Incidental thyroid nodules: should we observe or operate?
Reviewed by Shabbir Akhtar

Thyroid nodules are extraordinarily prevalent, detected by physical examination in 7% and by imaging studies in 67% of the population. Although most of these nodules are benign, up to 20% are found to be malignant on excision. It’s a very difficult decision for a clinician to offer surgery or observation for such incidental thyroid nodules. The precise reasons for the increased incidence of thyroid cancer are difficult to determine. Increased use of diagnostic imaging capable of exposing subclinical disease is considered the most likely explanation. More than half of the cases detected incidentally through imaging can be labelled as low risk cancers. There is much uncertainty about the benefits of surgical intervention for low-risk thyroid cancers, especially papillary thyroid cancer. The number of thyroidectomy procedures performed to treat thyroid cancer in the United States has risen by 60% over the past 10 years. Thyroidectomy usually requires hospital admission and carries a 1- 6% risk of complications, including hypoparathyroidism and recurrent laryngeal nerve injury. Two recent large observational studies from Japan offering patients with low-risk thyroid cancer (papillary microcarcinoma) the choice of thyroidectomy or active surveillance suggest that small papillary thyroid cancer may never progress to cause symptoms or death. These studies provide an opportunity for the medical community to start a dialogue among all stakeholders about novel management approaches for these incidentally detected cancers. The costs and psychosocial implications of prolonged surveillance versus current accepted treatment of surgery also need to be assessed. With time, molecular markers may add more objective measures by providing a better understanding of the biology and behaviour of individual cancers. Until these studies are completed, patients must be objectively and supportively presented with all possible management options.

Incidental thyroid nodules and thyroid cancer: considerations before determining management.
Tufano RP, Noureldine SI, Angelos P.
JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;141(6):566-72.