Will multiple large thyroid nodules require removal of the thyroid gland?

Management of Multiple Large Thyroid Nodules

Multiple large thyroid nodules may require thyroid removal (thyroidectomy) depending on their characteristics, symptoms, and pathology results, but alternative treatments like thermal ablation may be considered in select cases.

Evaluation of Thyroid Nodules

• Fine-needle aspiration biopsy (FNAB) is the preferred initial diagnostic method for thyroid nodules and should be performed to confirm pathological diagnosis before determining management 1
• Complete ultrasound evaluation of both the thyroid and cervical lymph nodes should be performed when thyroid nodules are found 1, 2
• Core needle biopsy (CNB) should be reserved for patients with FNAB-undiagnosed thyroid nodules 1

Indications for Thyroid Removal

• Multiple large nodules with confirmed malignancy on biopsy require surgical removal of the thyroid 3
• Nodules with suspicious or malignant cytology should be referred for surgical evaluation 2
• Surgery is the first-line option for thyroid cancer, and risk of cancer relapse can only be assessed after thyroidectomy 3
• Multiple large nodules causing compressive symptoms (difficulty breathing or swallowing) may require surgical intervention 3

Alternative Management Options

• For benign multiple large nodules that are symptomatic or gradually increasing in size, thermal ablation may be considered as an alternative to surgery 3, 1
• Thermal ablation is recommended for:
  • Nodules that cause clinical symptoms such as compression 3
  • Nodules with maximal diameter ≥2cm 3
  • Nodules that are enlarging gradually 3

Special Considerations for Multiple Nodules

• The presence of multiple nodules increases the risk of nodule growth (OR 2.2 for 2 nodules; OR 3.2 for 3 nodules; OR 8.9 for 4 nodules) 4
• Approximately 11.1% of nodules increase in size over a 5-year period 4
• The risk of malignancy in thyroid nodules is approximately 5%, but this risk must be evaluated for each nodule 5, 6

Management Algorithm

1. Initial Assessment:

   • Perform ultrasound evaluation of all nodules and cervical lymph nodes 1
   • Conduct FNAB on nodules based on size and suspicious ultrasound features 1

2. If Malignancy Confirmed:

   • Refer for thyroidectomy (partial or total depending on extent of disease) 3

3. If Benign Nodules:

   • For asymptomatic nodules: Consider surveillance with periodic ultrasound 4
   • For symptomatic nodules or nodules ≥2cm with gradual increase in size: Consider thermal ablation or surgery 3, 1

4. If Indeterminate Cytology:

   • Consider molecular testing to further stratify risk 2
   • Surgical consultation may be needed for definitive diagnosis 3

Common Pitfalls to Avoid

• Failing to perform FNAB before deciding on treatment pathway 1
• Not evaluating all nodules and cervical lymph nodes during initial assessment 1, 2
• Overlooking compressive symptoms that may indicate need for intervention regardless of cytology 3
• Assuming all nodules in a multinodular thyroid have the same pathology 7

Remember that while most thyroid nodules are benign (>95%), the possibility of thyroid cancer must always be considered, especially in the context of multiple large nodules 5, 6.