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Thyroid nodule — Clinical Guidelines

Overview

Thyroid nodules are solid or fluid-filled lumps that develop within the thyroid gland. Most are benign, but evaluation is crucial to rule out malignancy.

Diagnosis

Ultrasound Examination: Essential for initial assessment, using risk stratification systems like ATA (American Thyroid Association) or ACR TI-RADS 6 30 36.

Fine-Needle Aspiration (FNA) Biopsy: Recommended for nodules meeting certain size and ultrasound criteria; Bethesda System categorizes results 6 29 33 39.

Risk Stratification Systems: Utilize ultrasound features to stratify malignancy risk 6 30 36.

Repeat FNA for AUS/FLUS: Considered for nodules initially classified as Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance to refine diagnosis 25.

Management

Observation: For small, low-risk nodules without symptoms, regular monitoring is often sufficient 6.

Thermal Ablation: Ultrasound-guided techniques such as radiofrequency ablation (RFA) and microwave ablation (MWA) are effective for symptomatic benign nodules 1 5 22 24.

Surgical Intervention: Indicated for nodules with high suspicion of malignancy, large size, compressive symptoms, or indeterminate cytology requiring histological confirmation 6 15 20.

AI and Advanced Imaging Techniques: Utilization of AI and modalities like superb microvascular imaging (SMI) and S-Detect mode can enhance diagnostic accuracy 3 10 11.

Special Populations

Pregnancy: Management strategies may vary; close monitoring and conservative approaches are preferred unless malignancy is suspected 12.

Pediatrics: Higher malignancy risk; careful risk stratification using adult systems with caution 7.

Elderly: Focus on symptomatology and risk stratification; consider comorbidities when planning interventions 4.

Key Recommendations

Initial Evaluation with Ultrasound and Risk Stratification: Use ultrasound-based risk stratification systems to guide further management 6 30 36 (Evidence: Strong).

FNA Biopsy for Suspicious Nodules: Perform FNA for nodules meeting specific size and ultrasound criteria to assess malignancy risk 6 29 33 (Evidence: Strong).

Consider Thermal Ablation for Symptomatic Benign Nodules: Employ thermal ablation techniques for symptomatic benign nodules to reduce size and alleviate symptoms 1 5 22 (Evidence: Moderate).

Regular Follow-Up for Low-Risk Nodules: Monitor low-risk nodules with regular ultrasound examinations to detect changes 6 (Evidence: Moderate).

Surgical Consultation for High-Risk Features: Refer nodules with high-risk features or indeterminate cytology for surgical evaluation 6 15 20 (Evidence: Strong).

References

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Endocrinologia, diabetes y nutricion 2024. link 5 Santos GPL, Kulcsar MAV, Capelli FA, Steck JH, Fernandes KL, Mesa CO et al.. Brazilian Consensus on the Application of Thermal Ablation for Treatment of Thyroid Nodules: A Task Force Statement by the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), Brazilian Society of Head and Neck Surgery (SBCCP), and Brazilian Society of Endocrinology and Metabolism (SBEM). Archives of endocrinology and metabolism 2024. link 6 Durante C, Hegedüs L, Czarniecka A, Paschke R, Russ G, Schmitt F et al.. 2023 European Thyroid Association Clinical Practice Guidelines for thyroid nodule management. European thyroid journal 2023. link 7 Xing Z, Qiu Y, Zhu J, Su A, Wu W. Diagnostic performance of adult-based ultrasound risk stratification systems in pediatric thyroid nodules: a systematic review and meta-analysis. 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Thyroid nodule