2
Thyroid Nodules
Figure 1. Initial Evaluation, Treatment and Follow Up of the
Pediatric Thyroid Nodule
Solitary or suspicious thyroid
nodule detected by imaging
or physical examination
1
Benign
4
Nuclear thyroid
scintigraphy
Malignant
3
FNA under US guidance
Hypofunctioning
Inadequate or
Nondiagnostic
4
Indeterminate
or Suspicious
Repeat US in 6-12 mo.
Repeat US &
FNA in 3-6 mo.
Surgery
5
Malignant:
PTC/MTC
3
FTC
6
Benign: Check
adequacy of thyroid
hormone levels in
4 wks & follow
clinically
Repeat US in
6-12 mo.
Repeat
US every
1-2 yrs.
Repeat
FNA &/or
Surgery
5
TSH not suppressed
TSH suppressed
2
Hyperfunctioning
Nodule
stable &/or
benign FNA
Nodule
growing or
suspicious
findings
Nodule
stable
Nodule
growing &/or
abnormal
FNA
1
Assumes a solid or partially cystic nodule ≥1 cm or a nodule with concerning ultrasonographic
features in a patient without personal risk factors for thyroid malignancy.
2
A suppressed TSH indicates a value below the lower limits of normal.
3
Refer to PTC management guidelines or MTC management guidelines.
4
Surgery can always be considered based upon suspicious ultrasound findings, concerning clinical
presentation, nodule size >4 cm, compressive symptoms, &/or patient/family preference.
5
Surgery implies lobectomy + isthmusectomy in most cases. Surgery may be deferred in patients
with an autonomous nodule and subclinical hyperthyroidism, but FNA should be considered if the
nodule has features suspicious for PTC. Consider intraoperative frozen section for indeterminate
and suspicious lesions. Can consider total thyroidectomy for nodules suspicious for malignancy on
FNA.
6
Consider completion thyroidectomy ± RAI vs. observation ± TSH suppression based upon final
patholog y.
Diagnosis
