I Initial Assessment of the Thyroid Nodule (indicating risk of malignancy)

• Size more than 1 cm
• Recent increase in size
• Associated symptoms: dysphagia, hoarseness of voice, local pain, stredor, dyspnoea, systemic symptoms suggestive of metastatic disease.
• Age less than ten or more than 60 yrs
• Male sex
• Family history of thyroid cancer, breast cancer or previous hysterectomy
• History of radiation

II Fine-Needle Aspiration Cytology (FNAC)

• To be done in all cases
• * Ultrasound may be considered in areas endemic for goiter
  FNAC is to be done by a trained cytopathologist or endocrinologist/surgeon with a cytologist for assistance
• Site of FNAC – it is to be done from a solitary/dominant nodule of a multinodular goiter/solid part of a mixed lesion (ultrasound guidance)

III Management Based on FNAC findings

• Benign: follow up six monthly, reassure
• Inconclusive: treat according to risk category/if clear fluid aspirated, treat as benign
• Hemorrhagic -exclude malignancy

If, Malignant or Suspicious, operate based on the following protocol

(a) When diagnosis is confirmed preoperatively When well differentiated Ca thyroid is confirmed in a patient preoperatively near total thyroidectomy is recommended.

(b) When diagnosis is not confirmed preoperatively i.e. FNAC is suspicious – When preoperatively diagnosis is not confirmed or is doubtful, frozen section biopsy (if available) – may be used to help surgeons.

The decision to undertake total/near total thyroidectomy may be made also by the clinical judgement of the surgeon based on the intraoperative findings.

© This pertains to the histological surprise of malignancy after thyroidectomy (Here the diagnosis was not entertained preoperatively but after thyroidectomy the pathologist reports well – differentiated carcinoma) – After hemithyroidectomy (lobectomy + isthmusectomy) if there is a histological surprise of malignancy, in this situation re-exploration and complete total thyroidectomy is recommended. This is also done in following situations

(i) In follicular carcinoma

(ii) In high risk papillary carcinoma thyroid by anyone of the risk stratification classification.

In low risk group and in cases of papillary carcinoma less than 1 cm, the decision to re-explore and complete thyroidectomy should be decided by the surgeon and the patient after complete discussion.

(d) Pertains to histological surprise of malignancy after subtotal thyroidectomy In the event of histological surprise of malignancy after subtotal thyroidectomy.

(i) Patient can be followed up when complete lobectomy of the more affected side and subtotal lobectomy on the opposite side has been done.

(ii) When bilateral subtotal lobectomy has been done, the decision to reoperate or to ablate the remnant can be decided by discussion between the surgeon, endocrinologist and nuclear medicine specialist.