Specialist Management of Thyroid Nodules
Endocrinologists are the primary specialists who manage thyroid nodules, with ultrasound-guided fine-needle aspiration biopsy serving as the cornerstone diagnostic procedure. 1, 2, 3
Primary Specialist: Endocrinologist
Endocrinologists serve as the principal specialists for thyroid nodule evaluation and management, handling the complete diagnostic workup including risk stratification, biopsy coordination, and long-term surveillance. 4, 5
The endocrinologist's role encompasses two critical determinations: (1) assessing for thyroid hormonal excess (hyperthyroidism) through TSH measurement, and (2) evaluating malignancy risk through ultrasound and fine-needle aspiration cytology. 4
Endocrinologists typically manage approximately 89 thyroid nodule patients annually, significantly more than general practitioners (6 patients/year) or ENT specialists (30 patients/year), reflecting their central role in this condition. 6
Multidisciplinary Team Involvement
When Surgical Specialists Enter Care
Thyroid surgeons or endocrine surgeons become involved when nodules demonstrate malignant or suspicious cytology on fine-needle aspiration, as surgery remains the first-line treatment for these cases. 3, 7
Surgical referral is indicated when nodules grow to ≥1 cm on surveillance imaging, develop suspicious ultrasound features (irregular margins, microcalcifications, extrathyroidal extension), or cause true compressive symptoms (dysphagia with drooling, dyspnea, dysphonia). 2
Interventional Specialists for Thermal Ablation
Interventional ultrasound specialists perform thermal ablation procedures for select benign symptomatic nodules or very specific papillary thyroid cancers meeting strict criteria (single nodule ≤1 cm, classical variant, no invasion). 1, 3
This emerging alternative requires careful patient selection and should only be performed in experienced centers with multidisciplinary expertise. 8
Nuclear Medicine Specialists
Nuclear medicine practitioners contribute when TSH levels are low or suppressed, performing radioisotope thyroid scans to identify autonomously functioning nodules. 4, 7
They also participate in radioactive iodine treatment for large symptomatic goiters when appropriate. 4
Initial Diagnostic Pathway
All patients with thyroid nodules require ultrasound-guided fine-needle aspiration biopsy (FNAB) as the preferred diagnostic method—this is accurate, economical, safe, and recommended by multiple guidelines. 1, 3
Core needle biopsy (CNB) should be reserved for cases where FNAB is nondiagnostic, as CNB carries higher hemorrhage risk. 1, 8
Ultrasound of the thyroid and central neck is recommended for all patients with clinically palpable nodules, though ultrasound should not be performed as a screening test in asymptomatic individuals. 1, 7
Common Pitfall to Avoid
- Do not perform FNA on subcentimeter nodules (<1 cm) based solely on ultrasound features or patient symptoms, as current TIRADS guidelines explicitly do not recommend biopsy for nodules <1 cm regardless of ultrasound characteristics. 2 This is particularly important in patients with Hashimoto's thyroiditis, where FNA may yield indeterminate results. 2