Nonsurgical Approaches to the Management of Thyroid Nodules

Sebastiano Filetti; Cosimo Durante; Massimo Torlontano


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

In This Article

Excluding Malignancy

Most thyroid nodules are benign, and will never progress to clinically significant tumors. At most, 5% of patients evaluated for a palpable thyroid nodule harbor thyroid malignancy.[13] This observation means that, despite the alarmingly high prevalence of nodular thyroid disease, only 25,690 cases of thyroid cancer are expected to be diagnosed in the US during 2005.[14] The first step in the management of a patient with nodular thyroid disease is, therefore, to exclude the presence of malignancy. The work-up includes a thorough history, complete physical examination, and laboratory studies (Box 3). Ultrasonography provides important information on the morphologic characteristics of the nodule(s) and the potential involvement of cervical lymph nodes. Autonomously functioning thyroid nodules (those that secrete thyroid hormones but do not respond to normal physiological control mechanisms) can be identified by thyroid scintigraphy; therefore, solitary thyroid nodules should be scanned when associated with low or suppressed TSH levels.

Fine-needle aspiration (FNA) cytology results have a central role in decisions that affect the management of patients with thyroid nodules (Figure 1). According to the cytologic findings, nodules can be classified as benign (about 70%), suspicious (about 10%), malignant (about 5%) or nondiagnostic (about 15%) (Box 4). The diagnostic accuracy of FNA is close to 98%, with rates of false positives and false negatives that are less than 2%.[15] Nodules with malignant or suspicious cytology should be scheduled for surgery.[16,17] Indeed, in cases classed as suspicious, cytology cannot reliably separate follicular carcinomas or Hurthle cell carcinomas from follicular carcinomas or Hurthle cell adenomas; in these cases only histology can identify malignant features (such as blood vessels and/or capsule invasion) although in 80% of cases the lesion will turn out to be benign.[18] Patients whose FNA cytology is nondiagnostic should be closely monitored or managed surgically, according to clinical judgment.[16,17,18]

Diagnostic procedure for deciding between surgical and nonsurgical approaches to the management of nonautonomous thyroid nodules. Abbreviation: FNA, fine-needle aspiration.

An increasing percentage of the nodules detected today are <10 mm in diameter, and FNA might be more difficult to perform in these cases. For this reason, FNA is often reserved for nodules that present suspicious findings on ultrasonography and/or color Doppler sonography.[19,20] In 2002, a study of 402 consecutive patients with nonpalpable nodules 8–15 mm in diameter reported that irregular margins, intranodular vascular spots, and microcalcifications were independent predictors of malignancy; in fact, among the patients who underwent surgery for suspicious or malignant cytology, 31 cancers were detected and 27 (87%) of these were hypoechoic, solid nodules with at least one of these features on ultrasonography.[20,21] If multiple nodules are present, FNA should be performed on all initially detected nodules and, eventually, also on sonographically suspicious nodule(s) (see above).[16]


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