submandibular gland, which may represent a distinct pathological process requiring separate evaluation.
- Initial steps should include:
- Fine-needle aspiration (FNA) biopsy of the thyroid nodules, particularly those that are larger or have suspicious features, to assess for malignancy, as recommended by the guidelines for thyroid cancer diagnosis and treatment 1.
- Ultrasound-guided FNA of the submandibular nodule to determine its nature and guide further management.
- Additional diagnostic tests may be necessary, including:
- Laboratory tests such as TSH, free T4, and calcitonin levels to evaluate thyroid function and rule out medullary thyroid cancer, as suggested by the clinical recommendations for differentiated thyroid cancer 1.
- Imaging studies like CT or MRI with contrast to assess the extent of the submandibular gland lesion and its relationship to surrounding structures, if initial findings suggest malignancy or uncertainty.
- Management of the thyroid nodules and the submandibular gland nodule will depend on the results of these diagnostic tests, with options ranging from regular monitoring for benign nodules to surgical intervention for malignant or suspicious findings, as outlined in the guidelines for thyroid cancer treatment 1.
- A dual-focused approach is necessary because the coexistence of nodules in both locations raises concern for separate disease processes, potentially including primary malignancies or metastatic disease, requiring thorough evaluation of each site independently, as emphasized by the most recent and highest quality study 1.
From the Research
Recommended Management
The recommended management for a patient with bilateral solid thyroid nodules and a solid nodule in the left submandibular gland includes:
- Clinical correlation and endocrine assessment to evaluate the risk of malignancy and the presence of compressive symptoms 2, 3
- Functional lab tests, such as thyroid function tests, to guide the initial management of thyroid nodules 2, 3
- Follow-up sonogram to monitor the size and characteristics of the nodules 2, 3
- Fine-needle aspiration biopsy (FNAB) may be considered for nodules with suspicious sonographic patterns, such as solid composition, hypoechogenicity, irregular margins, and microcalcifications 2, 3, 4
- Additional diagnostic procedures, such as molecular testing, may be indicated in selected cases, such as indeterminate cytology 2, 3
Diagnostic Approach
The diagnostic approach for thyroid nodules should use ultrasound and, when indicated, fine-needle aspiration biopsy and molecular testing, to facilitate a personalized, risk-based protocol that promotes high-quality care and minimizes cost and unnecessary testing 2, 3
- Ultrasound characteristics, such as size, number, echogenicity, echotexure, margin regularity, presence of calcifications, and presence of a hypoechoic rim, can help differentiate benign from malignant thyroid nodules 4
- Sonographically guided FNA should be performed on thyroid nodules with sonographic characteristics that suggest malignancy 4
Treatment Options
Treatment options for thyroid nodules depend on the estimated risk of malignancy and the presence and severity of compressive symptoms 2, 3
- Simple observation may be recommended for benign nodules with low risk of malignancy 2, 3
- Local treatments, such as radioactive iodine ablation, may be considered for toxic nodules or Graves' disease 5
- Surgery may be indicated for nodules with suspicious cytology, large nodules with symptoms of mass effect, or in patients with thyrotoxicosis 2, 3