Insights on Management of Thyroid Nodules – April 2, 2016

Today, I saw a female 52-year-old patient who came for her regular check-up on her thyroid concern.

Two years ago, when I saw her for a second opinion, she was told to undergo a thyroidectomy by another surgeon.  I said wait.  At that time, she presented with a palpable but not visually evident 2-cm thyroid nodule on the right with other smaller nodules reported on ultrasound on the other lobe.  I did a needle evaluation and aspiration biopsy and it showed a colloid nodule on the mass that I aspirated.  I recommended to her a trial of medical therapy to which she agreed.  After 2 months of treatment, the nodule decreased in size to 1 cm.  After 5 months, the nodule was not palpable anymore.  From thereon, I just maintained her on levothyroxine.  Two years after treatment (today), there is no palpable thyroid nodule and the patient is happy and kept on repeating that it was nice she came to see me.  Otherwise, she would have been operated on 2 years ago.

Approaches to management of thyroid nodules vary from one endocrinologist to another; from one general surgeon to another; from one head and neck surgeon to another (the specialists who usually see patients with thyroid nodules). It all depends on their philosophy and perception.

My personal approach, which is influenced by my philosophy and perception derived from experience, consists of the following:

  1. If on clinical diagnosis, there is a high chance (more than 90% probability) that the nodule is malignant, I recommend operation.
  2. If on clinical diagnosis,there is high chance (more than 90% probability) that the nodule is benign and the nodule is not big (not more than 4 cm), I usually try medical therapy and monitor the treatment outcome.  If there is decrease in size, I continue on with the medical therapy (which could be as long as one year) until the mass disappears.  If the mass does not disappears, but has decreased in size and remained stationery, I just maintain her on levothyroxine and continue to monitor.  If there is appearance of a sign or symptom that will make me suspect malignancy, then I recommend operation.
  3. I rely on needle evaluation and aspiration biopsy for my diagnosis. It carries a 90% yield and accuracy rate.
  4. I have heard of the approach of other specialists on recommending operation on the basis of multiple nodules despite a high probability of multiple colloid adenomatous goiter.  I don’t use the presence of multiple nodules, especially small ones, as an indication for operation.  I recommend operation on the basis of high probability of malignancy (if there are clinical evidences to point to this in the other nodules).


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