From the Guidelines
Thyroid nodules should be evaluated with a physical examination, blood tests to check thyroid function, and an ultrasound, with fine needle aspiration biopsy recommended for nodules larger than 1-1.5 cm or those with suspicious features on ultrasound, as stated in the most recent guidelines 1. The initial assessment of thyroid nodules is crucial to determine the appropriate management strategy. According to the latest evidence, the majority of thyroid nodules are benign, but evaluation is essential to rule out cancer 1.
Key Considerations
- The American College of Radiology (ACR) has developed guidelines for the management of thyroid nodules, including the use of ultrasound and fine needle aspiration biopsy 1.
- The American Thyroid Association (ATA) recommends active surveillance as the first-line management for papillary microcarcinoma, with surgery reserved for cases with evidence of progression or metastasis 1.
- Recent studies have shown that molecular diagnostics can help identify indolent subtypes of thyroid cancer, allowing for less aggressive treatment and improved patient outcomes 1.
Management Strategies
- Benign nodules often require no treatment beyond monitoring with periodic ultrasounds every 6-12 months.
- Cancerous nodules typically require surgical removal, possibly followed by radioactive iodine treatment.
- Active surveillance is recommended for papillary microcarcinoma, with regular follow-up and monitoring for signs of progression or metastasis.
Important Factors
- Iodine deficiency, radiation exposure, and genetic predisposition can increase the risk of developing thyroid nodules.
- Regular follow-up is essential even for benign nodules to monitor for any changes in size or characteristics.
- The use of molecular diagnostics and targeted therapies can improve treatment outcomes for patients with advanced or metastatic thyroid cancer 1.
From the Research
Thyroid Nodules Overview
- Thyroid nodules are common, with importance lying in assessing thyroid function, degree of and future risk of mass effect, and excluding thyroid cancer, which occurs in 7-15% of thyroid nodules 2.
- The primary goal of thyroid nodule evaluation is to determine whether it is malignant 3.
Evaluation and Management
- There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound, and, if indicated, fine-needle aspiration (FNA) 2.
- Fine-needle aspiration remains the primary diagnostic intervention for the evaluation of most thyroid nodules larger than 1-1.5 cm 4.
- Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography 2.
- Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management 2, 3.
Risk Assessment and Treatment
- Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy 5.
- Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context 2.
- Treatment of pregnant women with nonfunctioning thyroid nodules and of children with thyroid nodules is similar to that for nonpregnant adults, with the exception of molecular testing, which has not been validated in these populations 3.
Diagnostic Classification
- The Bethesda System (categories 1 through 6) is used to classify samples 3.
- Molecular testing can be used to guide treatment when aspiration yields an indeterminate result, detecting mutations associated with thyroid cancer and helping inform decisions about surgical excision vs. continued ultrasound monitoring 3, 5.