What is the management plan for a 22-year-old female with a multinodular goiter, 3 mm and 5 mm Thyroid Imaging Reporting and Data System (TiRads) 4 nodules in the right lobe, and normal Thyroid-Stimulating Hormone (TSH) levels?

Management of Multinodular Goiter with TI-RADS 4 Nodules in a Young Female

For a 22-year-old female with multinodular goiter, 3mm and 5mm TI-RADS 4 nodules in the right lobe, and normal TSH levels, fine needle aspiration biopsy (FNAB) is not indicated at this time due to the small size of the nodules, and clinical follow-up with repeat ultrasound in 6-12 months is recommended.

Risk Assessment and Diagnostic Considerations

TI-RADS 4 nodules carry a moderate risk of malignancy (10-50%) 1, but nodule size is a critical factor in determining management:

• The American College of Radiology (ACR) guidelines recommend that nodules should be evaluated based on both TI-RADS category and size 2
• For TI-RADS 4 nodules, FNAB is typically recommended only for nodules ≥1 cm 1
• Both nodules in this case (3mm and 5mm) are significantly smaller than the 1cm threshold

Management Algorithm

1. Initial Assessment:

   • Normal TSH indicates euthyroid status, which is favorable 2
   • Small nodule size (3mm and 5mm) does not meet criteria for immediate FNAB

2. Recommended Approach:

   • Ultrasound surveillance is the appropriate management strategy
   • Schedule follow-up ultrasound in 6-12 months to assess for any changes in nodule size or characteristics 1
   • Continue monitoring thyroid function with TSH measurements

3. When to Consider FNAB:

   • If either nodule grows to ≥1 cm
   • If new suspicious sonographic features develop
   • If clinical symptoms of compression appear
   • If cervical lymphadenopathy develops

Important Considerations

• Despite being TI-RADS 4, the small size of these nodules makes the overall risk of clinically significant malignancy very low
• The patient's young age (22) is a risk factor for malignancy 2, but this alone does not override size criteria for FNAB
• Multinodular goiters generally have a similar risk of malignancy per nodule as solitary nodules (approximately 5%) 3

Pitfalls to Avoid

1. Overtreatment: Avoid unnecessary FNAB for very small nodules, as this can lead to anxiety, additional procedures, and potential complications without clear benefit

2. Undertreatment: Don't dismiss follow-up because the patient is young; ensure proper surveillance is maintained

3. Missing Clinical Changes: During follow-up visits, assess for:

   • Development of compressive symptoms (dysphagia, dyspnea)
   • Changes in nodule size or characteristics
   • Development of abnormal thyroid function

Patient Education

• Explain that the risk of clinically significant malignancy is low given the small nodule size
• Emphasize the importance of follow-up ultrasound examinations
• Instruct on self-monitoring for significant growth or symptoms 1

By following this evidence-based approach, you can provide appropriate care while avoiding unnecessary invasive procedures for this young patient with small TI-RADS 4 nodules in a multinodular goiter.