Thyroid Nodules: Diagnosis and Treatment in Primary Care

Thyroid nodules are very common, with a prevalence of more than 75% among persons over age 60 in Germany, yet more than 80% of them remain asymptomatic and undetected. Only a small fraction of thyroid nodules pose a relevant risk to health; these include carcinomas of the thyroid gland (prevalence 0.027%) and functionally autonomous adenomas (clinically relevant prevalence 0.34%).

Systematic literature searches based on the PICO scheme or exploratory key questions were carried out during the development of an S3-level clinical practice guideline for the management of patients with thyroid nodules in primary care. The quality of the pertinent guidelines and studies was assessed with standardized instruments. Selected findings are described in this article.

Most thyroid nodules are discovered incidentally. Further diagnostic evaluation by the primary care physician is generally only indicated if the patient is symptomatic, has a family history of thyroid cancer, or has a low TSH (thyroid-stimulating hormone) level. Ultrasonography should be performed in targeted and standardized fashion (TIRADS classifications) and cascading diagnostic studies should be avoided. If the nodule is considered potentially malignant, the patient should be referred to a specialist. The indications for treatment include symptoms due to compression, esthetic impairment, or functionally relevant autonomous adenomas. Pharmacotherapy with the goal of shrinking the nodule(s) is now obsolete, and other measures can only be carried out after specialized referral.

Rational, patient-centered approaches are needed in primary care so that overdiagnosis and overtreatment can be avoided and appropriate care provided as efficiently as possible. The diagnostic evaluation is focused on the meticulous selection of patients who must be referred to a specialist. For most thyroid nodules, no treatment is indicated.