From the Guidelines
The management of thyroid nodules should prioritize a systematic approach beginning with risk stratification, using the most recent guidelines and recommendations, such as those suggested by the Thyroid Imaging Reporting And Data Systems (TIRADS) 1.
Initial Assessment
Initially, all patients should undergo a thorough history and physical examination, followed by measurement of thyroid-stimulating hormone (TSH) levels.
- Ultrasound evaluation is essential to assess nodule characteristics and guide further management.
- The TIRADS system should be used to standardize the terminology used in thyroid US reports and minimize unnecessary fine needle aspiration (FNA) 1.
Fine-Needle Aspiration (FNA) Biopsy
Fine-needle aspiration (FNA) biopsy should be performed for nodules with suspicious ultrasound features or those larger than 1 cm, with the exact size threshold depending on the nodule's sonographic appearance, as recommended by the TIRADS system 1.
- For nodules less than 1 cm, FNA is not recommended unless there are suspicious features or metastatic neck lymph nodes.
- The results of FNA are very sensitive for the differential diagnosis of benign and malignant nodules, although there are limitations, such as inadequate samples and follicular neoplasia 1.
Management of Benign Nodules
For benign nodules, observation with periodic ultrasound follow-up every 6-24 months is appropriate.
- Patients with indeterminate cytology may require molecular testing or diagnostic lobectomy.
- Levothyroxine suppression therapy may be considered for selected patients but is not routinely recommended for benign nodules due to potential adverse effects.
Management of Malignant Nodules
Malignant or highly suspicious nodules typically warrant surgical intervention, ranging from thyroid lobectomy to total thyroidectomy depending on tumor size, multifocality, and other risk factors.
- Radioactive iodine ablation may be indicated for certain thyroid cancers following surgery.
- Throughout management, shared decision-making with patients is crucial, considering individual risk factors, preferences, and comorbidities to determine the optimal approach for each patient 1.
From the Research
Diagnostic Approach
- The evaluation of thyroid nodules typically involves measurement of serum TSH to assess thyroid function and fine-needle aspiration biopsy of the nodule, with or without ultrasound (US) guidance 2.
- Fine-needle aspiration cytology (FNAC) is the most reliable tool to select patients requiring surgery, and its accuracy approaches 95% 3.
- High-resolution thyroid US, in conjunction with FNAC, are currently the most accurate and cost-effective diagnostic approach for the evaluation of patients with nodular thyroid disease 4.
Management of Benign Thyroid Nodules
- The majority of benign thyroid nodules are nearly asymptomatic, remain stable in size, and do not require treatment 5.
- However, a minority of patients with growing nodules may complain of local symptoms or have cosmetic concerns, and thus seek surgical consultation 5.
- Minimally invasive procedures such as laser, radiofrequency, and ethanol ablation can produce persistent shrinkage of thyroid nodules and improve local symptoms 5.
- Percutaneous ethanol injection represents the first-line treatment for relapsing thyroid cysts, while laser and radiofrequency ablation are suitable for solid nonfunctioning nodules 5.
Management of Suspicious or Malignant Thyroid Nodules
- Patients with nodules yielding malignant cytology should be referred for surgery 2.
- Patients with suspicious (indeterminate) cytology are generally advised to have surgery, unless autonomous function of these nodules can be confirmed by scintigraphy 2.
- The prevalence of cancer is as frequent for isolated nodules or multinodular goiter, and thyroid cancer corresponds to 9 to 13% of nodules undergoing FNAC 6.
- The prognosis is good for differentiated carcinomas, and careful clinical follow-up of benign nodules and surgical excision of malignant nodules are recommended 3.