What are the next steps in managing a patient with thyroid nodules and a submandibular cyst?

Management of Thyroid Nodules and Submandibular Cyst

Fine-needle aspiration biopsy (FNAB) should be performed as the next step for the thyroid nodules, as this is the preferred method to confirm pathological diagnosis before considering any treatment options. 1

Assessment of Thyroid Nodules

Initial Evaluation

• The ultrasound reveals two small thyroid nodules in the right lobe:
  • Lower pole nodule: 0.28 x 0.27 cm, hypoechoic with peripheral calcification
  • Mid portion nodule: 0.35 x 0.25 cm, isoechoic with internal calcification
• Both nodules are very small (<1 cm) but contain calcifications, which is a concerning feature

Recommended Diagnostic Approach

1. FNAB for thyroid nodules:

   • Despite the small size (<1 cm), the presence of calcifications warrants further investigation
   • US-guided FNAB is accurate, economical, safe, and effective for diagnosing thyroid nodules 1
   • For solid nodules with calcifications, FNAB should be performed twice or in combination with core needle biopsy (CNB) for more accurate diagnosis 1

2. Risk stratification using TI-RADS:

   • The calcifications in both nodules are concerning features that may increase the TI-RADS score 2
   • Internal and peripheral calcifications can be associated with higher risk of malignancy

Management of Submandibular Cyst

• The right submandibular gland shows normal size (2.94 x 1.77 x 0.94 cm)
• The report mentions a right submandibular cyst
• For submandibular cysts:
  • Clinical correlation is needed to determine if the cyst is causing any symptoms
  • Follow-up ultrasound is recommended as indicated in the impression

Follow-up Plan

For Thyroid Nodules:

• If FNAB results are benign:

  • Schedule follow-up ultrasound in 6-12 months to monitor for changes in size or characteristics 2
  • Annual follow-up thereafter for stable, benign nodules

• If FNAB results are malignant or suspicious:

  • For nodules <1 cm with no evidence of extrathyroidal extension or lymph node involvement, active surveillance may be appropriate 1, 2
  • For larger nodules or those with aggressive features, surgical management would be indicated

For Submandibular Cyst:

• Follow-up ultrasound in 6 months to assess stability
• If the cyst enlarges or becomes symptomatic, consider aspiration or surgical removal

Important Considerations

• The small size of the thyroid nodules (<1 cm) would typically not warrant immediate intervention if confirmed benign, as 60-80% of newly detected thyroid carcinomas are micropapillary (<1 cm) with excellent prognosis 2

• However, the presence of calcifications increases suspicion and justifies FNAB despite the small size

• Be aware that cystic thyroid lesions can harbor malignancy (14% of cystic thyroid lesions may be malignant) 3, so proper evaluation of any cystic component is important

• Avoid overtreatment of micropapillary carcinomas, as they generally have excellent outcomes 2

By following this approach, you can properly evaluate both the thyroid nodules and submandibular cyst while avoiding unnecessary procedures for lesions that are likely benign.