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What Size Thyroid Nodule Should Be Removed

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Thyroid nodule update on diagnosis and management

Clinical Diabetes and Endocrinology volume two, Article number:17 (2016) Cite this article

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Abstruse

Thyroid nodules are common. The clinical importance of thyroid nodules is related to excluding malignancy (4.0 to 6.5% of all thyroid nodules), evaluate their functional condition and appraise for the presence of pressure level symptoms. Incidental thyroid nodules are being diagnosed with increasing frequency in the recent years with the use of newer and highly sensitive imaging techniques. The high prevalence of thyroid nodules necessitates that the clinicians use evidence-based approaches for their assessment and management. New molecular tests accept been developed to assist with evaluation of malignancy in thyroid nodules. This review addresses advances in thyroid nodule evaluation, and their direction because the current guidelines and supporting evidence.

Background

Thyroid nodule is a discrete lesion in the thyroid gland that is radiologically singled-out from the surrounding thyroid parenchyma [1]. Thyroid nodules are mutual; their prevalence in the general population is high, the percentages vary depending on the way of discovery: ii–half dozen % (palpation), 19–35 % (ultrasound) and 8–65 % (autopsy data) [2–4]. They are discovered either clinically on cocky-palpation by a patient, or during a physical examination by the clinician or incidentally during a radiologic procedure such as ultrasonography (US) imaging, computed tomography (CT) or magnetic resonance imaging (MRI) of the neck, or fluorodeoxyglucose (FDG) positron emission tomography; with the increased apply of sensitive imaging techniques, thyroid nodules are being diagnosed incidentally with increasing frequency in the contempo years [5, 6]. Though thyroid nodules are common, their clinical significance is mainly related to excluding malignancy (4.0 to six.5% of all thyroid nodules) [3, vii–9], evaluating their functional status and if they crusade pressure level symptoms.

Diagnosis and evaluation of thyroid nodules

Thyroid nodules can be caused past many disorders: beneficial (colloid nodule, Hashimoto's thyroiditis, simple or hemorrhagic cyst, follicular adenoma and subacute thyroiditis) and malignant (Papillary Cancer, Follicular Cancer, Hurthle Cell (oncocytic) Cancer, Anaplastic Cancer, Medullary Cancer, Thyroid Lymphoma and metastases −3 most common primaries are renal, lung & head-neck) [3, 10, 11].

Initial assessment of a patient found to have a thyroid nodule either clinically or incidentally should include a detailed and relevant history plus physical exam. Laboratory tests should begin with measurement of serum thyroid-stimulating hormone (TSH). Thyroid scintigraphy/radionuclide thyroid scan should be performed in patients presenting with a low serum TSH [one]. Thyroid ultrasound should be performed in all those suspected or known to take a nodule to confirm the presence of a nodule, evaluate for additional nodules and cervical lymph nodes and assess for suspicious sonographic features. The next pace in the evaluation of a thyroid nodule, if they run into the criteria as discussed later, is a fine needle aspiration (FNA) biopsy [12].

*Algorithm of thyroid nodule work up is presented at the end of the review (Fig. 1).

Fig. 1
figure 1

Thyroid Nodule Workup Algorithm

Full size prototype

History and physical examination

Comprehensive history with focus on take a chance factors predicting malignancy (Tabular array ane [1, 3, xiii]) should exist function of the initial evaluation of a patient with thyroid nodule. Symptoms of hypothyroidism or hyperthyroidism should be assessed. Patients should be questioned about local pressure symptoms such as difficulty in swallowing or breathing, cough and change in voice.

Tabular array i Increased risk of malignancy in thyroid nodule on history and physical test [1, 3, 13]

Total size table

Table 2 Recommendations for diagnostic FNA based on size and Us features [one, 35–37, 85, 86, 118–120]

Full size table

Physical examination focusing on the thyroid gland assessing the volume and consistency and the nodular features such equally size, number, location and consistency should be performed. Thyroid nodules that are smaller, usually < 1 cm and those located posteriorly or substernally will be difficult to palpate [14, xv]. Cervical lymph nodes should be assessed. Examination of signs of hypo or hyperthyroidism should be done.

Laboratory tests

Serum TSH

Serum TSH should be measured in all patients with thyroid nodules. In patients with low TSH levels, radionuclide thyroid scan should be performed side by side to assess the functional status of the nodule. In a patient with a thyroid nodule, an increased serum TSH or TSH even in the upper limit of normal is associated with increased hazard and an avant-garde phase of malignancy [16, 17].

Serum calcitonin

In patients with thyroid nodules, the routine assessment of serum calcitonin is controversial and there are no definite recommendations for or against it [1, 18, 19]. Many prospective, non-randomized studies, generally from outside United states of america have assessed the value of measuring serum calcitonin [xx–22]. The studies which show that use of serum calcitonin for screening may detect C-cell hyperplasia and MTC at an before stage and overall survival may exist improved, are based on pentagastrin stimulation testing to increment specificity. Pentagastrin is non bachelor in the United States, and in that location is even so an ambiguity almost the sensitivity/specificity, threshold cut off values and cost-effectiveness [22–24]. Imitation-positive calcitonin results may be obtained in patients with hypercalcemia, hypergastrinemia, neuroendocrine tumors, renal insufficiency, papillary and follicular thyroid carcinomas, goiter, chronic autoimmune thyroiditis and prolonged use of certain medications [12, 25, 26]. False negative test upshot may be seen in rare MTCs that do not secrete calcitonin [27, 28].

Serum thyroglobulin (Tg)

In patients with thyroid nodules, routine measurement of serum thyroglobulin is not recommended as it can exist elevated in many thyroid diseases and is neither specific nor sensitive for thyroid cancer [29, 30].

Serum TPO antibodies

Routine measurement of serum anti-thyroid peroxidase (TPO) antibodies is not necessary for thyroid nodule evaluation [31].

Imaging studies

Radionuclide thyroid scan/scintigraphy

In patients with thyroid nodule and a depression serum TSH, suggesting overt or subclinical hyperthyroidism, the next step is to determine if the nodule is apart functioning. Thyroid scintigraphy is useful to determine the functional condition of a nodule.

Scintigraphy, a diagnostic test used in nuclear medicine, utilizing iodine radioisotopes (more than normally used; normally 123I) or technetium pertechnetate (99Tc), measures timed radioisotope uptake by the thyroid gland. The uptake of the radioisotopes will exist greater in hyperfunctioning nodule and will be lower in most benign and virtually all malignant thyroid nodules than side by side normal thyroid tissue [32–34].

Nodules may appear 'hot', 'warm' or 'cold' depending on whether the tracer uptake is greater than, equal to or less than the surrounding normal thyroid tissue respectively [11]. Autonomous nodules may announced hot or indeterminate and business relationship for 5 to 10 % of palpable nodules. FNA evaluation of a hyperfunctioning nodule is non necessary as most hyperfunctioning nodules are benign [i].

Thyroid sonography/ultrasound

Thyroid Ultrasound (U.s.) is a noninvasive imaging technique that should be performed on all patients with nodules suspected clinically or incidentally noted on other imaging studies such as carotid ultrasound, CT, MRI, or 18-FDG-PET scan.

Ultrasound will help confirm the thyroid nodule/due south, assess the size, location and evaluate the composition, echogenicity, margins, presence of calcification, shape and vascularity of the nodules and the adjacent structures in the neck including the lymph nodes. If there are multiple nodules, all the nodules should be assessed for suspicious US characteristics.

FNA conclusion making is guided by both nodule size and ultrasound characteristics, the latter being more predictive of malignancy than size [35, 36]. The nodular characteristics that are associated with a higher likelihood of malignancy include a shape that is taller than broad measured in the transverse dimension, hypoechogenicity, irregular margins, microcalcifications, and absent halo [35–41]. The feature with the highest diagnostic odds ratio for malignancy was suggested to be the nodule being taller than wider [42]. The more suspicious characteristics that the nodule has, it increases the likelihood of malignancy. In contrast, beneficial nodule predicting The states characteristics include purely cystic nodule (< two % risk of malignancy) [39], spongiform appearance (99.7 % specific for benign thyroid nodule) [40, 42–44].

The contempo ATA guidelines classify nodules into 5 risk groups based on United states of america results [ane]. However, the current AACE guidelines suggest a more practical, 3-tier hazard classification: depression hazard, intermediate chance and loftier take chances thyroid lesions, based on their US characteristics [xiii].

In patients with thyroid nodules and depression TSH who have undergone thyroid scintigraphy, ultrasound is useful to check for cyclopedia of the nodule and hyperfunctioning area on the browse, which do not need FNA and to evaluate other nonfunctional or intermediate nodules, which may crave FNA based on sonographic criteria [1].

Fine needle aspiration biopsy (FNA)

FNA is considered the aureate standard test for evaluating thyroid nodules. It is an office process, washed under no or local anesthesia with 23 to 27 judge needle, to obtain tissue samples for cytological examination. It is a condom, accurate and cost-effective way for evaluating thyroid nodules [45–54].

FNA can be done using palpation or with ultrasound guidance. The states machines (7.five to 10 MHz transducers), provide clear and continuous visualization of thyroid gland and let for real fourth dimension visualization of the needle tip to ensure accurate sampling. Ultrasound guided technique has lower nondiagnostic and false negative cytology rates compared to palpation technique [48, 55]. US guided FNA is preferred for difficult to palpate nodules, predominantly cystic or posteriorly located nodules [i]. In practise more clinicians are using ultrasound guided FNA (either free hand technique or with the help of a needle guide) over palpation guided technique for all thyroid FNA.

Indications for FNA

Over the years there has been a change in guidelines with regards to judiciously selecting the thyroid nodules for further evaluation with FNA. The approach has been toward a bourgeois direction. The changes are reflected in the recently published ATA guidelines [one] (Table ii).

FNA should not be performed on thyroid nodules < 1 cm in diameter with some exceptions discussed later in this department. For nodules > ane cm, FNA is recommended to further evaluate the thyroid nodule with some exceptions [one].

FNA biopsy is recommended for nodules > i cm with high suspicion features (solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with either one or more of features: irregular margin or microcalcification or taller than wide shape or rim calcification or evidence of actress thyroidal extension; estimated malignancy risk of 70–90 %) or > ane cm with intermediate suspicion features (hypoechoic solid nodule with smooth margins without microcalcification, extra thyroidal extension or taller than wide shape; estimated malignancy run a risk 10–xx %). Low suspicion features include isoechoic or hyperechoic solid nodule or partially cystic nodules with eccentric solid areas without the features of highly suspicious nodule (estimated malignancy run a risk of 5–10 %). Cyst drainage may also be performed, especially in symptomatic patients. Very low suspicion features include spongiform (assemblage of multiple microcystic components in more than 50 % of the nodule volume [40, 52]) or partially cystic nodules without the features of the in a higher place mentioned suspicious category features (estimated malignancy risk of < 3 %).

Cervical lymph node assessment (anterior, key and lateral compartment) should exist performed in all patients with thyroid nodule. Suspicious lymph nodes (microcalcification, cystic, peripheral vascularity, hyperechogenicity, round shape [56]) should accept FNA evaluation for cytology and washout Tg measurement. This is one of the scenarios where a subcentimeter thyroid nodule associated with these abnormal cervical lymph nodes should undergo FNA. Likewise in patients with the clinical take chances factors mentioned in Tabular array i and with the high pretest likelihood for thyroid cancer associated with these features, FNA at sizes lower than those recommended can be considered [1, 13]. PET positive nodules have a higher incidence of malignancy ~xl–45 % and FNA is recommended in nodules > 1 cm [1, 57, 58].

The The states features of each nodule should exist assessed independently to determine the demand for FNA biopsy. The nodules that are not biopsied should be monitored with periodic US with follow upwards duration and frequency based on factors including sonographic features and risk factors. Too conservative approach of active surveillance without FNA may be reasonable approach for patients who encounter the above FNA criteria just are at high surgical risk and those with relatively short life expectancy [one].

Cytological diagnosis

FNA cytology of the thyroid nodule is reported using diverse nomenclature systems. In Usa, the Bethesda Arrangement for Reporting Thyroid Cytopathology is the most commonly used. The diagnostic groups suggested are [59, 60]:

  • ➢ Benign – This includes macrofollicular or adenomatoid/hyperplastic nodules, colloid adenomas (well-nigh common), nodular goiter, lymphocytic and granulomatous thyroiditis. 0–3 % predicted risk of malignancy.

  • ➢ Follicular lesion or atypia of undetermined significance (FLUS or AUS) – This includes lesions with singular cells, or mixed macro- and microfollicular nodules. 5–fifteen % predicted chance of malignancy.

  • ➢ Follicular neoplasm or suspicious for a follicular tumour (FN/SFN) – This includes microfollicular nodules, including Hurthle cell lesions/ suspicious for Hurthle jail cell neoplasm. fifteen–30 % predicted hazard of malignancy.

  • ➢ Suspicious for malignancy. threescore–75 % predicted risk of malignancy.

  • ➢ Malignant. This includes PTC (nigh common), MTC, anaplastic carcinoma, and loftier-grade metastatic cancers. 97–99 % predicted risk for malignancy.

  • ➢ Nondiagnostic or Unsatisfactory. 1–4 % predicted risk of malignancy.

Other classification systems such as UK-RCPath (Royal Higher of Pathology) or Italian AME Consensus and modifications of these systems are also used to report cytology results [thirteen]. The estimation of the FNA smears is influenced by the expertise of the cytopathologist and in that location is inherent limitation to the reproducibility of the cytopathological results [45, 46, 61, 62]. Accuracy of the results is also influenced by the skill of the operator, FNA technique and specimen preparation. FNA results are categorized as either diagnostic/satisfactory, if it contains at least six groups, each containing of at least 10 well-preserved thyroid epithelial cells, else nondiagnostic/unsatisfactory [11, thirteen]. FNA results are crucial in guiding the further steps in the management of thyroid nodule.

Benign cytology (~seventy % of all FNAs) is the nigh common finding on FNA [13, 45, 48]. Indeterminate results (~ten–15 % of all FNAs), which are without a distinct cytological diagnosis [45, 46, 63], include the diagnostic groups of FLUS/AUS and FN/SFN. This diagnostic group possesses a claiming in terms of adjacent steps for management. In practise, although the bulk of these patients undergo surgery, the majority of the nodules are found benign. Molecular tests have been developed in an attempt to determine whether an indeterminate nodule is benign or malignant.

Nondiagnostic or unsatisfactory smears (~15 % of all FNAs) have inadequate number of cells to make a diagnosis and event from cystic fluid without cells, bloody smears, or improper techniques in preparing slides [11, 64–67].

Molecular markers

The use of molecular markers in thyroid nodules has been suggested for diagnostic purpose in case of indeterminate cytological diagnosis, to assist with decision making most management choice (surgical handling). These tests are performed using samples from needle washings collected during fine needle aspiration biopsy. The molecular tests which take the most available data are: Afirma Gene-expression Classifier [68], 7-cistron panel of genetic mutations and rearrangements [69] and galectin-3 immunohistochemistry [70].

The Afirma gene-expression classifier (167 GEC; mRNA expression of 167 genes) evaluates for the presence of benign cistron expression profile. It has a loftier sensitivity (92 %) and negative predictive (93 %) value but low positive predictive value and specificity (48–53 %) [68, 71]. It is used every bit a rule out examination to identify beneficial nodules. A benign GEC result predicts low risk of malignancy but the nodules classified every bit benign still accept ~5 % hazard of malignancy [71, 72].

The seven factor mutation and rearrangement analysis panel evaluates for BRAF, NRAS, HRAS and KRAS point mutations and common rearrangements of RET/PTC and PAX8/PPARγ. Information technology has a high specificity (86–100 %) and positive predictive value (84–100 %) but poor sensitivity (reported from 44 to 100 %) [69, 73–75]. Information technology is being used as a rule in test for thyroid malignancy.

This field is evolving and many other molecular tests are being adult (mRNA markers, miRNA markers, etc.) [70, 76–80]. None of the bachelor tests can decisively ostend the presence or absence of malignancy in all indeterminate thyroid nodules. Long term data are needed to confirm its utility in clinical practice. Most of the assays are trained on classic papillary cancers and have limited data in follicular cancers. I has to consider functioning of a diagnostic test based on prevalence of the affliction (cancer); at loftier cancer prevalence rate, NPV falls dramatically. Tests are expensive and in deciding their use in direction of indeterminate nodules, one should as well consider the pretest probability of malignancy with clinical risk features, sonographic characteristics and the size of the nodule, the caste of patient concern and patient preferences, and if the patient would be able to come back for a follow up. In the electric current settings, molecular testing should just be used to supplement cytopathologic evaluation or clinical and imaging cess [81]. Patients should be counselled regarding the electric current clinical utility and limitations of these tests. The AACE Guidelines recommend neither for nor against their use in clinical practice [xiii]. This field is new and evolving, the recommendations of the use of these molecular tests tin can be expected to modify in the hereafter.

Management

Various factors including serum TSH, clinical risk gene assessment, size of the nodule, ultrasound characteristics, patient preferences and results of the FNA biopsy should be considered in management of thyroid nodule. FNA biopsy cytological diagnosis is the most crucial determinant in decision making.

For autonomous or hyperfunctioning nodules, if the patient has hyperthyroidism, management options include radioiodine therapy or surgery. If the patient has subclinical hyperthyroidism (low TSH with normal FT4), management depends on clinical risk of complications (atrial fibrillation in patients over the age of 60 to 65 years and osteoporosis in postmenopausal women) and the degree of TSH suppression [82–84].

Nodules less than 1 cm with some exceptions should not be biopsied and followed up closely [i]. Also for these patients the frequency and elapsing of follow up will depend on the boosted risk factors nowadays.

For nodules selected for FNA, direction primarily depends on cytologic results. According to the Bethesda Classification scheme, FNA of the nodules yields half-dozen major results with subsequent unlike direction for each category. However the management of indeterminate nodules (FLUS/AUS and FN/SFN) has similar principles and will exist discussed together.

Nodules with beneficial cytology

The adventure of malignancy in nodules reported as beneficial is 0–3 % [85–88]. Patients with benign nodules are usually managed conservatively without surgery; immediate further diagnostic studies are not required [1]. Though at that place is a run a risk of faux negative results associated with cytology reporting, initial benign FNA has negligible mortality take chances in long term follow up [89].

The frequency and duration of follow up of the benign nodules have been variable in clinical practice. In the nodules that have suddenly enlarged, hemorrhage and cystic degeneration is the most common cause; malignancy is rare even in nodules that have grown [xc, 91]. There is no clear prove to suggest that nodules with larger size (> iii or 4 cm) with benign cytology should be managed differently than smaller nodules [62, 92]. The follow upwards of the benign cytological diagnosis should be decided on the sonographic characteristic of the nodule rather than growth [93, 94].

Per the 2015 ATA guidelines, nodules with high suspicious US pattern should have repeat US and FNA within 12 months; while those with low to intermediate suspicious U.s.a. pattern should have repeat US in 12–24 months. The conclusion to repeat FNA or observe with echo United states of america is based on > xx % growth in at least 2 nodule dimensions or > l % increment in nodule volume or the appearance of new suspicious Us pattern. Nodules with very depression suspicious patterns should have U.s.a. repeated at 24 months or more. Continued surveillance for a nodule with echo 2d benign cytology is not needed [1, 95].

Surgical removal may be needed for benign nodules if they are causing force per unit area or structural symptoms. TSH suppressive therapy has no role in the management of benign nodule. Percutaneous ethanol ablation can be considered for thyroid cysts and certain complex thyroid nodules [13].

Indeterminate nodules (FLUS/ AUS or FN/SFN)

FLUS/AUS and FN/SFN have 5–15 % and fifteen–30 % predicted hazard of malignancy, respectively. Practice pattern vary considerably in management of indeterminate nodules [96]. Molecular tests have impacted the management strategies in this category. The clinical risk factors, US characteristics (Elastography in add-on can be considered in these cases), patient preference and availability/feasibility of the molecular tests should be considered in the decision making process. Some scores such every bit Mcgill thyroid nodule scores have been tried in pre-operative conclusion making in thyroid nodules [97].

FLUS/AUS category includes lesions with focal architecture or nuclear atypia whose significance cannot be further determined and specimens that are limited because of poor fixation or obscuring blood [98]. The interpretation of the features which incorporate this category is based entirely on the observer which results in poor reproducibility and a 2nd review by experienced high volume cytopathologist can be considered [99, 100]. Repeat FNA or molecular testing (actress sample can be nerveless at the time of initial testing) can be considered to supplement the malignancy gamble assessment [68, 69, 101, 102]. If either of them is non performed or inconclusive, based on clinical and United states risk factors and patient preference, either surveillance with repeat US or diagnostic surgery can be chosen [1]. With the new developments in molecular testing, the approach to this category may modify in the future.

For FN/SFN, surgical excision for diagnosis had been an established practice. With the molecular testing being available, it tin can be used to supplement the malignancy risk assessment again afterwards considering the clinical and Us risk factors and patient preference [68, 103]. If the molecular testing is non available/performed or inconclusive, diagnostic surgical excision can be considered. Patients with surgical histology specimens showing benign follicular adenoma (absenteeism of capsular or vascular invasion) do not require further treatment. Still, patients whose surgical histology shows follicular thyroid cancer might demand to accept a completion thyroidectomy [i, 13, 69].

Suspicious for malignancy

This category includes specimens strongly suspicious for malignancy, but lacking diagnostic criteria [60]. Diagnostic surgery and histologic examination would be needed in nearly of the cases. For nodules with the cytology reported every bit suspicious for malignancy, after consideration of clinical and United states of america risk factors and patient preference, molecular tests (seven-factor mutation and rearrangement console) can be considered if it would alter the surgical determination making, which is the recommended modality of direction [one, 69, 104].

Every bit more data become bachelor on the molecular tests, the direction of this category may potentially change in the future.

Malignant

This category includes papillary cancer, follicular carcinoma, Hurthle cell (oncocytic) carcinoma, medullary cancer, thyroid lymphoma, anaplastic cancer, and cancer metastatic to the thyroid. Surgery is generally recommended for these patients [one, 13, 105, 106]. Circumstances in which agile surveillance may be considered include low take chances papillary microcarcinoma (< 1 cm), patients with loftier surgical take chances, brusk life expectancy and if concurrent surgical or medical bug need to be addressed get-go. For cancer due to metastasis, further investigations to find the primary lesion should be undertaken.

Nondiagnostic

This category includes cytologically inadequate specimen. If no or scant follicular tissue is obtained, the absence of malignant cells does not mean a negative biopsy in patients with nondiagnostic FNA. In such cases, FNA using The states-guidance should exist repeated and if possible with onsite cytological cess [one, 13, 107]. If the results are still nondiagnostic, cadre needle biopsy or shut observation or diagnostic surgical excision can be considered depending on the suspicious pattern on sonography, clinical risk factors and growth of the nodule during active surveillance [1, 108, 109].

Pregnancy

The evaluation of a thyroid nodule in a pregnant woman should be done in aforementioned style equally one would in nonpregnant state. However, for the pregnant women with nodule and suppressed TSH that persists later first trimester, further evaluation can exist delayed afterwards pregnancy and cessation of lactation when the radionuclide browse can be performed. For a nodule with FNA suggesting PTC, if it is discovered early in pregnancy and if it grows substantially (twenty % growth in at least ii dimensions or 50 % increase in book or new suspicious US pattern) by 24 weeks gestation or if suspicious cervical lymph nodes are noted on US, surgery should be considered during the second trimester of pregnancy. Notwithstanding, if information technology is diagnosed in the latter half of the pregnancy or if it is diagnosed early in the pregnancy and remains stable by midgestation, surgery may be performed after commitment. Consideration could be given to assistants of levothyroxine therapy to continue the TSH in the range of 0.i–one mU/L [1, thirteen, 110–112].

Conclusions

Thyroid nodules are common and carry a iv–six.5 % adventure of malignancy. The initial evaluation in all patients with a thyroid nodule includes a detailed history and physical examination assessing risk factors, measurement of serum TSH and neck ultrasonography to assess the size and suspicious characteristics. Fine needle aspiration (FNA) biopsy is an accurate and toll constructive way to evaluate thyroid nodules. Nodules with diameter < i cm with some exceptions crave no FNA and can exist observed with a follow up Us. Patients with benign nodules are usually followed without surgery. Where available, mRNA classifier system or mutational analysis can exist used for further evaluating FNA aspirates with cytology of follicular neoplasm or follicular lesion/ atypia of undetermined significance. Patients with cytology suggesting cancer should be referred for surgery. The loftier prevalence and increasing diagnosis of incidental thyroid nodules requires clinicians to prefer testify-based approaches to evaluate, risk stratify and provide appropriate treatment. As more than show becomes available, active surveillance may become possible for selected cases of thyroid cancer patients.

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  1. Mayo Clinic Higher of Medicine, Rochester, MN, 55905, U.s.a.

    Shrikant Tamhane & Hossein Gharib

  2. Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Shrikant Tamhane & Hossein Gharib

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Correspondence to Shrikant Tamhane.

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Tamhane, Southward., Gharib, H. Thyroid nodule update on diagnosis and management. Clin Diabetes Endocrinol two, 17 (2016). https://doi.org/10.1186/s40842-016-0035-seven

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Keywords

  • Thyroid
  • Thyroid nodules
  • Molecular markers
  • Beneficial
  • Malignant
  • FNA
  • Management
  • Ultrasonography

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