Controversies in the Management of Nodular Thyroid Disease

  • Judy Jin
  • Christopher R. McHenryEmail author


The American Thyroid Association guidelines serve as the foundation for the management of patients with nodular thyroid disease. While the evaluation and management of nontoxic nodular thyroid disease are straightforward, several areas of controversy exist including the appropriate management of patients with a thyroid nodule and an FNAB categorized as atypia/follicular lesion of undetermined significance (AFLUS), the intraoperative management and extent of thyroidectomy for patients with an FNAB suspicious for papillary thyroid cancer, and the extent of thyroidectomy for patients with benign nodular thyroid disease and an established indication for surgical therapy. Some of the controversy is related to the introduction of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) in 2008. This is especially true for AFLUS, a new heterogeneous category with at least eight cytologic possibilities that are neither definitively benign nor definitively neoplastic. Due to institutional variation in experience with the BSRTC, there is significant variation in the reported incidence and rate of malignancy for each cytologic category.

Thyroid lobectomy and isthmusectomy with intraoperative frozen section exam is the standard operation for a patient with nodular thyroid disease and a fine needle aspiration biopsy (FNAB) that is persistently nondiagnostic, AFLUS or suspicious for PTC. Thyroid lobectomy and isthmusectomy without FSE is the standard operation for patients with nodular thyroid disease and an FNAB classified as a follicular or Hurthle cell neoplasm. Definitive total thyroidectomy is performed for patients with a malignant FNAB. Clinical factors and the results of molecular testing may also lead to the performance of definitive total thyroidectomy in patients with indeterminate FNAB results.


Thyroid nodule Bethesda System for Reporting Thyroid Cytopathology Atypia/follicular lesion of undetermined significance Frozen section exam 


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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Surgery, Cleveland Clinic FoundationCaseWestern Reserve University School of MedicineClevelandUSA
  2. 2.Department of Surgery, MetroHealth Medical CenterCaseWestern Reserve University School of MedicineClevelandUSA

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