What is the initial management step for a patient presenting with a thyroid nodule?

From the Guidelines

The initial management step for a patient presenting with a thyroid nodule is to obtain a thorough history and physical examination, followed by measurement of thyroid-stimulating hormone (TSH) levels and a high-resolution thyroid ultrasound, as recommended by the most recent guidelines 1.

Initial Assessment

The ultrasound is crucial as it helps characterize the nodule's features (size, composition, margins, echogenicity, and presence of calcifications) and guides risk stratification.

• The Thyroid Imaging Reporting And Data Systems (TIRADSs) have emerged as crucial tools for risk stratification of TNs detected on US 1.
• TIRADSs use nodule size as a criterion for recommending FNA; smaller nodules require a higher TIRADS category to warrant FNA.

Fine-Needle Aspiration (FNA) Biopsy

Based on ultrasound findings and TSH results, fine-needle aspiration (FNA) biopsy may be indicated for nodules meeting specific size criteria or displaying suspicious sonographic features, such as solid hypoechoic nodules with irregular margins, microcalcifications, or extrathyroidal extension 1.

• FNA is a very sensitive tool for the differential diagnosis of benign and malignant nodules, although there are limitations: inadequate samples and follicular neoplasia 1.
• In the event of inadequate samples, FNA should be repeated, while in the case of follicular neoplasia, with normal thyroid stimulating hormone (TSH) and ‘cold’ appearance at thyroid scan, surgery should be considered 1.

Additional Considerations

Additional history elements to assess include family history of thyroid cancer, prior radiation exposure, rapid nodule growth, voice changes, or dysphagia, as these factors may influence the management approach 1.

• Measurement of serum calcitonin is a reliable tool for the diagnosis of the few cases of medullary thyroid cancer (5–7% of all thyroid cancers) and has higher sensitivity compared with FNA 1.

From the Research

Initial Management of Thyroid Nodules

The initial management step for a patient presenting with a thyroid nodule involves several key components:

• Thyroid function testing to evaluate the functional status of the thyroid gland 2, 3
• Ultrasonographic characteristics to guide the initial management and identify suspicious features that may indicate malignancy 2, 3, 4
• Measurement of serum thyroid-stimulating hormone (TSH) to determine if the nodule is hyperfunctioning or nonfunctioning 3

Evaluation and Diagnosis

The evaluation and diagnosis of thyroid nodules involve:

• Thyroid ultrasonography to detect and characterize the nodule 2, 3, 4
• Fine-needle aspiration biopsy (FNAB) for nodules with suspicious features or solid hypoechoic nodules 1 cm or larger 2, 3, 4
• Molecular testing to guide treatment in cases with indeterminate cytology results 2, 3

Treatment Options

Treatment options for thyroid nodules depend on the estimated risk of malignancy and the presence and severity of compressive symptoms:

• Simple observation for benign nodules with low risk of malignancy 2
• Local treatments, such as radiofrequency ablation, for benign nodules with cosmetic or symptomatic concerns 5
• Surgery for nodules with high risk of malignancy or significant compressive symptoms 2, 3, 4, 6