From the Guidelines
The most appropriate next step in management for this patient is to check TSH levels. Given the small size of the thyroid nodule (7 mm) and the absence of symptoms suggesting thyroid dysfunction, measuring TSH is the initial recommended approach, as suggested by the American College of Radiology Appropriateness Criteria 1. Thyroid nodules smaller than 1 cm generally do not require immediate fine needle aspiration (FNA) unless there are suspicious ultrasound features or risk factors for thyroid cancer, as indicated by the European Society for Medical Oncology guidelines 1. In this case, the nodule is described as well-demarcated, which is typically a benign characteristic. TSH testing will help determine thyroid function status and guide further management decisions. If TSH is abnormal, additional testing may be warranted. A thyroid scan would be more appropriate if hyperthyroidism is suspected based on TSH results. FNA would be considered if the nodule were larger (typically ≥1 cm) or had suspicious ultrasound features, which are not described in this case. Some studies suggest that serum calcitonin levels may be useful in the initial workup of thyroid nodules, but this is not universally recommended and is more relevant for medullary thyroid carcinoma 1. Key points to consider in the management of thyroid nodules include:
- Nodule size and ultrasound characteristics
- Presence of symptoms or risk factors for thyroid cancer
- TSH levels to assess thyroid function
- Selective use of FNA and thyroid scan based on initial evaluation.
From the Research
Thyroid Nodule Management
The patient presented with a 7 mm thyroid nodule on the right side, which is firm and non-tender. The most appropriate next step in management can be determined based on the following considerations:
- The nodule is small (7 mm) and the patient has no symptoms of hyperthyroidism or hypothyroidism.
- According to 2, thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules, and FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer.
- As stated in 3, biopsy should not be performed routinely on small nodules < 1 cm.
- The key investigation for thyroid nodules is ultrasound-guided fine needle aspiration biopsy, depending on size and sonographic appearance, as mentioned in 3.
- Measurement of serum TSH is the best screening tool for thyroid dysfunction, as indicated in 3 and 4.
Recommended Next Steps
Based on the evidence, the most appropriate next step in management would be to:
- Measure the serum TSH level to assess thyroid function, as recommended in 3 and 4.
- Consider ultrasound-guided fine needle aspiration biopsy if the nodule is ≥ 1 cm or if there are clinical and sonographic risk factors for thyroid cancer, as stated in 2 and 3.
- A thyroid scan may be considered if the serum TSH is suppressed, as mentioned in 2.
- FNA may be considered if the nodule is ≥ 1 cm or if there are clinical and sonographic risk factors for thyroid cancer, as stated in 2 and 3.