Thyroid Nodules: Advances in Evaluation and Management

 

Am Fam Physician. 2020 Sep 1;102(5):298-304.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/thyroid-nodules.

Author disclosure: No relevant financial affiliations.

Thyroid nodules can be detected by ultrasonography in up to 68% of the general population. They are typically benign and are often discovered incidentally. The primary goal of thyroid nodule evaluation is to determine whether it is malignant. After thyroid ultrasonography has been performed, the next step is measurement of serum thyroid-stimulating hormone. If levels are low, a radionuclide thyroid uptake scan is indicated. Hyperfunctioning nodules are rarely malignant and do not require tissue sampling. Nonfunctioning nodules and nodules in a patient with a normal or high thyroid-stimulating hormone level may require fine-needle aspiration based on ultrasound characteristics and size. Nodules with suspicious features and solid hypoechoic nodules 1 cm or larger require aspiration. The Bethesda System (categories 1 through 6) is used to classify samples. Molecular testing can be used to guide treatment when aspiration yields an indeterminate result. Molecular testing detects mutations associated with thyroid cancer and can help inform decisions about surgical excision vs. continued ultrasound monitoring. 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.

New advances in molecular testing have changed the management of thyroid nodules. This article reviews the workup for thyroid nodules, including how to interpret ultrasound findings and fine-needle aspiration (FNA) cytopathology, and a comparison of new molecular testing modalities to determine the appropriate management strategy.

WHAT'S NEW ON THIS TOPIC

Over the past few years, molecular testing of fine-needle aspiration specimens has changed the way thyroid nodules with indeterminate cytology are managed. A benign pattern on molecular testing significantly decreases the risk of malignancy in indeterminate thyroid nodules. However, these nodules still require ultrasound surveillance.

There is growing evidence that low-risk micropapillary thyroid cancers smaller than 1 cm can be followed with observation as an alternative to immediate surgical excision.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Thyroid ultrasonography with a survey of the cervical lymph nodes should be performed in all patients with thyroid nodules.11,12

C

Cross-sectional prevalence studies and expert opinion

The serum thyroid-stimulating hormone level should be measured during the initial evaluation of a thyroid nodule. If it is low, a radionuclide thyroid uptake scan should be performed.11,12

C

Cross-sectional prevalence studies and expert opinion

Fine-needle aspiration is recommended for thyroid nodules 1 cm or larger that have a suspicious pattern on ultrasonography.11,12

C

Cross-sectional prevalence studies and expert opinion

Before molecular testing is performed, patients should be counseled about the potential benefits and limitations of the test.11

C

Expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Thyroid ultrasonography with a survey of the cervical lymph nodes should be performed in all patients with thyroid nodules.11,12

C

Cross-sectional prevalence studies and expert opinion

The serum thyroid-stimulating hormone level should be measured during the initial evaluation of a thyroid nodule. If it is low, a radionuclide thyroid uptake scan should be performed.11,12

C

Cross-sectional prevalence studies and expert opinion

Fine-needle aspiration is recommended for thyroid nodules 1 cm or larger that have a suspicious pattern on ultrasonography.11,12

C

Cross-sectional prevalence studies and expert opinion

Before molecular testing is performed, patients should be counseled about the potential benefits and limitations of the test.11

C

Expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN ENDOCRINOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.

Society of Nuclear Medicine and Molecular Imaging


Source: For more information

The Authors

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RAVI KANT, MD, is an endocrinologist at AnMed Health, Anderson, S.C., and an affiliate associate professor in the Division of Endocrinology, Diabetes, and Metabolism at the Medical University of South Carolina, Charleston....

AMANDA DAVIS, MD, is a faculty member at AnMed Health Family Medicine Residency Program, Anderson, S.C., and an affiliate associate professor in the Department of Family Medicine at the Medical University of South Carolina.

VIPIN VERMA, MD, is a faculty member at AnMed Health Family Medicine Residency Program and an affiliate assistant professor in the Department of Medicine at the Medical University of South Carolina.

Published online May 19, 2020.

Address correspondence to Ravi Kant, MD, Medical University of South Carolina/AnMed Campus, 2000 E. Greenville St., Ste. 3100, Anderson, SC 29621 (email: kant.ravi.md@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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