Recent developments in predicting thyroid malignancy

To provide an update on potential predictors of thyroid malignancy and how their use may alter clinical management.

As thyroid nodules become more prevalent clinicians are increasingly impelled to identify the optimal predictor(s) of thyroid malignancy, with the goal of guiding management based on assessed risk. The gold standard evaluation for thyroid nodules is ultrasound-guided fine-needle aspiration biopsy. Fine-needle aspiration biopsy is not perfect and adjuncts which complement its predictive value are being investigated from several innovative perspectives. These include large tumor size (> or =4 cm), which appears to be an independent predictor of thyroid malignancy; 18F-fluorodeoxyglucose positron emission tomography, which appears to facilitate exclusion of malignancy in cytologically indeterminate thyroid nodules; and peripheral blood and fine-needle aspiration biopsy analysis of molecular markers, which may help to identify malignant thyroid nodules with greater specificity.

Fine-needle aspiration biopsy of large thyroid nodules has a high false-negative rate and should be considered for diagnostic lobectomy. Nodule size appears to be an independent factor predicting malignancy and indeterminate lesions at least 4 cm should be considered for initial total thyroidectomy. Nuclear imaging may aid exclusion of malignancy in thyroid nodules and molecular markers have great promise in predicting thyroid malignancy with higher specificity.