What is the best course of action for a patient with multiple thyroid nodules?

Management of Multiple Thyroid Nodules

The best course of action for patients with multiple thyroid nodules is to perform ultrasound evaluation followed by fine-needle aspiration biopsy (FNAB) of suspicious nodules >1 cm or smaller nodules with concerning features, with subsequent management determined by cytology results. 1, 2

Initial Evaluation

• Complete ultrasound evaluation of both the thyroid and cervical lymph nodes should be performed when thyroid nodules are found 2, 3
• Thyroid function testing (TSH) should be performed to assess for functional nodules 1, 3
• Ultrasound features associated with malignancy include:
  • Hypoechogenicity
  • Microcalcifications
  • Absence of peripheral halo
  • Irregular borders
  • Solid aspect
  • Intranodular blood flow
  • Shape (taller than wide) 1

Biopsy Decision-Making

• FNAB should be performed in any thyroid nodule >1 cm 1
• Nodules <1 cm should undergo FNAB if there are suspicious clinical features (history of head/neck irradiation, family history of thyroid cancer, suspicious palpation findings, cervical adenopathy) or suspicious ultrasound features 1, 2
• In multinodular goiter, nodules with suspicious ultrasound features should be prioritized for FNAB 1
• Ultrasound-guided FNAB is preferred as it has higher sensitivity, specificity, and accuracy than palpation-guided techniques 2, 4

Management Based on FNAB Results

For Benign Nodules:

• Observation is recommended for asymptomatic, cytologically benign nodules 2, 5
• Symptomatic nodules or nodules ≥2 cm with gradual increase in size should be considered for intervention 2, 6
• Options include:
  • Continued surveillance with serial ultrasounds
  • Thermal ablation for symptomatic benign nodules
  • Surgery for significantly growing nodules (increase by ≥50% in volume or ≥20% in two dimensions) 6

For Indeterminate, Suspicious, or Malignant Nodules:

• Surgical management is typically recommended 2, 6
• Total or near-total thyroidectomy is indicated for differentiated thyroid carcinoma 1
• Less extensive procedures may be acceptable for small, unifocal, intrathyroidal tumors of favorable histology 1

Follow-Up Protocol

• Regular follow-up is required after treatment of both benign and malignant thyroid nodules 2, 6
• Follow-up should include:
  • Volume assessment
  • Evaluation of compression symptoms
  • Cosmetic concerns
  • Residual nodules
  • Recurrence monitoring
  • Thyroid function testing 2, 6

Special Considerations

• Molecular testing can be helpful for indeterminate cytology results to guide further management decisions 1, 7
• Pregnant women and patients with severe cardiopulmonary insufficiency require special consideration 2
• Patients with contralateral vocal cord paralysis should be referred to otolaryngology before any invasive procedure 2

Common Pitfalls to Avoid

• Failing to perform FNAB before deciding on management pathway 2, 3
• Referring small (<1 cm) asymptomatic nodules without suspicious features for unnecessary procedures 2
• Not evaluating cervical lymph nodes during initial assessment, potentially missing metastatic disease 2, 3
• Overlooking the need for specialized care in patients with contraindications to certain treatments 2