Management of thyroid nodules

Management of thyroid nodules. Thyroid nodules are frequent and most of them are benign incidentalomas. Physical examination will search for risk factors of thyroid cancer and should evaluate the presence of local or cosmetic symptoms. Whatever the way they are discovered, TSH assessment and ultrasound (US) examination should be systematic. Scintigraphy should be reserved to low TSH patients. US allows to assert the nodule's existence, to measure it and to assess the context (goiter, auto-immune disease). US also allows quantitative risk stratification of malignancy using the EU-TIRADS score, which goes from 1 to 5 and defines the indications for fine-needle aspiration : all nodules above 20 mm (except non compressive EU-TIRADS 2 cysts), EUTIRADS 4 nodules above 15mm and EU-TIRADS 5 nodules above 10 mm. Surgery is indicated for compressive benign nodules and for suspect and malignant nodules above 10 mm. For those below 10 mm in diameter, the patient may be offered active surveillance and surgery in case of progression, provided that there is no lymph node involvement and no extra-capsular extension. Other nodules will be monitored after one year, three years and every five years if needed. Laser and radiofrequency thermoablation will probably partially replace over time surgery for solitary benign nodules.