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Nonsurgical approaches to the management of thyroid nodules

Abstract

Epidemiologic studies have documented substantial increases in the frequency of nodular thyroid disease. This trend is largely due to the increasing detection of nodules by the routine use of sonography in clinical practice. Only a small percentage of the nodules currently being detected will prove to be malignant. The probability of malignancy is similar in nonpalpable and palpable nodules. Fine-needle aspiration cytology has a central role in identifying malignant nodules, which are generally treated with surgery. Most thyroid nodules are cytologically benign and can be managed nonsurgically. Nodules that are completely asymptomatic require follow-up without treatment. Cosmetic problems and/or compression-related symptoms may be indications for surgery. When surgery is contraindicated or refused, several nonsurgical approaches are available. These include levothyroxine therapy, radioiodine treatment, percutaneous ethanol injections, and the new technique of laser photocoagulation. Levothyroxine therapy is the most widely used approach, but its clinical efficacy and safety are controversial. Levothyroxine might, nonetheless, be appropriate in selected cases characterized by low risk for adverse effects and nodule characteristics associated with response to this type of therapy. Radioiodine is the therapy of choice for toxic nodules or for symptomatic nodular goiters when surgery is not possible. Percutaneous ethanol injection should be used, in our opinion, as the first-line therapy only for recurrent symptomatic cystic nodules. Laser therapy should be reserved for selected patients treated in experienced centers only. With these options, clinicians can personalize the management of nodular thyroid disease according to a careful cost–benefit analysis.

Key Points

  • Nodular thyroid disease is now frequently detected, which reflects its high prevalence in the general population

  • The majority of thyroid nodules are benign and do not need surgery

  • Most benign thyroid nodules are asymptomatic, nontoxic and slow-growing and they require a simple follow-up without treatment

  • The rationale, efficacy and safety of levothyroxine (thyroid-hormone-suppressive) therapy are not established; thus, currently, it is not recommended as standard therapy for single nodular goiter

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Figure 1: Diagnostic procedure for deciding between surgical and nonsurgical approaches to the management of nonautonomous thyroid nodules
Figure 2: Management of benign, nonautonomous thyroid nodules

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Acknowledgements

This work was supported by grants of Ministero della Salute and of MURST (COFIN 2004) to S Filetti. Support by the “Fondazione Umberto Di Mario ONLUS” is also acknowledged. We thank E Papini, “Regina Apostolorum” Hospital, Albano, Rome, for helpful discussion and for sharing with us his experience in interstitial laser photocoagulation.

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Correspondence to Sebastiano Filetti.

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Filetti, S., Durante, C. & Torlontano, M. Nonsurgical approaches to the management of thyroid nodules. Nat Rev Endocrinol 2, 384–394 (2006). https://doi.org/10.1038/ncpendmet0215

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