Q: What is the follow-up care/management for benign thyroid nodules and subclinical hyperthyroidism (persistent thyroid-stimulating hormone [TSH] approximately 0.01 µU/mL)?
A: The American Association of Clinical Endocrinologists recommends making sure that the suppressed TSH is persistent by repeating thyroid function tests in two to four months and excluding other causes of low TSH, such as nonthyroidal illness or medications, and then monitoring thyroid function tests every six months. Any patient with symptoms of hyperthyroidism, atrial fibrillation, or weight loss would be a candidate for treatment, as would anyone with osteoporosis or osteopenia. For additional information, see
N Engl J Med. 2001;345:512-516.
If a patient has a suppressed TSH and thyroid nodules, a nuclear thyroid scan would be indicated to determine whether there are any functioning or “hot” nodules. A hot nodule is generally benign and thus does not require fine-needle aspiration (FNA) but could be resected to cure the hyperthyroidism. A nodule that is not “hot” would require an ultrasound looking for characteristics that are concerning for malignancy and FNA for cytologic evaluation. Nodules diagnosed as benign still need to be followed, as the false-negative rate can be as high as 5%. The American Thyroid Association recommends serial ultrasound to follow benign nodules starting 6-18 months after the initial FNA, and “if nodule size is stable, the interval before the next clinical examination or ultrasound may be longer” (Thyroid. 2006;16:109-142).