Management Approach to Thyroid Nodule and Differentiated American Thyroid Association Guideline Published January 2016

1. Management Approach to
Thyroid Nodule
American Thyroid Association
Guideline, January, 2016
Dr. S G Mogni Mowla
Asst. Professor of Medicine
Dhaka Medical College
Dhaka, Bangladesh

2. 2015 American Thyroid
Association Management
Guidelines for Adult Patients
with Thyroid Nodules and
Differentiated Thyroid Cancer
 Published in Thyroid.
Volume: 26 Issue 1: January 12, 2016
2016 Jan;26(1):1-133.
Source

3. Thyroid nodules are common
Prevalence of palpable thyroid nodules is
approximately 5% in women and 1% in men
High-resolution ultrasound (US) can detect
thyroid nodules in 19–68% of randomly
selected individuals
The clinical importance rests in excluding
thyroid cancer, which occurs in 7–15%
By 2019, one study predicts that papillary
thyroid cancer will become the third most
common cancer in women at a cost of 19-21
billion dollars in the U.S.
Introduction

4. The aim of these guidelines is to inform
clinicians, patients, researchers, and
health policy makers on published
evidence relating to the diagnosis and
management of thyroid nodules and
differentiated thyroid cancer.
We will focus on management
approach of thyroid nodules only
Aims & Objectives

5. Thyroid nodule is a discrete lesion within the
thyroid gland that is radiologically distinct
from the surrounding parenchyma.
Some palpable lesions may not correspond
to distinct radiologic abnormalities. They do
not meet the strict definition for thyroid
nodules.
Non-palpable nodules detected on US or
other anatomic imaging studies are termed
incidentally discovered nodules or
“incidentalomas”
Nodules

6. 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 evaluation because of
suspicious sonographic findings,
associated lymphadenopathy, or
other high-risk clinical factors such as
a history of childhood head and neck
irradiation or
a history of thyroid cancer in one or more
first degree relatives.
Nodules…

7. With the discovery of a thyroid nodule,
a complete history and physical
examination focusing on the thyroid
gland and adjacent cervical lymph
nodes should be performed.
Clinics

8. Pertinent historical factors predicting
malignancy include:
a history of childhood head and neck
irradiation,
total body irradiation for bone marrow
transplantation
exposure to ionizing radiation from
fallout in childhood or adolescence
familial thyroid carcinoma, or thyroid
cancer syndrome in a first-degree
relative,
rapid nodule growth and/or hoarseness.
History

9. Pertinent physical findings suggesting
possible malignancy include
vocal cord paralysis,
cervical lymphadenopathy, and
fixation of the nodule to surrounding
tissues.
Examination

10. What is the appropriate laboratory
and imaging evaluation for patients
with clinically or incidentally
discovered thyroid nodules?
Recommendations

11. A serum TSH level
If the serum TSH is subnormal, a
radionuclide thyroid scan should be obtained
If the serum TSH is normal or elevated, a
radionuclide scan should not be performed
as the initial imaging evaluation
Ultrasound of neck
Thyroidal uptake on F18-flurodeoxyglucose
positron emission tomography (18FDG-
PET) scan
FNAC
Investigations

12.  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
 If TSH low, risk of malignancy depends on
radio uptake scan:
 Tracer uptake : hyperfunctioning “hot” nodule-
rarely harbor malignancy, no cytologic
evaluation is necessary.
 Tracer uptake is equal to the surrounding
thyroid isofunctioning “warm” nodule
 Uptake : nonfunctioning “cold”nodule
TSH & Scan

13.  Thyroid sonography with survey of the cervical
lymph nodes should be performed in all patients
with known or suspected thyroid nodules.
 Thyroid US can answer the following:
 Is there truly a nodule?
 How large is the nodule?
 What is the nodule’s pattern of ultrasound imaging
characteristics?
 Is suspicious cervical lymphadenopathy present?
 Is the nodule greater than 50% cystic?
 Is the nodule located posteriorly in the thyroid
gland?
Sonography

14.  Sonography features that are associated with
thyroid cancer include:
 microcalcifications,
 nodule hypoechogenicity compared with the
surrounding thyroid or strap muscles,
 irregular margins (defined as either infiltrative,
microlobulated or spiculated), and
 A shape taller than wide measured on a transverse
view.
 Features with the highest specificities (median
>90%) for thyroid cancer are microcalcifications,
irregular margins, and tall shape,
Sonography

15. Fig: Sonographic Patterns & Risk
of Malignancy

16. High suspicion [malignancy risk >70-90%]:
Solid hypoechoic nodule or
a solid hypoechoic component in a partially
cystic nodule with one or more of the
following features:
 irregular margins (specifically defined as
infiltrative, microlobulated, or spiculated),
 microcalcifications,
 taller than wide shape,
 disrupted rim calcifications, or
 evidence of extrathyroidal extension
US-characteristics

17. Intermediate suspicion [malignancy
risk 10-20%]:
Hypoechoic solid nodule with a
smooth regular margin,
without -
microcalcifications,
extrathyroidal extension, or
taller than wide shape
US-Characteristics

18. Low suspicion [malignancy risk 5-10%]:
Isoechoic or hyperechoic solid
nodule, or
partially cystic nodule with eccentric
uniformly solid areas
without –
microcalcifications,
Irregular margin
extrathyroidal extension, or
taller than wide shape
US-Characteristics

19. Very low suspicion [<3%]:
Spongiform or partially cystic nodules
without any of the sonographic features
described in the low, intermediate or
high suspicion patterns have a low risk
of malignancy (<3%).
US-Characteristics

22. Thyroid nodule diagnostic FNA is
recommended for:
A) Nodules > 1cm in greatest dimension
with high suspicion sonographic pattern
B) Nodules > 1 cm in greatest dimension
with intermediate suspicion sonographic
C) Nodules > 1.5cm in greatest dimension
with low suspicion sonographic pattern
(Weak recommendation, Low-quality
evidence)
FNAC

23. Thyroid nodule diagnostic FNA may be
considered for:
D) Nodules > 2cm in greatest dimension
with very low suspicion sonographic pattern
(e.g. – spongiform). Observation without
FNA is also a reasonable option
Thyroid nodule diagnostic FNA is not
required for:
E) Nodules that do not meet the above
criteria.
F) Nodules that are purely cystic
FNAC

24. Thyroid nodule FNA cytology should be
reported using diagnostic groups
outlined in the:
Bethesda System for Reporting
Thyroid Cytopathology
FNAC: Interpretation

25. (i) nondiagnostic/unsatisfactory;
(ii) benign;
(iii) atypia of undetermined significance/
follicular lesion of undetermined
significance (AUS/FLUS)
(iv) follicular neoplasm/suspicious for
follicular neoplasm (FN), a category that
also encompasses the diagnosis of
Hürthle cell neoplasm/suspicious for
Hürthle cell neoplasm;
(v) suspicious for malignancy (SUSP), and
(vi) malignant.
Categories

27. Nondiagnostic cytology
A) FNA should be repeated with US guidance
and, if available, on-site cytologic evaluation
B) Repeatedly nondiagnostic nodules without a
high suspicion sonographic pattern require
close observation or surgical excision for
histopathologic diagnosis
C) Surgery should be considered for
histopathologic diagnosis if the cytologically
nondiagnostic nodule has a high suspicion
sonographic pattern, high growth rate or clinical
risk factors for malignancy are present
Recommendations

28. Benign cytology
If the nodule is benign on cytology,
further immediate diagnostic studies or
treatment are not required
Recommendations

29. AUS/FLUS Cytology
If repeat FNA cytology and/or molecular
testing are not performed or inconclusive,
either surveillance or diagnostic surgical
excision may be performed for an
AUS/FLUS thyroid nodule,
depending on clinical risk factors,
sonographic pattern, and patient
preference.

30. Follicular Neoplasm/Suspicious for
Follicular Neoplasm (FN/SFN)
Cytology
If molecular testing is either not
performed or inconclusive, surgical
excision may be considered for
removal and definitive diagnosis of an
FN/SFN thyroid nodule.

31. Suspicious for Malignancy (SUSP)
Cytology
Surgical management should be similar to
that of malignant cytology, depending on
clinical risk factors, sonographic features,
patient preference
When surgery is considered for patients
with a solitary, cytologically indeterminate
nodule, thyroid lobectomy is the
recommended initial surgical approach.
This approach may be modified based on
clinical or sonographic characteristics,
patient preference

32.  Malignant Cytology
If a cytology result is diagnostic for primary
thyroid malignancy, surgery is generally
recommended.
 An alternative active surveillance
management approach can be considered in:
A) patients with very low risk tumors
B) patients at high surgical risk because of co-
morbid conditions,
C) patients expected to have a relatively short
remaining life span

33. A) 18FDG-PET imaging is not recommended for the
evaluation of patients with newly detected thyroid
nodules or thyroidal illness, the incidental
detection of abnormal thyroid uptake may be
encountered
B) Focal 18FDG-PET uptake within a sonographically
confirmed thyroid nodule conveys an increased
risk of thyroid cancer, and fine needle aspiration
is recommended for those nodules > 1 cm.
C) Diffuse 18FDG-PET uptake, in conjunction with
sonographic and clinical evidence of chronic
lymphocytic thyroiditis, does not require further
imaging or fine needle aspiration
18FDG-PET scan

34. Algorithm for evaluation and management of patients with
thyroid nodules

35. How should multinodular thyroid
glands (i.e. 2 or more clinically
relevant nodules) be evaluated for
malignancy?

36. A) Patients with multiple thyroid nodules >1 cm
should be evaluated in the same fashion as
patients with a solitary nodule >1 cm,
excepting that each nodule >1 cm carries an
independent risk of malignancy and therefore
multiple nodules may require FNA.
B) When multiple nodules >1 cm are present,
those with a suspicious sonographic patern
should be aspirated preferentially. FNA
should be performed preferentially based
upon nodule sonographic pattern and
respective size cut-off.

37. A low or low-normal serum TSH
concentration in patients with multiple
nodules may suggest that some nodule(s)
may be autonomous.
In such cases, a radionuclide thyroid scan
should be considered and directly
compared to the US images to determine
functionality of each nodule >1 cm.
FNA should then be considered only for
those isofunctioning or nonfunctioning
nodules with high suspicion

38. What are the best methods for
long-term follow-up of patients
with thyroid nodules?

39. Recommendations for initial
follow-up of nodules with benign
FNA cytology

40. A) Nodules with high suspicion US pattern:
repeat US and US-guided FNA within 12
months
B) Nodules with low to intermediate
suspicion US pattern: repeat US at 12-
24 months. If sonographic evidence of
growth is rapid or development of new
suspicious sonographic features, the
FNA could be repeated or observation
continued with repeat US

41. C. Nodules with very low suspicion US
pattern (including spongiform nodules):
the utility of surveillance is not known
D. If a nodule has undergone repeat US-
guided FNA with a second benign
cytology result, ultrasound surveillance
for this nodule for continued risk of
malignancy is no longer indicated

42. Follow-up for nodules that do
not meet FNA criteria

43. A) Nodules with high suspicion US pattern:
repeat US in 6-12 months
B) Nodules with sonographic features of low to
intermediate suspicion US pattern: consider
repeat US at 12-24 months.
C) Nodules > 1 cm with very low suspicion US
pattern (including spongiform nodules) and
pure cyst: risk not known. If US is repeated, it
should be at > 24 months
D) Nodules < 1 cm with very low suspicion US
pattern (including spongiform nodules) and
pure cysts do not require routine sonographic
follow-up

44. What is the role of medical or
surgical therapy for benign
thyroid nodules?

45.  Routine TSH suppression therapy for benign
thyroid nodules in iodine sufficient populations is
not recommended. Though modest responses to
therapy can be detected, the potential harm
outweighs benefit for most patients.
 Individual patients with benign, solid or mostly
solid nodules should have adequate iodine intake.
If inadequate, a daily supplement (containing 150
mcg iodine) is recommended.
 Surgery may be considered for growing nodules
that are benign after repeat FNA if they are large
(>4 cm), causing compressive or structural
symptoms, or based upon clinical concern.

46.  Patients with growing nodules that are benign
after FNA should be regularly monitored. Most
asymptomatic nodules demonstrating modest
growth should be followed without intervention.
 Recurrent cystic thyroid nodules with benign
cytology should be considered for surgical
removal or percutaneous ethanol injection (PEI)
based on compressive symptoms and cosmetic
concerns. Asymptomatic cystic nodules may be
followed conservatively
 There are no data to guide recommendations on
the use of thyroid hormone therapy in patients
with growing nodules that are benign on cytology

47. How should thyroid
nodules in pregnant
women be managed?

48. FNA for thyroid nodules
discovered during pregnancy
A) FNA of clinically relevant thyroid nodules
(refer to section [A10]) should be performed
in euthyroid and hypothyroid pregnant
women
B) For women with suppressed serum TSH
levels that persist beyond 16 weeks
gestation, FNA may be deferred until after
pregnancy and cessation of lactation. At that
time, a radionuclide scan can be performed
to evaluate nodule function if the serum TSH
remains suppressed.

49. Approaches to pregnant patients with
malignant or indeterminate cytology
A) PTC discovered by cytology in early pregnancy should
be monitored sonographically.
B) If it grows substantially before 24-26 weeks gestation,
or if US reveals cervical lymph nodes that are
suspicious for metastatic disease, surgery should be
considered during pregnancy.
C) However, if the disease remains stable by mid-
gestation,or if it is diagnosed in the second half of
pregnancy, surgery may be deferred until delivery
D) In pregnant women with FNA that is suspicious for or
diagnostic of PTC, thyroid hormone therapy to keep
the serum TSH 0.1-1.0mU/L is recommended.

50. Thank You