What is the initial evaluation and management approach for a patient presenting with a thyroid nodule?

From the Guidelines

The initial evaluation of a thyroid nodule should begin with a thorough history and physical examination, followed by measurement of thyroid-stimulating hormone (TSH) levels and a high-resolution thyroid ultrasound, as recommended by recent guidelines 1. The goal of this approach is to identify the small percentage of thyroid nodules that represent malignancy while avoiding unnecessary procedures for benign nodules.

Key Components of Initial Evaluation

• Measurement of TSH levels to assess thyroid function
• High-resolution thyroid ultrasound to evaluate nodule size, echogenicity, margins, calcifications, and shape
• Assessment of clinical risk factors, such as history of head and neck irradiation, family history of thyroid cancer, and presence of cervical adenopathy

Indications for Fine-Needle Aspiration (FNA) Biopsy

• Nodules larger than 1 cm, as recommended by the American Thyroid Association 1
• Nodules with suspicious sonographic features, such as hypoechogenicity, microcalcifications, and irregular borders 1
• Nodules associated with lymphadenopathy

Management After FNA

• Benign nodules: periodic ultrasound surveillance
• Suspicious or malignant nodules: surgical consultation
• Indeterminate results: molecular testing, such as BRAF, RAS, RET/PTC, and PAX8/PPARγ mutations, to help differentiate between benign and malignant nodules 1 Throughout this process, patients should be assessed for compressive symptoms like dysphagia or voice changes.

Importance of Recent Guidelines

The most recent guidelines, such as those published in 2025 1, should be followed to ensure that patients receive the most up-to-date and effective care. By following this systematic approach, clinicians can provide high-quality care for patients with thyroid nodules while minimizing unnecessary procedures and improving outcomes.

From the Research

Initial Evaluation of Thyroid Nodules

• The initial evaluation of a patient presenting with a thyroid nodule involves a systematic approach to exclude the possibility of malignancy 2, 3, 4.
• A sensitive thyrotropin (thyroid-stimulating hormone or TSH) assay is usually the first investigation, and a suppressed TSH level may lead to a radionuclide scan and an FT4 level to detect toxic nodules 2, 3.
• Thyroid peroxidase antibody is estimated if the TSH level is high 2, 3.

Role of Ultrasonography and Fine-Needle Aspiration Biopsy

• High-resolution ultrasonography (HRUSG) is recommended for all patients with a palpable thyroid nodule, and US-guided fine-needle aspiration (FNA) biopsy is recommended for nodules ≥ 10 mm 2, 3.
• For nodules < 10 mm, USG-guided FNA is recommended only if clinical or USG features are suspicious 2, 3.
• FNA biopsy is a safe, simple, reliable, and cost-effective means of detecting benign nodules, with an accuracy of cytologic diagnosis approaching 95% 5.

Management of Thyroid Nodules

• Patients with benign thyroid nodules should undergo follow-up, and malignant or suspicious nodules should be treated surgically 2, 3.
• Cystic thyroid lesions can be managed by percutaneous ethanol ablation 2, 3.
• Routine measurement of serum calcitonin is not recommended 2, 3.

Quality of Thyroid Nodule Evaluations

• There is great variation in the quality of thyroid nodule evaluations before surgical referral, with only 51.5% of evaluations including both a TSH and a thyroid ultrasound 6.
• Obtaining a TSH value and an ultrasound with enough information to risk stratify the nodule are necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines 6.