Referral Pathway for Confirmed Thyroid Nodules
Patients with confirmed thyroid nodules should be referred to an endocrinologist for initial evaluation, with subsequent referral to interventional radiology or endocrine surgery based on nodule characteristics and diagnostic findings. 1
Initial Diagnostic Evaluation
- Fine-needle aspiration biopsy (FNAB) is the preferred diagnostic method for thyroid nodules and should be performed to confirm the pathological diagnosis before determining management 1, 2
- Ultrasound-guided FNAB is accurate, economical, safe, and effective for diagnosing thyroid nodules 1
- Core needle biopsy (CNB) should be reserved for patients with FNAB-undiagnosed thyroid nodules 1
- Complete ultrasound evaluation of both the thyroid and cervical lymph nodes should be performed when thyroid nodules are found 1, 3
Referral Algorithm Based on FNAB Results
For Benign Nodules:
- Asymptomatic nodules <2 cm: Follow-up with endocrinologist 2
- Symptomatic nodules or nodules ≥2 cm with gradual increase in size: Refer to interventional radiology for consideration of thermal ablation 1, 2
- Cystic or predominantly cystic nodules: Consider referral for percutaneous ethanol injection (PEI) 3
For Indeterminate, Suspicious, or Malignant Nodules:
- Refer to endocrine surgery for surgical evaluation 3
- For recurrent thyroid cancer with limited metastatic cervical lymph nodes: Consider referral to interventional radiology for thermal ablation 1
Special Considerations for Referral
- Patients with autonomously functioning thyroid nodules should be referred to both endocrinology and interventional radiology 1
- Pregnant women and patients with severe cardiopulmonary insufficiency require special consideration and should be initially evaluated by endocrinology 1
- Patients with contralateral vocal cord paralysis should be referred to otolaryngology before any invasive procedure 1
Post-Treatment Follow-Up
- Regular follow-up is required after treatment of both benign and malignant thyroid nodules 1
- Follow-up should include volume reduction rate assessment, evaluation of compression symptoms, cosmetic concerns, residual nodules, recurrence, metastasis, recovery from complications, and thyroid function 1
- For malignant nodules treated with thermal ablation, TSH suppression therapy should be implemented with endocrinology follow-up 1
Common Pitfalls in Referral Decisions
- Failing to perform FNAB before deciding on referral pathway 1, 3
- Referring small (<1 cm) asymptomatic nodules without suspicious features for unnecessary procedures 1, 3
- Not evaluating cervical lymph nodes during initial assessment, potentially missing metastatic disease 1
- Overlooking the need for specialized care in patients with contraindications to thermal ablation 1
By following this structured approach to referral for thyroid nodules, clinicians can ensure appropriate specialist care while avoiding unnecessary procedures for low-risk nodules.