Nonsurgical Approaches to the Management of Thyroid Nodules

Sebastiano Filetti; Cosimo Durante; Massimo Torlontano

Disclosures

Nat Clin Pract Endocrinol Metab. 2006;2(7):384-394. 

In This Article

Summary and Introduction

Epidemiologic studies have documented substantial increases in the frequency of nodular thyroid disease. This trend is largely due to the increasing detection of nodules by the routine use of sonography in clinical practice. Only a small percentage of the nodules currently being detected will prove to be malignant. The probability of malignancy is similar in nonpalpable and palpable nodules. Fine-needle aspiration cytology has a central role in identifying malignant nodules, which are generally treated with surgery. Most thyroid nodules are cytologically benign and can be managed nonsurgically. Nodules that are completely asymptomatic require follow-up without treatment. Cosmetic problems and/or compression-related symptoms may be indications for surgery. When surgery is contraindicated or refused, several nonsurgical approaches are available. These include levothyroxine therapy, radioiodine treatment, percutaneous ethanol injections, and the new technique of laser photocoagulation. Levothyroxine therapy is the most widely used approach, but its clinical efficacy and safety are controversial. Levothyroxine might, nonetheless, be appropriate in selected cases characterized by low risk for adverse effects and nodule characteristics associated with response to this type of therapy. Radioiodine is the therapy of choice for toxic nodules or for symptomatic nodular goiters when surgery is not possible. Percutaneous ethanol injection should be used, in our opinion, as the first-line therapy only for recurrent symptomatic cystic nodules. Laser therapy should be reserved for selected patients treated in experienced centers only. With these options, clinicians can personalize the management of nodular thyroid disease according to a careful cost–benefit analysis.

Thyroid nodules are detected in fewer than 5% of individuals screened by cervical palpation,[1,2] but autopsy data suggest that the prevalence of nodular lesions in clinically normal thyroid glands is roughly 50%.[3] This discrepancy indicates that the majority of nonpalpable nodules are clinically insignificant. With the increasing availability of highly sensitive imaging techniques, these nodules are emerging from hiding and demanding our attention. Indeed, sonographic screening of an unselected population has revealed a prevalence of thyroid nodules as high as 67%.[4]

The unexpected detection of nonpalpable thyroid nodules less than 10–15 mm in diameter (thyroid incidentalomas) is also becoming an increasingly frequent event in clinical practice.[5] This trend is a result of various factors. Ultrasonography and color Doppler sonography studies are becoming integral parts of the physical examination in almost all medical specialties, and are widely used for evaluating nonthyroid structures in the neck (e.g. carotid arteries, parathyroid glands, lymph nodes, salivary glands).[6] Recent (1999–2002) surveys indicate that more and more endocrinologists are using ultrasonography in the management of thyroid disease.[7,8,9,10] In almost half of all patients undergoing ultrasonography for work-up of a solitary thyroid nodule, the scan reveals additional, unsuspected nodules.[11]

The consequence of widespread screening is that nodular thyroid disease (Box 1) has become a frequently diagnosed disorder, which is partly responsible for increases in the incidence of thyroid cancer.[5,12] The discovery of a thyroid nodule is, naturally, a source of patient concern. Very few of these nodules will require surgery, but once this choice has been excluded, the physician is faced with a variety of nonsurgical options, and choosing the optimal approach can be a difficult task (Box 2).

In this review we tried to examine the rationale and the main indications for the nonsurgical therapeutic options that are available for the management of benign thyroid nodules.

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