Note to myself: The key to detecting thyroid nodules is to have an effective physical examination of the thyroid. And so I’ve linked to the YouTube video, An Easier Thyroid Exam by M Kyu Chung MD. The video is a brief explanation of a thyroid examination protocol that is worth reviewing as there are many subtle pearls.
Here is the link to the web page of American Thyroid Association® (ATA) Guidelines and Surgical Statements. At the time of this post there are ten ATA Guidelines and ten ATA Surgical Statements on the web page.
In this post I link to and excerpt from 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Thyroid. 2016 Jan;26(1):1-133. doi: 10.1089/thy.2015.0020.
Basically, I’ve excerpted things I want to know as a primary care physician. I refer my patients with a thyroid nodule to endocrinologist with special expertise in thyroid evaluation.
And here are the excerpts:
INTRODUCTION
Thyroid nodules are a common clinical problem.
Epidemiologic studies have shown the prevalence of
palpable thyroid nodules to be approximately 5% in women
and 1% in men living in iodine-sufficient parts of the world
(1,2). In contrast, high-resolution ultrasound (US) can detect
thyroid nodules in 19%–68% of randomly selected individuals, with higher frequencies in women and the elderly (3,4)The clinical importance of thyroid nodules rests with the need
to exclude thyroid cancer, which occurs in 7%–15% of cases
depending on age, sex, radiation exposure history, family
history, and other factors (5,6).The yearly incidence has nearly tripled from 4.9 per
100,000 in 1975 to 14.3 per 100,000 in 2009 (9). Almost the
entire change has been attributed to an increase in the incidence of papillary thyroid cancer (PTC). Moreover, 25% of the
new thyroid cancers diagnosed in 1988–1989 were ≤ 1 cm
compared with 39% of the new thyroid cancer diagnoses in
2008–2009 (9). This tumor shift may be due to the increasing
use of neck ultrasonography or other imaging and early diagnosis and treatment (10), trends that are changing the initial treatment and follow-up for many patients with thyroid cancer.A recent population-based study from Olmsted County reported the doubling of thyroid cancer incidence from 2000 to
2012 compared to the prior decade as entirely attributable to
clinically occult cancers detected incidentally on imaging or
pathology (11).By 2019, one study predicts that PTC will become the third most common cancer in women at a cost of $19–21 billion in the United States (12). Optimization of longterm health outcomes and education about potential prognosis for individuals with thyroid neoplasms is critically important.
AIM AND TARGET AUDIENCE
Our objective in these guidelines is to inform clinicians,
patients, researchers, and health policy makers about the best
available evidence (and its limitations), relating to the diagnosis and treatment of adult patients with thyroid nodules
and DTC. These guidelines should not be applied to children
(<18–20 years old); recent ATA guidelines for children with
thyroid nodules and DTC were published in 2015 (14).This document is intended to inform clinical decision-making. A
major goal of these guidelines is to minimize potential harm
from overtreatment in a majority of patients at low risk for
disease-specific mortality and morbidity, while appropriately
treating and monitoring those patients at higher risk.Other groups have previously developed clinical practice
guidelines, including the American Association of Clinical
Endocrinologists, Associazione Medici Endocrinologi, and
the European Thyroid Association (18), the British Thyroid
Association and The Royal College of Physicians (19), and
the National Comprehensive Cancer Network (www.nccn
.org).Given the existing controversies in the field, differences in critical appraisal approaches for existing evidence, and differences in clinical practice patterns across geographic regions and physician specialties, it should not be surprising that the organizational guidelines are not in complete agreement for all issues. Such differences highlight the
importance of clarifying evidence uncertainties with future
high quality clinical research.Table 5. Organization of the 2015 ATA Guidelines for Thyroid Nodules and Differentiated Thyroid Cancer
p. 10 [A1] THYROID NODULE GUIDELINES
pp. 10 – 28 [A2] – [A30]
p. 28 [B1] DIFFERENTIATED THYROID CANCER: INITIAL MANAGEMENT GUIDELINES
pp. 28 – 65 [B2] – [B47]
p. 65 [C1] DTC: LONG-TERM MANAGEMENT AND ADVANCED CANCER MANAGEMENT GUIDELINES
pp. 65 – 88 [C2] – [C47]
[A1] THYROID NODULE GUIDELINES
A thyroid nodule is a discrete lesion within the thyroid gland
that is radiologically distinct from the surrounding thyroid parenchyma. Some palpable lesions may not correspond to distinct radiologic abnormalities (32). Such abnormalities do not meet the strict definition for thyroid nodules. Nonpalpable nodules detected on US or other anatomic imaging studies are termed incidentally discovered nodules or ‘‘incidentalomas.’’Generally, only nodules >1 cm should be evaluated, since they
have a greater potential to be clinically significant cancers.Occasionally, there may be nodules <1 cm that require further
evaluation because of clinical symptoms or associated lymphadenopathy.In very rare cases, some nodules <1 cm lack these
sonographic and clinical warning signs yet may nonetheless
cause future morbidity and mortality. This remains highly unlikely, and given the unfavorable cost/benefit considerations,
attempts to diagnose and treat all such small thyroid cancers in
an effort to prevent exceedingly rare outcomes is deemed to
cause more harm than good.In general, the guiding clinical strategy acknowledges that most thyroid nodules are low risk, and many thyroid cancers pose minimal risk to human health and can be effectively treated.
[A3] What is the appropriate laboratory and imaging
evaluation for patients with clinically or incidentally
discovered thyroid nodules?[A4] Serum thyrotropin measurement
RECOMMENDATION 2
(A) Serum thyrotropin (TSH) should be measured during
the initial evaluation of a patient with a thyroid nodule.
(Strong recommendation, Moderate-quality evidence)(B) If the serum TSH is subnormal, a radionuclide (preferably 123I) thyroid scan should be performed. (Strong
recommendation, Moderate-quality evidence)(C) If the serum TSH is normal or elevated, a radionuclide
scan should not be performed as the initial imaging evaluation.
(Strong recommendation, Moderate-quality evidence)With the discovery of a thyroid nodule >1 cm in any diameter, a serum TSH level should be obtained.
If the serum TSH is subnormal, a radionuclide thyroid scan should be obtained to document whether the nodule is hyperfunctioning (‘‘hot,’’ i.e., tracer uptake is greater than the surrounding normal thyroid), isofunctioning (‘‘warm,’’ i.e., tracer uptake is equal to the surrounding thyroid), or nonfunctioning (‘‘cold,’’ i.e., has uptake less than the surrounding thyroid tissue) (44).
Since hyperfunctioning nodules rarely harbor malignancy, if one is found that corresponds to the nodule in question, no cytologic evaluation is necessary.
If overt or subclinical hyperthyroidism is present, additional evaluation is required. A higher serum TSH level, even within the upper part of the reference range, is associated with increased risk of malignancy in a thyroid nodule, as well as more advanced stage thyroid cancer (45,46).
RECOMMENDATION 6
Thyroid sonography with survey of the cervical lymph
nodes should be performed in all patients with known or
suspected thyroid nodules.(Strong recommendation, High-quality evidence)
Diagnostic thyroid/neck US should be performed in all
patients with a suspected thyroid nodule, nodular goiter, or
radiographic abnormality suggesting a thyroid nodule incidentally detected on another imaging study (e.g., computed
tomography [CT] or magnetic resonance imaging [MRI]
or thyroidal uptake on 18FDG-PET scan) (www.aium.org/
resources/guidelines/thyroid.pdf).RECOMMENDATION 7
FNA is the procedure of choice in the evaluation of thyroid
nodules, when clinically indicated.
(Strong recommendation, High-quality evidence)
