Who should patients with confirmed thyroid nodules be referred to for further evaluation and management?

Referral Pathway for Patients with Confirmed Thyroid Nodules

Patients with confirmed thyroid nodules should be referred to an endocrinologist for initial evaluation, with subsequent referral to interventional radiology or surgery depending on the nodule characteristics and biopsy results. 1

Initial Evaluation and Diagnostic Process

• All patients with thyroid nodules should undergo fine-needle aspiration biopsy (FNAB) to confirm the pathological diagnosis before determining management pathway 1, 2
• Ultrasound-guided FNAB is the preferred method as it 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 2

Specialist Referral Based on Nodule Characteristics

Endocrinology Referral

• All patients with thyroid nodules should first be evaluated by an endocrinologist for comprehensive assessment 1, 2
• Patients with autonomously functioning thyroid nodules require endocrinology management for thyroid function assessment 1
• Pregnant women and patients with severe cardiopulmonary insufficiency should be initially evaluated by endocrinology 1

Interventional Radiology Referral

• Symptomatic benign nodules or nodules ≥2 cm with gradual increase in size should be referred to interventional radiology for consideration of thermal ablation 1
• Patients with recurrent thyroid cancer with limited metastatic cervical lymph nodes may be referred to interventional radiology for thermal ablation 1

Surgical Referral

• Nodules with suspicious or malignant cytology (Bethesda categories V-VI) should be referred for surgical evaluation 2, 3
• Indeterminate nodules (Bethesda categories III-IV) often require surgical consultation, especially with suspicious ultrasound features 2, 3
• Large nodules causing compressive symptoms may require surgical evaluation regardless of cytology 3

Otolaryngology Referral

• Patients with contralateral vocal cord paralysis should be referred to otolaryngology before any invasive procedure 1
• Patients with voice changes or symptoms suggesting laryngeal involvement should be evaluated by otolaryngology 2

Special Considerations for Pediatric Patients

• Adolescent patients with PTEN hamartoma tumor syndrome should be referred to pediatric endocrinology with transition to adult endocrinology at appropriate age 4
• Baseline thyroid ultrasound is suggested at age 12 for high-risk pediatric patients 4
• Pediatric patients with thyroid nodules may benefit from evaluation at a thyroid center of excellence 4

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, and thyroid function 1
• For malignant nodules treated with thermal ablation, TSH suppression therapy should be implemented with endocrinology follow-up 1

Common Pitfalls to Avoid

• Failing to perform FNAB before deciding on referral pathway 1
• Referring small (<1 cm) asymptomatic nodules without suspicious features for unnecessary procedures 1, 2
• Not evaluating cervical lymph nodes during initial assessment, potentially missing metastatic disease 1, 2
• Overlooking the need for specialized care in patients with contraindications to thermal ablation 1
• Failing to consider molecular testing for indeterminate nodules, which can assist in diagnosis and guide appropriate referral 2