From the Guidelines
The recommended management approach for thyroid nodule burden involves a combination of surveillance, diagnostic evaluation, and selective intervention based on nodule characteristics, with a focus on minimizing unnecessary procedures for benign nodules while identifying clinically significant thyroid cancer. Initial assessment should include a thorough history, physical examination, thyroid function tests, and ultrasound imaging to characterize nodules, as outlined in the guidelines for thyroid cancer diagnosis and treatment 1. Fine-needle aspiration (FNA) biopsy is recommended for nodules larger than 1-1.5 cm with suspicious ultrasound features or for nodules larger than 2 cm even with benign appearance, according to the Thyroid Imaging Reporting And Data Systems (TIRADSs) 1.
Key considerations in thyroid nodule management include:
- Nodule size and ultrasound characteristics, with TIRADSs providing a framework for risk stratification 1
- Clinical and radiological features, such as suspicious metastatic neck lymph nodes or subcapsular nodules 1
- Patient factors, including history of head and neck irradiation, family history of thyroid cancer, and presence of cervical adenopathy 1
For benign nodules, periodic surveillance with ultrasound every 6-24 months is appropriate, with repeat FNA if significant growth occurs (typically defined as >20% increase in two dimensions or >50% increase in volume) 1. Symptomatic benign nodules causing compression or cosmetic concerns may be treated with levothyroxine suppression therapy, radiofrequency ablation, ethanol ablation, or surgical removal, as supported by recent guidelines 1. Suspicious or malignant nodules typically require surgical intervention, ranging from lobectomy to total thyroidectomy depending on nodule characteristics and patient factors, with the goal of balancing the need to identify clinically significant thyroid cancer while avoiding unnecessary procedures for the majority of benign nodules 1.
From the Research
Thyroid Nodule Burden Management
The management of thyroid nodule burden involves a personalized, risk-based approach to identify and treat nodules that harbor clinically significant cancer, cause compressive symptoms, or progress to functional disease.
- The initial evaluation of thyroid nodules should include serum thyroid-stimulating hormone measurement, fine-needle aspiration (FNA) biopsy, and ultrasonography (US) 2.
- Thyroid function testing and ultrasonographic characteristics guide the initial management of thyroid nodules, with certain ultrasound features suggesting a benign process that does not require additional testing 3.
- Suspicious sonographic patterns, such as solid composition, hypoechogenicity, irregular margins, and microcalcifications, should prompt cytological evaluation 3.
Diagnostic Approach
- Fine-needle aspiration (FNA) biopsy is a safe, simple, reliable, and cost-effective means of detecting benign nodules, with an accuracy of cytologic diagnosis approaching 95% 4.
- The traditional diagnostic approach to thyroid nodules is ultrasound-guided FNA of the thyroid nodule followed by cytologic examination, which reliably establishes the diagnosis in 70% to 80% of cases 5.
- New approaches to diagnosis of cancer in thyroid nodules are based on mutational and other molecular markers, which can be reliably detected in cells aspirated during the FNA procedure, offering significant improvement in the diagnostic accuracy of FNA cytology 5.
Treatment and Follow-up
- 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 3.
- Cytologically benign thyroid nodules should be followed rather than treated, with routine measurement of serum calcitonin and thyroglobulin and FNA rebiopsy not recommended 2.
- Novel treatment options, including iodine 131, percutaneous ethanol injection, and percutaneous laser thermal ablation, have specific indications, advantages, and adverse effects 2.