Incidental Thyroid Nodule: OK, Now What?

Gordon H. Sun, MD, MS


December 13, 2016

Surgery Now, Later, or Never?

Either surgery or "active surveillance" is an option for indeterminate FNA findings (eg, FLUS/AUS), as well as for patients with low-risk papillary thyroid microcarcinomas without neck metastases or recurrent laryngeal nerve palsy.[14] Thyroid surgery has the distinct advantage of offering more definitive management and is the most commonly pursued option.

Active surveillance, also known as "expectant management" or "watchful waiting," is a therapeutic strategy with curative intent in which eligible patients are closely monitored and active treatment is delayed until the cancer shows significant progression. This technique was first reported in 2002 for patients diagnosed with low-risk, localized prostate cancer and is currently being used in at least nine major centers worldwide.[24] Active surveillance is also being utilized or considered for other neoplasms, including DCIS,[25] nonmelanoma skin cancer,[26,27] and stage I renal masses.[28]

When the ATA guidelines on thyroid nodules were published in 2015, active surveillance was a little-understood option, results being publicly available from just two centers in Japan that had begun prospective observational studies in the 1990s.[29,30] However, Brito and colleagues[31] recently published a framework for evaluating patients with thyroid cancer who might be eligible for active surveillance, identifying a potential ideal candidate as one "usually older than 60 years of age with a thyroid nodule with well-defined borders and surrounding normal thyroid parenchyma who is willing to accept an observational management program under the guidance of an experienced thyroid cancer management team that uses high-quality neck ultrasonography."

The authors of a commentary published in November 2016 indicated that research into this novel treatment strategy is ongoing at centers in the United States, France, and Italy.[32,33] Dr Michael Tuttle, clinical director of the endocrinology service and professor of medicine at Memorial Sloan Kettering Cancer Center and one of the coauthors of the above commentary, stated that about 325 patients are now undergoing active surveillance of selected thyroid cancers at his institution [Personal communication].

Whether active surveillance will become a popular option for patients with indolent thyroid cancers is unknown.

Whether active surveillance will become a popular option for patients with indolent thyroid cancers is unknown. Recent research has demonstrated decreased postoperative complications, such as temporary vocal cord paralysis and hypoparathyroidism, in patients with papillary thyroid microcarcinomas who undergo thyroid surgery for progressive disease after active surveillance compared with those undergoing immediate surgery.[34] Dr Tuttle commented that his institution has become "more convinced that although thyroid hormone replacement is certainly beneficial, many times it does not completely replace the function of the normal thyroid and many people just don't feel normal after total thyroidectomy." However, it is not yet certain which clinical, radiologic, and histopathologic risk factors are predictive of advanced disease or other poor outcomes in individuals with papillary thyroid microcarcinoma.[35] There may be substantial costs to long-term surveillance, as well as potentially more complex surgery for patients with progressive disease, that could outweigh the greater short-term costs associated with upfront intervention.[36]

Brito and colleagues[31] also have observed that many patients may not be psychologically prepared to accept active surveillance, knowing that they carry a diagnosis of thyroid cancer. Finally, Dr Tuttle noted that "a lack of aggressiveness in patients who would benefit from surgery" owing to overemphasis of active surveillance would not be ideal, especially since thyroidectomy "is still a key lifesaving intervention for many patients diagnosed with thyroid cancer." For these reasons, the strategy remains highly controversial, and some authorities believe that active surveillance should be considered only in the context of an institutional review board-approved protocol.[37]

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