J Korean Med Assoc.  2011 Jun;54(6):629-636. 10.5124/jkma.2011.54.6.629.

Updated guidelines for the diagnosis and management of thyroid nodules

• Yi KH

• KMID: 2190750
• DOI: http://doi.org/10.5124/jkma.2011.54.6.629

Abstract

The incidental detection of thyroid nodules by ultrasound (US) is increasing explosively. The clinical significance of these nodules is that 5% to 15% of them are malignant, requiring adequate treatment including surgery. Clinical guidelines for the management of thyroid nodules has been published and revised by many thyroid associations around the world in the past decade. The Korean Endocrine Society has also published guidelines for the management of thyroid nodules and thyroid cancer, and the Korean Thyroid Association has recently revised these guidelines. The revised guidelines include the size criteria for which fine needle aspiration cytology (FNAC) is warranted and the Bethesda system, a new cytologic diagnosis system in which thyroid nodules are classified by the degree of malignancy potential. US is recommended to evaluate thyroid nodules in detail. FNAC should be performed for the suspicious cervical lymph nodes regardless of their size and for thyroid nodules larger than 0.5 cm in patients with clinically high risk history and sonographically suspicious findings. Otherwise, FNAC is indicated for thyroid nodules larger than 1 cm in diameter. Repeated FNAC is indicated for nodules with cytologic diagnosis of 'nondiagnostic' or 'atypical cell of unknown significance'. Surgery is needed for nodules diagnosed as 'follicular neoplasm (Hurthle cell type)', 'suspcious for malignancy' and 'malignancy'. For 'benign' nodules, only follow-up with US+/-FNAC is needed. Well-designed studies on thyroid nodules in Korean patients would provide evidence for Korean guidelines for thyroid nodules. Conclusion: The revised Korean Thyroid Association guidelines for thyroid nodules are very useful for managing patients.

Keyword

Guideline; Korean Thyroid Association; Thyroid nodule

MeSH Terms

Biopsy, Fine-Needle
Follow-Up Studies
Humans
Lymph Nodes
Thyroid Gland
Thyroid Neoplasms
Thyroid Nodule

Figure

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  Figure 1 Algorithm for the evaluation of patients with thyroid nodules. TSH, thyroid stimulating hormone; US, ultrasonography; FNAC, fine needle aspiration cytology; PTC, papillary thyroid carcinoma (From Yi KH, et al. Endocrinol Metab 2010;25:270-297, with permission from Korean Endocrine Society) [4].

Reference

1. Tan GH, Gharib H. Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med. 1997. 126:226–231.

2. Hegedus L. Clinical practice. The thyroid nodule. N Engl J Med. 2004. 351:1764–1771.

3. Kim WB, Kim TY, Kwon HS, Moon WJ, Lee JB, Choi YS, Kim SK, Kim SW, Chung KW, Baek JH, Kim BI, Park DJ, Na DG, Choe JH, Chung JH, Jung HS, Kim JH, Nam KH, Chang HS, Chung WY, Hong SW, Hong SJ, Lee JH, Yi KH, Jo YS, Kang HC, Shong M, Park JW, Yoon JH, Kang SJ, Lee KW. Management guidelines for patients with thyroid nodules and thyroid cancer. J Korean Endocr Soc. 2007. 22:157–187.

4. Yi KH, Park YJ, Koong SS, Kim JH, Na DG, Ryu JS, Park SY, Park IA, Baek CH, Shong YK, Lee YD, Lee J, Lee JH, Chung JH, Jung CK, Choi SH, Cho BY. Revised Korean Thyroid Association management guidelines for patients with thyroid nodules and thyroid cancer. Endocrinol Metab. 2010. 25:270–297.

5. Hagag P, Strauss S, Weiss M. Role of ultrasound-guided fine-needle aspiration biopsy in evaluation of nonpalpable thyroid nodules. Thyroid. 1998. 8:989–995.

6. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Society of Radiologists in Ultrasound. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005. 237:794–800.

7. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002. 87:1941–1946.

8. Wienke JR, Chong WK, Fielding JR, Zou KH, Mittelstaedt CA. Sonographic features of benign thyroid nodules: interobserver reliability and overlap with malignancy. J Ultrasound Med. 2003. 22:1027–1031.

9. Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, Yoo HS. New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol. 2002. 178:687–691.

10. Moon WJ, Jung SL, Lee JH, Na DG, Baek JH, Lee YH, Kim J, Kim HS, Byun JS, Lee DH. Thyroid Study Group, Korean Society of Neuro- and Head and Neck Radiology. Benign and malignant thyroid nodules: US differentiation. Multicenter retrospective study. Radiology. 2008. 247:762–770.

11. Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, Yee J. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol. 2009. 193:207–213.

12. Moon WJ, Kwag HJ, Na DG. Are there any specific ultrasound findings of nodular hyperplasia ("leave me alone lesion") to differentiate it from follicular adenoma? Acta Radiol. 2009. 50:383–388.

13. Singh B, Shaha AR, Trivedi H, Carew JF, Poluri A, Shah JP. Coexistent Hashimoto's thyroiditis with papillary thyroid carcinoma: impact on presentation, management, and outcome. Surgery. 1999. 126:1070–1076.

14. Repplinger D, Bargren A, Zhang YW, Adler JT, Haymart M, Chen H. Is Hashimoto's thyroiditis a risk factor for papillary thyroid cancer? J Surg Res. 2008. 150:49–52.

15. Pacini F, Pinchera A, Giani C, Grasso L, Doveri F, Baschieri L. Serum thyroglobulin in thyroid carcinoma and other thyroid disorders. J Endocrinol Invest. 1980. 3:283–292.

16. Elisei R, Bottici V, Luchetti F, Di Coscio G, Romei C, Grasso L, Miccoli P, Iacconi P, Basolo F, Pinchera A, Pacini F. Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders. J Clin Endocrinol Metab. 2004. 89:163–168.

17. Hahm JR, Lee MS, Min YK, Lee MK, Kim KW, Nam SJ, Yang JH, Chung JH. Routine measurement of serum calcitonin is useful for early detection of medullary thyroid carcinoma in patients with nodular thyroid diseases. Thyroid. 2001. 11:73–80.

18. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002. 87:1941–1946.

19. Camargo R, Corigliano S, Friguglietti C, Gauna A, Harach R, Munizaga F, Niepomniszcze H, Pitoia F, Pretell E, Vaisman M, Ward LS, Wohllk N, Tomimori E. Latin American Thyroid Society. Latin American Thyroid Society recommendations for the management of thyroid nodules. Arq Bras Endocrinol Metabol. 2009. 53:1167–1175.

20. Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedus L, Vitti P. AACE/AME/ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2010. 16:Suppl 1. 1–43.

21. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009. 19:1167–1214.

22. Ali SZ, Cibas ES. The Bethesda system for reporting thyroid cytopathology: definitions, criteria, and explanatory notes. 2010. New York: Springer.

23. Layfield LJ, Abrams J, Cochand-Priollet B, Evans D, Gharib H, Greenspan F, Henry M, LiVolsi V, Merino M, Michael CW, Wang H, Wells SA. Post-thyroid FNA testing and treatment options: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008. 36:442–448.

24. Franco C, Martinez V, Allamand JP, Medina F, Glasinovic A, Osorio M, Schachter D. Molecular markers in thyroid fine-needle aspiration biopsy: a prospective study. Appl Immunohistochem Mol Morphol. 2009. 17:211–215.

25. Bartolazzi A, Orlandi F, Saggiorato E, Volante M, Arecco F, Rossetto R, Palestini N, Ghigo E, Papotti M, Bussolati G, Martegani MP, Pantellini F, Carpi A, Giovagnoli MR, Monti S, Toscano V, Sciacchitano S, Pennelli GM, Mian C, Pelizzo MR, Rugge M, Troncone G, Palombini L, Chiappetta G, Botti G, Vecchione A, Bellocco R. Italian Thyroid Cancer Study Group (ITCSG). Galectin-3-expression analysis in the surgical selection of follicular thyroid nodules with indeterminate fine-needle aspiration cytology: a prospective multicentre study. Lancet Oncol. 2008. 9:543–549.

26. Nikiforov YE, Steward DL, Robinson-Smith TM, Haugen BR, Klopper JP, Zhu Z, Fagin JA, Falciglia M, Weber K, Nikiforova MN. Molecular testing for mutations in improving the fine-needle aspiration diagnosis of thyroid nodules. J Clin Endocrinol Metab. 2009. 94:2092–2098.

27. Alexander EK, Hurwitz S, Heering JP, Benson CB, Frates MC, Doubilet PM, Cibas ES, Larsen PR, Marqusee E. Natural history of benign solid and cystic thyroid nodules. Ann Intern Med. 2003. 138:315–318.

28. Zelmanovitz F, Genro S, Gross JL. Suppressive therapy with levothyroxine for solitary thyroid nodules: a double-blind controlled clinical study and cumulative meta-analyses. J Clin Endocrinol Metab. 1998. 83:3881–3885.

29. Castro MR, Caraballo PJ, Morris JC. Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis. J Clin Endocrinol Metab. 2002. 87:4154–4159.

30. Wemeau JL, Caron P, Schvartz C, Schlienger JL, Orgiazzi J, Cousty C, Vlaeminck-Guillem V. Effects of thyroid-stimulating hormone suppression with levothyroxine in reducing the volume of solitary thyroid nodules and improving extranodular nonpalpable changes: a randomized, double-blind, placebo-controlled trial by the French Thyroid Research Group. J Clin Endocrinol Metab. 2002. 87:4928–4934.