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Thyroid nodules

Definition
Thyroid nodules are solid growths in the thyroid gland that are radiologically distinct from surrounding thyroid parenchyma.
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Pathophysiology
Thyroid nodules may be benign (follicular adenoma, Hurthle cell adenoma, colloid cyst, simple or hemorrhagic cyst, lymphocytic thyroiditis, granulomatous thyroiditis, infectious processes) or malignant (malignancy of follicular or C-cell origin, papillary carcinoma, follicular carcinoma, Hurthle cell carcinoma, medullary thyroid carcinoma, anaplastic carcinoma, thyroid lymphoma, or malignancy metastatic to the thyroid).
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Epidemiology
The prevalence of thyroid nodules in the general population is > 65%. The estimated incidence of thyroid nodules in the US is around 0.1% per year.
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Disease course
Large thyroid nodules can result in dysphagia, dyspnea, and dysphonia. Thyroid nodules may also become malignant over time.
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Prognosis and risk of recurrence
The risk of malignancy in thyroid nodules is around 4-6.5%.
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Key sources
The following summarized guidelines for the evaluation and management of thyroid nodules are prepared by our editorial team based on guidelines from the European Thyroid Association (ETA 2023; 2022; 2020), the American Academy of Family Physicians (AAFP 2020), the American Thyroid Association (ATA 2017; 2016), the American College of Endocrinology (ACE/AME/AACE 2016), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: do not obtain screening ultrasound in the general population or patients with a normal thyroid on palpation and a low clinical risk of thyroid disease.
D
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2.Classification and risk stratification

Risk of malignancy
Recognize that most thyroid nodules are asymptomatic and benign but do not exclude malignancy based on the absence of symptoms.
B
Recognize that the risk of cancer is not substantially different in the case of a solitary nodule versus a multinodular goiter.
B

3.Diagnostic investigations

History and physical examination
As per ETA 2023 guidelines:
Elicit a personal and family history and perform a physical examination in the initial evaluation of patients with thyroid nodules.
E
Consider using disease-specific patient-reported outcome measures for the evaluation of symptoms.
B

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  • Diagnostic imaging (ultrasound)

  • Diagnostic imaging (elastography)

  • Diagnostic imaging (CT/MRI)

  • Diagnostic imaging (PET)

  • Diagnostic imaging (radionuclide scan)

  • Laboratory tests (thyroid hormones and antibodies)

  • Laboratory tests (calcitonin)

  • Laboratory tests (parathyroid tests)

4.Diagnostic procedures

Core-needle biopsy: as per ETA 2023 guidelines, do not perform a core-needle biopsy as a first-line procedure to assess thyroid nodules after ultrasound evaluation. Consider performing core-needle biopsy as a second-line procedure for specific conditions.
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  • Fine-needle aspiration (indications based on nodule size)

  • Fine-needle aspiration (indications based on other characteristics)

  • Fine-needle aspiration (image-guidance)

  • Fine-needle aspiration (complex nodules)

  • Fine-needle aspiration (cystic nodules)

  • Fine-needle aspiration (multiple nodules)

  • Fine-needle aspiration (lymph nodes)

  • Fine-needle aspiration (aspirate washout)

  • Fine-needle aspiration (reporting)

  • Molecular testing

5.Medical management

Levothyroxine: as per ETA 2023 guidelines, do not initiate thyroid hormone treatment in euthyroid patients with nodular thyroid disease.
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  • Iodine supplementation

  • Selenium supplementation

  • Radioactive iodine therapy (indications)

  • Radioactive iodine therapy (pretreatment counseling)

  • Radioactive iodine therapy (pretreatment evaluation)

  • Radioactive iodine therapy (treatment monitoring)

6.Therapeutic procedures

Percutaneous ethanol injection: as per ETA 2023 guidelines, consider performing ethanol ablation as first-line therapy in patients with pure (or dominantly) cystic thyroid lesions.
B

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  • Thermal ablation (indications)

  • Thermal ablation (preprocedural counseling)

  • Thermal ablation (preprocedural evaluation)

  • Thermal ablation (anesthesia)

  • Thermal ablation (modalities)

  • Thermal ablation (postprocedural care)

7.Perioperative care

Preoperative imaging
As per AACE 2016 guidelines:
Consider obtaining PET/CT for the preoperative staging of malignant nodules with aggressive features.
C
Consider obtaining MRI, CT, and/or 18F-FDG-PET/CT for more accurate preoperative staging in selected patients with aggressive features.
C

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  • Preoperative laboratory tests

  • Preoperative fine-needle aspiration

  • Preoperative voice assessment

  • Postoperative voice assessment

8.Surgical interventions

Diagnostic surgical excision: as per AACE 2016 guidelines, consider performing surgery on persistently nondiagnostic solid nodules. Consider obtaining follow-up in a minority of solid nodules with clearly favorable clinical and ultrasound features.
C

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  • Indications for surgery (benign nodule)

  • Indications for surgery (indeterminate nodule)

  • Indications for surgery (suspicious nodule)

  • Indications for surgery (malignant nodule)

  • Indications for surgery (other indications)

  • Technical considerations for surgery (recurrent laryngeal nerve preservation)

  • Technical considerations for surgery (parathyroid gland preservation)

9.Specific circumstances

Pediatric patients, evaluation, ETA
Obtain thyroid ultrasound to assess the risk of malignancy in a thyroid nodule based on multiple ultrasound characteristics. Do not use ultrasound alone to definitively distinguish a benign thyroid nodule from thyroid cancer. Perform FNA in patients with suspected nodules.
B
Obtain complete neck ultrasound to evaluate all cervical levels for the presence of lymph node enlargement in pediatric patients with thyroid nodules.
B

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  • Pediatric patients (monitoring)

  • Pediatric patients (surgery)

  • Pregnant patients (radionuclide scan)

  • Pregnant patients (fine-needle aspiration)

  • Pregnant patients (serum calcitonin)

  • Pregnant patients (management of benign nodules)

  • Pregnant patients (management of indeterminate nodules)

  • Pregnant patients (management of malignant nodules)

10.Patient education

Pretreatment counseling, radioiodine therapy
Counsel female patients to avoid pregnancy for 6-12 months after receiving radioactive iodine.
B
Counsel male patients receiving cumulative radioactive iodine activities ≥ 400 mCi on potential risks of infertility.
B

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  • Pretreatment counseling (thermal ablation)

  • Pretreatment counseling (surgery)

11.Follow-up and surveillance

Management of treatment-related complications: insufficient evidence to recommend for or against the routine use of measures to prevent salivary gland damage after radioactive iodine therapy.
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  • Follow-up evaluation (incidentalomas)

  • Follow-up evaluation (asymptomatic nodules)

  • Follow-up evaluation (nondiagnostic by FNA)

  • Follow-up evaluation (benign by FNA)

  • Follow-up evaluation (indeterminate by FNA)

  • Follow-up evaluation (suspicious by FNA)

  • Follow-up evaluation (nodule growth)

  • Follow-up evaluation (after intervention)