ATA Guidelines Tools

9 Treatment 19. When surgery is considered for patients with a solitary, cytologically indeterminate nodule, thyroid lobectomy is the recommended initial surgical approach. This approach may be modified based on clinical or sonographic characteristics, patient preference and/or molecular testing when performed. (SR-M) 20. A) Because of increased risk for malignancy, total thyroidectomy may be preferred in patients with indeterminate nodules which are cytologically suspicious for malignancy, positive for known mutations specific for carcinoma, sonographically suspicious, large (>4 cm), or in patients with familial thyroid carcinoma or history of radiation exposure, if completion thyroidectomy would be recommended based on the indeterminate nodule being malignant following lobectomy. (SR-M) B) Patients with indeterminate nodules who have bilateral nodular disease, those with significant medical comorbidities, or those who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe, may undergo total or near-total thyroidectomy, assuming completion thyroidectomy would be recommended if the indeterminate nodule proved malignant following lobectomy. (WR-L) 21. A) Patients with multiple thyroid nodules >1 cm should be evaluated in the same fashion as patients with a solitary nodule >1 cm, excepting that each nodule >1 cm carries an independent risk of malignancy and therefore multiple nodules may require FNA. (SR-M) B) When multiple nodules >1 cm are present, those with a suspicious sonographic pattern (Table 1, Figure 2) should be aspirated preferentially. FNA should be performed preferentially based upon nodule sonographic pattern and respective size cut-off (Table 1, Figure 2). (SR-M) C) If none of the nodules has a high or moderate suspicion sonographic pattern, and multiple sonographically similar very low or low suspicion pattern nodules coalesce with no intervening normal parenchyma, the likelihood of malignancy is low and it is reasonable to aspirate only the largest nodules (>2 cm) or continue surveillance without FNA while observing the others with serial US examinations. (WR-L)

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