[G] How should thyroid nodules be managed in patients with GD?

    If a thyroid nodule is discovered in a patient with GD, the nodule should be evaluated and managed according to recently published guidelines regarding thyroid nodules in euthyroid individuals. 1/++0

Thyroid cancer occurs in GD with a frequency of 2% or less (139). Thyroid nodules larger than 1–1.5 cm should be evaluated before radioactive iodine therapy. If a radioactive iodine scan is performed, any nonfunctioning or hypo-functioning nodules should be considered for fine needle aspiration (FNA), as these may have a higher probability of being malignant (46). If the cytopathology is indeterminate (suspicious) or is diagnostic of malignancy, surgery is advised after normalization of thyroid function with ATDs. Disease-free survival at 20 years is reported to be 99% after thyroidectomy for GD in patients with small (≤1 cm) coexisting thyroid cancers (140).

The use of thyroid ultrasonography in all patients with GD has been shown to identify more nodules and cancer than does palpation and 123I scintigraphy. However, since most of these cancers are papillary microcarcinomas with minimal clinical impact, further study is required before routine ultrasound (and therefore surgery) can be recommended (141,142).

Technical remarks: Both the ATA and AACE, the latter in conjunction with the European Thyroid Association and Associazione Medici Endocrinologi, have recently published updated management guidelines for patients with thyroid nodules (143,144).