Approach to Thyroid Nodules

Paul R. Maddox, MCh, FRCS ■ Malcolm H. Wheeler, MD

Thyroid nodules are the most common thyroid disorder, and their incidence increases with advancing age.1 The prevalence of palpable thyroid nodules in adult Americans has been estimated to be 4% to 7%2; about 9 million adults harbor a thyroid nodule,3 and new nodules appear at a rate of 0.08% per year.4 However, the true prevalence of thyroid nodules has been shown to be far greater.5 Autopsy studies reveal that 50% of adults had nodules, most of which were impalpable.5-6 In agreement with these data, Horlocker and colleagues have shown, using high-resolution ultrasonography, that 50% of patients have thyroid nodules by the age of 50 years.7

Most thyroid nodules are benign, and thyroid cancer is comparatively rare, with an incidence of approximately 4 per 100,000 individuals per year,8 constituting only 1% of all malignancies3 and 0.5% of all cancer-related deaths.9 Postmortem data, however, have demonstrated that occult thyroid cancer, which is mostly papillary, has a prevalence ranging from 6% to 28%.10,11 Although the natural history of thyroid carcinoma usually involves a slow, indolent course, with a death rate of only 6 per 1 million, it is equally true that small, seemingly innocuous tumors with a diameter smaller than 1 cm have been known to develop into progressive metastatic disease and cause death.12

It is the anxiety induced by the fear of malignancy within the solitary thyroid nodule against a background of common benign nodular disease that generates the diagnostic dilemma for the clinician. Consequently, the management of thyroid nodules has been controversial,13-14 with the ironic stance of some physicians advocating aggressive surgery15 and many surgeons continuing to advise a more conservative approach.16 Clearly, the truth must lie in the gray area between these two extremes, and the approach to thyroid nodule management must be a selective one, embracing the appropriate use of continually improving diagnostic techniques, thereby identifying those patients with malignancy who require surgery and avoiding thyroidectomy in most patients with benign lesions.

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