What is the recommended follow-up imaging schedule for an elderly female patient with a history of left lobectomy due to thyroid nodules, who also has remaining nodules on the right side?

Follow-Up Imaging for Remaining Thyroid Nodules After Lobectomy

For an elderly female patient with remaining thyroid nodules on the right side after left lobectomy, perform ultrasound surveillance at 3,6, and 12 months during the first year, then annually thereafter if nodules remain stable and non-suspicious. 1, 2

Initial Surveillance Protocol

First-year follow-up schedule:

• Ultrasound at 3 months post-lobectomy 2
• Ultrasound at 6 months post-lobectomy 2
• Ultrasound at 12 months post-lobectomy 2

This intensive first-year surveillance establishes nodule stability and detects early changes that may indicate malignancy. 2

Long-Term Surveillance After First Year

After the initial 12-month period, perform annual ultrasound surveillance to monitor for changes in nodule characteristics or size. 1, 2 This recommendation applies specifically to benign-appearing nodules without suspicious features. 2

What to Assess at Each Follow-Up Visit

At every surveillance ultrasound, systematically evaluate:

• Nodule dimensions and size changes - measure in three dimensions 2
• Nodule composition - assess whether solid, cystic, or mixed 2
• Echogenicity changes - note any evolution toward hypoechogenicity 2
• Development of suspicious features - specifically microcalcifications, irregular margins, taller-than-wide shape, or central hypervascularity 1, 2
• New nodule formation - document any additional nodules that appear 2
• Cervical lymphadenopathy - examine central and lateral neck compartments 2
• TSH levels if clinically indicated - particularly if symptoms of thyroid dysfunction develop 2

Triggers for Additional Evaluation

Proceed to fine-needle aspiration if any of the following occur:

• Nodule increases by ≥3 mm in any dimension 1, 2
• Development of new suspicious ultrasound features including microcalcifications, irregular margins, hypoechogenicity, or taller-than-wide shape 1, 2
• New compressive symptoms such as dysphagia, voice changes, or difficulty breathing 2
• Detection of suspicious cervical lymphadenopathy 2

Special Considerations for This Patient Population

Research specifically examining contralateral nodules after lobectomy for papillary thyroid carcinoma found that after median 6-year follow-up, only 5% of patients developed contralateral cancer, and all were successfully treated. 3 This supports the safety of surveillance rather than immediate completion thyroidectomy.

Important caveat: If your patient's original left lobectomy was performed for malignancy (not just benign nodules as stated), the surveillance strategy may need modification based on the cancer type and risk stratification. 4

Nodules That May Not Require Routine Follow-Up

Low-risk patients with nodules <6 mm without suspicious features may not require routine follow-up. 1, 2 However, given this patient's history of lobectomy and your lack of access to prior records, err on the side of surveillance until you can establish the original indication for surgery and confirm benign pathology.

Critical Pitfall to Avoid

Do not proceed directly to radioiodine scanning in this patient unless TSH is suppressed. 2 Radionuclide scanning has low diagnostic value in euthyroid patients and should only be performed if TSH is low, suggesting a hyperfunctioning nodule. 1 The appropriate initial test is TSH measurement followed by ultrasound. 1

Practical Algorithm

1. Obtain surgical pathology report from the original lobectomy to determine if malignancy was present
2. Measure TSH - if low, consider radioiodine scan; if normal/elevated, proceed to ultrasound 1
3. Perform baseline thyroid ultrasound of remaining right lobe and neck 1
4. Schedule follow-up ultrasounds at 3,6, and 12 months 2
5. Continue annual ultrasounds after first year if stable 1, 2
6. Perform FNA if nodule grows ≥3 mm or develops suspicious features 1, 2