Thyroid Nodule Evaluation: Current, Evolving, and Emerging Tools

Thyroid nodules are common. They are predominantly benign and asymptomatic and do not require evaluation, treatment, or monitoring, while the majority of thyroid malignancies are low-risk neoplasms that do not have an impact on survival. Diagnosis and treatment are costly and often have a detrimental impact on a patient’s physical, emotional, and financial status. In the United States, well over 500 000 fine-needle aspirations (FNAs) of thyroid nodules are performed per year, with as many as 200 000 of them being unnecessary. Similarly, in European countries, such as Germany and France, with well-functioning National Health Services, the vast majority of thyroidectomies performed for nodular thyroid disease have benign histopathology, while the minority that proves to be malignant is predominantly composed of low-risk thyroid cancers. Guidelines from the American Association of Clinical Endocrinology (AACE), Associazione Medici Endocrinologi (AME), American Thyroid Association (ATA), and American College of Radiology provide recommendations for reducing the collective burden of evaluating and treating thyroid nodules and low risk thyroid cancers. However, their impact has been limited. The variation in ultrasound (US) risk classification systems and interobserver assessments of thyroid nodule features contribute to this.

Over the past 3 decades, clinical practice guidelines have emerged as an increasingly important tool to aid clinicians in managing a host of medical conditions. Guidelines are regularly cited in publications and medical education forums, and they are used as a basis for medical decision making in both clinical and administrative settings. Yet, despite their widespread clinical use, there is substantial room for improvement. This includes:
• Establishing the cost effectiveness and validity of recommendations, which are often based on expert opinion, retrospective studies, and study populations that are not generalizable.
• Implementing guidelines
• Creating mechanisms for vetting guideline recommendations in various clinical situations and across different populations and cultures
• Gauging their implementation by tracking their use and applicability
• Addressing their often-formidable length and the wealth of information they contain, which makes them hard to navigate as well as absorb and retain
• Providing timely updates of narrative multi-authored, highly validated documents
• Disseminating and distributing them Clinicians routinely using and assessing their effectiveness in real-world settings

The pieces in this issue of Frontiers in Endocrinology are written by a diverse group of authors representing various specialties and regions. The challenges and how they are presently being addressed are reviewed. Views are offered about what additional research and efforts are required to facilitate the care of patients with clinically significant thyroid nodules, while reducing the substantial burden incurred by those who would not benefit from further evaluation and treatment.