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FNA biopsy is the best method to assess a thyroid nodule for malignancy FNA biopsy is performed as an outpatient procedure and can be done while patients continue taking anticoagulants or aspirin For multinodular goiters, the four largest nodules ( 1 cm diameter) should be biopsied to minimize the risk of missing a malignancy Smaller thyroid nodules (8 10 mm) with a suspicious appearance on ultrasound should also be considered for ultrasound-guided FNA biopsy Using ultrasound guidance for FNA biopsy improves the diagnostic accuracy for both palpable and nonpalpable thyroid nodules The chance of an optimal tissue sampling is also improved by having an experienced clinician perform the FNA biopsy and by having the aspriate interpreted by a skilled cytopathologist In one review of thyroid FNA biopsies, about 70% were benign, 5% were malignant, 15% were nondiagnostic, and 10% were indeterminate or suspicious When the biopsy specimen yields suspicious results, there is a high risk of malignancy; the risk is higher in young patients and those with nodules that are fixed or over 2 cm in diameter Therefore, most of these patients undergo thyroid surgery However, in elderly patients with nodules < 4 cm in diameter for which cytologic results were suspicious, the malignancy rate is about 5%; such patients may elect to be monitored every 4 6 months with palpation and ultrasound
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D Incidentally Discovered Thyroid Nodules
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Thyroid nodules are frequently discovered as an incidental finding, with an incidence that depends on the imaging modality: MRI, 50%; CT, 13%; and [18F]fluorodeoxyglucose positron
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Cystic nodules yielding serous fluid are usually benign, but fluid should be submitted for cytologic testing Cystic nodules yielding bloody fluid have a higher chance of being malignant Repeat FNA biopsy is done if the cytologic test results are nondiagnostic (eg, diluted with blood or hypocellular) and the lesion remains palpable False-positive thyroid FNA biopsy results occur at a rate of about 4% False-negative thyroid FNA biopsy results also occur at an overall rate of about 4%, less commonly when performed under ultrasound guidance and interpreted by cytopathologists False-negative results delay surgical excision and lead to an increased risk of vascular and capsular invasion by the malignancy Some false-negative FNA biopsy results may not have actually been inaccurate, since truly benign thyroid nodules can later become malignant Patients who have a negative thyroid FNA should have observational follow-up, ideally with both palpation and ultrasound; nodules that continue to grow should be rebiopsied or excised
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therapy is most suitable for younger patients All patients require regular careful clinical evaluation and thyroid palpation or ultrasound examinations Levothyroxine suppression therapy is not usually given to patients with cardiac disease, since it increases the risk for angina and atrial fibrillation Levothyroxine suppression causes a small loss of bone density, particularly in postmenopausal women Patients at risk for osteoporosis are advised to have periodic bone density testing Bisphosphonate or other therapy for osteoporosis may be indicated
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Total thyroidectomy is required for thyroid nodules that are malignant on FNA biopsy (see Thyroid Cancer section) More limited thyroid surgery is indicated for benign nodules with indeterminate or suspicious cytologic test results, compression symptoms, discomfort, or cosmetic embarrassment Surgery may also be used to remove hyperfunctioning hot thyroid adenomas or toxic multinodular goiter causing hyperthyroidism (see Hyperthyroidism section)
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Treatment
All thyroid nodules, including those that are benign, need to be monitored by regular periodic palpation and ultrasound and rebiopsied if growth occurs A toxic multinodular goiter and hyperthyroidism, associated with the ingestion or intravenous administration of large amounts of iodine, may develop in patients with multinodular goiters It is therefore prudent to minimize excessive dietary iodine intake and intravenous iodinated contrast Patients found to have hyperthyroidism may have a RAI uptake and scan for additional evaluation, especially if 131I is a therapeutic consideration Patients with toxic multinodular goiters may also be treated with methimazole, propranolol, or surgery (see Hyperthyroidism section)
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