Evaluation and Management of Thyroid Nodules
Thyroid nodules are an increasingly common diagnosis, particularly in women and elderly patients. Nodules are often identified on imaging performed for other indications but may also be detected on routine physical exam with palpation of the neck. Between 7% and 15% of cases likely represent a thyroid carcinoma. Once a thyroid nodule is identified, additional evaluation is necessary:
Certain features on an ultrasound point toward a higher suspicion of malignancy.
A fine needle aspiration (FNA) is indicated when:
A patient should be referred to an endocrine surgeon when any of the following indications are present:
What to do with a non-diagnostic FNA results
Ultrasound-guided FNA is notably user-dependent, and occasionally results of a biopsy may be reported as non-diagnostic. In this case, the patient should return in 4 to 6 weeks for a repeat ultrasound-guided FNA. In some instances, multiple non-diagnostic biopsies may prompt surgical excision for definitive diagnosis.
What to do with a benign FNA result
Nodules that return with a benign cytology should be followed with a repeat ultrasound in 6-12 months, to assess for any changes in size or development of concerning features. Rapidly growing nodules should be re-biopsied and frequently necessitate surgical consultation and excision.
What to do with an indeterminate FNA result
Indeterminate nodules may be referred to as follicular lesions of undetermined significance (FLUS), atypical cell of undetermined significance (ACUS), follicular neoplasm, or suspicious for malignancy. All of these cytologic results should prompt further assessment by a surgeon. Most will require surgical excision for definitive diagnosis.
What to do with a diagnosis of Papillary Thyroid Carcinoma
In 5% of cases, a malignant diagnosis will result from FNA of a thyroid nodule. The most common malignancy is papillary thyroid carcinoma and is treated with surgical excision. After surgery (most commonly a total thyroidectomy, although select cases can be treated with a thyroid lobectomy), a multidisciplinary approach using TSH suppression and possible radioactive iodine (RAI) treatment will be discussed among the treatment team. Patients should undergo surveillance ultrasound imaging and serum thyroglobulin measurements at routine intervals after surgery.
For more information
The UW Endocrine Surgery Program performs nearly 300 thyroidectomies each year. Our Endocrine Surgery team includes Kristin Long, MD, Susan Pitt, MD, MPHS, David Schneider, MD, MS, and Rebecca Sippel, MD. Learn more about parathyroid and thyroid conditions online. The UW Health Endocrine Surgery Team is located at UW Health at The American Center. For questions about a patient or a referral, call the Endocrine Surgery Clinic at (608) 440-6300. UW Health providers can place a consult in Healthlink for an “endocrine surgery consult.”