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

Nonsurgical Management of Benign Thyroid Nodules

Benign thyroid nodules, which account for up to 95% of those seen by clinical endocrinologists,[22] rarely require surgery. Possible exceptions include large intrathoracic goiters, nodules that are exerting pressure on surrounding structures, and those that are cosmetically unacceptable. Most benign nodules can be managed nonsurgically. Autonomously functioning nodules can produce symptoms of thyroid-hormone hypersecretion (toxic nodules). Multinodular goiters (the most common presentation in adults) are often a mixture of autonomously functioning and hypofunctioning thyroid nodules. Pathologically distinct subtypes include inflammatory nodules (e.g. lymphocytic thyroiditis, subacute or acute bacterial thyroiditis), hyperplastic nodules (including colloid nodules), follicular adenomas, and cystic lesions (Box 1).[22]

There is a wide variability and a marked disagreement over the optimal management of benign nodules.[7,8,9,10] Indeed, our current knowledge of the natural history of benign thyroid nodules is limited, and there is a dearth of published information on the long-term effects of nonsurgical therapies. A clear and constant awareness of the objectives of treatment is also essential for sound management decisions. For benign but toxic nodules, the primary goal is clinical improvement; that is, treatment is successful if it relieves the patient's thyrotoxicosis symptoms. Unfortunately, when the subject is euthyroid, attention tends to shift from the patient to the nodule itself, in particular to its dimensions. The main argument used by those who advocate treatment is that an untreated thyroid nodule will grow, and new nodules might appear; however, in a series of 140 untreated patients followed for 15 years, only 14% of benign nodules displayed any growth at all.[23] Another report showed ultrasonography-documented volume increases of 30% or more in almost half of the 139 cytologically benign, untreated nodules followed for a mean of 3 years.[24] Similarly, volume increases of at least 15% have been documented in 39% of benign nodules followed for a mean of 20 months.[25]

These studies indicate that most benign nodules can grow, generally very slowly, over time; in women, nodules often cease growing after the onset of menopause.[26] Some investigators claim that nodule enlargement is predictive of malignancy,[23] but when 74 benign nodules were subjected to a second biopsy because of volume increases (mean increase 69%), only 1 nodule (1.4%) proved to be malignant.[25] There is no reason to believe that enlarging nodules are more likely to be malignant than those that shrink or remain stable in size. If a nodule has been classified as benign (on the basis of the absence of clinical features associated with malignancy and, when possible, cytologic findings) the focus of patient management has to be shifted to clinical aspects (Figure 2). Below, we detail the various available strategies.

Management of benign, nonautonomous thyroid nodules.Abbreviations: PEI, percutaneous ethanol injection; PLA, percutaneous laserablation; RAI, radioactive 131I.

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