From the Guidelines
The workup for thyroid cancer should begin with a thorough physical examination and medical history, followed by ultrasound imaging of the thyroid gland to evaluate any nodules, as recommended by the most recent guidelines 1. The initial evaluation should include fine needle aspiration (FNA) biopsy for suspicious nodules, with selection criteria generally including nodules larger than 1 cm, those with suspicious sonographic features, or smaller nodules with concerning characteristics. Some key points to consider in the workup include:
- Laboratory tests should include thyroid function tests (TSH, free T4), calcitonin (particularly if medullary thyroid cancer is suspected), and thyroglobulin levels (as a baseline for monitoring after treatment) 1.
- Cross-sectional imaging with CT or MRI may be necessary for larger tumors or suspected invasive disease, though iodinated contrast should be avoided if radioactive iodine therapy is planned within the next few months.
- Once thyroid cancer is confirmed, staging typically requires additional imaging such as neck ultrasound to assess for lymph node involvement, and in advanced cases, chest imaging to evaluate for metastatic disease.
- Genetic testing may be appropriate in certain cases, particularly for medullary thyroid cancer or when there's a family history of thyroid cancer, as noted in the guidelines 1. This comprehensive approach allows for accurate diagnosis, appropriate staging, and development of an individualized treatment plan, which typically involves surgery followed by potential adjuvant therapy depending on the specific type and stage of thyroid cancer, as outlined in the guidelines 1.
From the Research
Thyroid Cancer Workup
- The workup for thyroid cancer typically starts with a history and physical examination, followed by laboratory studies and imaging 2.
- Imaging criteria are used to select nodules for fine needle aspiration (FNA) biopsy, which is the gold standard for malignancy diagnosis in thyroid cancer 3.
- The Bethesda System for Reporting Thyroid Cytopathology provides standardized terminology for cytological determination of benign or malignant disease 4.
Diagnostic Tools
- Ultrasound is critical in the detection, diagnosis, and management of thyroid nodules, and is used to guide fine-needle aspiration biopsy of indeterminate or suspicious nodules 3, 5.
- Ultrasound detection of regional nodal metastatic disease is based on abnormal nodal morphology rather than size, and is critical to initial surgical and long-term management of thyroid cancer 3.
- Fine-needle aspiration biopsy provides further cytological determination of benign or malignant disease, and is generally applied to nodules larger than 1-2 cm in diameter, on the basis of holistic risk assessment 4.
Management
- Patients with malignant lesions require additional investigation before referral to an experienced thyroid surgeon 2.
- Surgery is curative in most cases of well-differentiated thyroid cancer, and radioactive iodine treatment after surgery improves overall survival in patients at high risk of recurrence 6.
- Antiangiogenic multikinase inhibitors and targeted therapies to genetic mutations that give rise to thyroid cancer are increasingly used in the treatment of metastatic disease 6.
- Low-risk thyroid nodules can be safely monitored in many patients with minimal diagnostic intervention 4.