A comprehensive approach to the management of thyroid nodules is needed to avoid unnecessary biopsy of benign nodules and to identify, triage and treat suspicious and malignant nodules.
Thyroid nodules are a very common clinical problem in adults. Detection rates of nodularity are now much higher because of improved availability of neck ultrasonography and other imaging modalities. A prevalence of thyroid nodules of 19 to 67% has been reported using high-resolution ultrasound on randomly selected individuals,1,2 with higher rates reported in women and with increasing age in both sexes. The risk of malignancy is about 7 to 15%,3 of which many are probably insignificant microcarcinomas. The remaining vast majority of thyroid nodules are benign. The Bethesda system for reporting thyroid cytopathology has been universally adopted and each diagnostic category portends a risk of malignancy. Indications for fine-needle aspiration (FNA) biopsy based on ultrasound features are summarised in Box 1. Risk factors implicated in thyroid nodular disease include increased age, female sex, low dietary iodine intake, neck irradiation and family history of thyroid cancer.
It is important for GPs to have a clear understanding and a precise approach to the management of thyroid nodules (see Flowchart).4,5 Selection of appropriate investigations, interpretation of the results, as well as short- and long-term management plans are demonstrated by the following clinical scenarios.
Picture credit: © Centre Jean Perrin/SPL