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Contemporary Thyroid Nodule Evaluation and Management

Contemporary Thyroid Nodule Evaluation and Management

Contemporary Thyroid Nodule Evaluation and Management


Grani G, Sponziello M, Pecce V, Ramundo V, Durante C. Contemporary Thyroid Nodule Evaluation and Management. J Clin Endocrinol Metab. 2020 Sep 1;105(9):2869–83. doi: 10.1210/clinem/dgaa322. PMID: 32491169; PMCID: PMC7365695.



Context: Approximately 60% of adults harbor 1 or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant. The widespread use of diagnostic imaging and improved access to health care favor the discovery of small, subclinical nodules and small papillary cancers. Overdiagnosis and overtreatment is associated with potentially excessive costs and nonnegligible morbidity for patients. Evidence acquisition: We conducted a PubMed search for the recent English-language articles dealing with thyroid nodule management. Evidence synthesis: The initial assessment includes an evaluation of clinical risk factors and sonographic examination of the neck. Sonographic risk-stratification systems (e.g., Thyroid Imaging Reporting and Data Systems) can be used to estimate the risk of malignancy and the need for biopsy based on nodule features and size. When cytology findings are indeterminate, molecular analysis of the aspirate may obviate the need for diagnostic surgery. Many nodules will not require biopsy. These nodules and those that are cytologically benign can be managed with long-term follow-up alone. If malignancy is suspected, options include surgery (increasingly less extensive), active surveillance or, in selected cases, minimally invasive techniques.


The evaluation and management of patients with thyroid nodules is no longer a 1-size-fits-all proposition. The tailored approach advocated today requires a careful assessment of each nodule to determine the likelihood that it is malignant and the chances that it will cause symptoms. Very few nodules will require an intensive workup that includes cytology and molecular testing of FNAB samples: for the vast majority, a systematic cervical US examination with assessment of clinical risk factors will provide a reliable foundation for identifying the initial management strategy. After an appropriate initial assessment, the frequency of subsequent surveillance visits for most nodules can be safely reduced compared with currently used schedules. This is particularly relevant for frail, elderly individuals, as they are unlikely to be harmed by the thyroid tumor itself, and overmedicalization can cause more harm than good. In these populations, surveillance can safely be confined to a periodic clinical examination. If surgery is needed, resections can often be less extensive. In some cases, minimally invasive, percutaneous approaches are a viable alternative to surgery. When there are multiple options, they should be discussed as frankly as possible with the patient, outlining the advantages, limitations, benefits, and risks of each. The goal is to identify the best strategy for the individual patient, in terms of disease outcomes and quality of life, avoiding the pitfalls of overdiagnosis and overtreatment. For health professionals, this means learning to work with some degree of clinical uncertainty rather than automatically resorting to intensive testing and intervention, and by weighing patients’ expectations and demands.

Key Words

biopsy, risk assessment, risk factors, TIRADS, ultrasonography, watchful waiting

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