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Guidelines provide insight on management of thyroid nodules
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In 2010, a set of guidelines for the diagnosis and management of thyroid nodules was published.
The American Association of Clinical Endocrinologists, the Associazione Medici Endocrinologi and the European Thyroid Association published a set of guidelines for the diagnosis and management of thyroid nodules.
Patient history, screening
Clinicians should record patient history as it pertains to thyroid nodules. This information should include age; radiation history; family history of thyroid disease or cancer; rate of growth of the neck mass; and dysphonia, dysphagea or dyspnea. A physical examination should be used to examine the thyroid gland and cervical lymph nodes for tenderness or adenopathy.
Screening ultrasound is not recommended for the general population in the United States. High-risk individuals, including those showing risk factors for thyroid malignancy or those with lymphadenopathy, may undergo ultrasonography. Ultrasound results should be used for risk stratification for malignancy and describe the features of the nodule. Fine-needle aspiration (FNA) biopsy is recommended for certain nodules, including those larger than 1 cm and those that are solid and hypoechoic.
Those suggestive of extracapsular growth or metastatic cervical lymph nodes and nodules in patients with a history of childhood neck radiation also may undergo FNA. Samples may be classed as nondiagnostic, benign, follicular lesions, suspicious or malignant. Clinicians should be aware of the potential for false-negative or false-positive results. For complete information on FNA biopsy and how those results should be interpreted, clinicians are encouraged to view the full document.
Grade A recommendations dictate that serum thyrotropin should be measured in a laboratory evaluation of samples. Free thyroxine and total or free triiodothyronine should also be measured, along with antithyroglobulin antibodies.
Nondiagnostic nodules should undergo repeated FNA biopsy. Clinicians should follow up on cytologically benign nodules. The panel contraindicates levothyroxine therapy for benign nodules. Clinicians should view the full document for surgical indications for benign nodules, percutaneous ethanol injection and image-guided thermal ablation.
Follicular lesions should not be repeatedly biopsied using FNA. Rather, they should be surgically excised in most cases. Surgery also is recommended for suspicious nodules, and for nodules with positive FNA biopsy for differentiated thyroid carcinoma. Clinicians should review the full document for information on surgical recommendations, including preoperative evaluation.
In pregnancy
The investigators recommended that thyroid nodules in pregnant women should be managed in the same way as in women who are not pregnant. Thyroidectomy may be appropriate in the second trimester if recommended. Waiting until after delivery to perform surgical treatment may not adversely effect outcomes.
When a thyroid malignancy is diagnosed during the first or second trimester, thyroidectomy may be performed during the second trimester, if recommended. Women with no evidence of aggressive thyroid cancer may be reassured that surgical treatment performed soon after delivery is unlikely to adversely affect prognosis.
The only absolute contraindications to radioiodine treatment include pregnant women and those who are lactating, according to the guidelines. Radioactive agents should be used for neither diagnostic nor therapeutic purposes in pregnant women. Levothyroxine also is contraindicated in certain patient populations.
Support for laser ablation
In May 2015, at the 24th annual American Association of Clinical Endocrinologists Scientific and Clinical Congress, researchers presented study findings in support of image-guided laser ablation of solid thyroid nodules.
The results, presented by Enrico Papini, MD, director of endocrinology and metabolism at Ospedale Regina Apostolorum Hospital, in Rome, said the practice was both safe and well-tolerated in most patients.
He added that past studies have also shown image-guided laser ablation therapy of thyroid nodules to yield favorable results in randomized trials.
According to Papini, 1.9% of patients reported moderate pain, while 0.2% reported severe pain.
References:
https://www.aace.com/files/thyroid-guidelines.pdf.
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