Management of Incidental Thyroid Mass

Initial Evaluation

The American College of Radiology recommends that the next step after an incidental finding of a thyroid mass should be a dedicated thyroid ultrasound followed by fine-needle aspiration (FNA) of nodules meeting size and suspicious feature criteria 1, 2
Thyroid-stimulating hormone (TSH) measurement should be the first laboratory test to assess thyroid function, as recommended by the American College of Radiology 1, 2
Dedicated thyroid and central neck ultrasound is essential to characterize the nodule(s) and evaluate for suspicious lymph nodes, according to the National Comprehensive Cancer Network 3, 2
Lateral neck ultrasound should be performed if there are concerning features in the thyroid nodule or central neck, as suggested by the National Comprehensive Cancer Network and the American College of Radiology 3, 2

The National Comprehensive Cancer Network recommends that FNA should be performed on nodules ≥1-1.5 cm with suspicious ultrasound features 3, 2
FNA should also be performed on nodules with suspicious lymph nodes regardless of size, as recommended by the National Comprehensive Cancer Network and the American College of Radiology 3, 2
Smaller nodules (<1 cm) without suspicious features can be followed clinically without immediate FNA, according to the National Comprehensive Cancer Network and the American College of Radiology 3, 2

The National Comprehensive Cancer Network recommends that benign cytology should be followed up with ultrasound at appropriate intervals 3
Malignant cytology should be treated with total thyroidectomy with or without central neck dissection depending on tumor size and other risk factors, as recommended by the National Comprehensive Cancer Network 3, 4
Indeterminate cytology should be considered for molecular testing to further stratify risk, according to the National Comprehensive Cancer Network 3

The majority of thyroid nodules are benign, but proper evaluation is essential to identify the minority that are malignant, as noted by the American College of Radiology 1, 2

Overdiagnosis and overtreatment of small, indolent thyroid cancers is a concern; not all nodules require immediate biopsy, as cautioned by the American College of Radiology 1, 2
Failure to evaluate for functional status with TSH may miss hyperfunctioning nodules that require different management, as warned by the American College of Radiology 1, 2
Incomplete neck evaluation may miss regional lymphadenopathy that would change management, according to the National Comprehensive Cancer Network and the American College of Radiology 3, 2