**8. Fine needle aspiration (FNA)**

FNA is the single most valuable, cost effective and accurate method in the evaluation of a nodular goitre. It has demonstrated a sensitivity and specificity of 65–98 and 72–100%, respectively [22]. The use of FNA results in fewer surgeries, reduced cost of care, while improving the malignancy yield at thyroidectomy [37]. Selection of which nodule to subject to FNA is crucial for optimum yield of the procedure. This is based on the sonographic criteria and the size cut-offs depending on which guideline one follows.

FNA is done as an outpatient procedure under local anaesthesia or no anaesthesia. 23–27 guage needles are used to obtain samples for cytopathology. For nodules with a high likelihood of non-diagnostic cytology (>25–50% cystic component) or sampling error (difficult to palpate or posteriorly located), ultrasound guided FNA is preferred [29].

To address variability in reporting thyroid cytopathology, **Bethesda System for reporting thyroid cytopathology** was introduced in 2007. Cytologic adequacy for reporting was defined as presence of at least six groups of well visualised follicular cells, each group containing at least 10 well preserved epithelial cells, preferably on a single slide. The Bethesda system recognises six diagnostic categories and provides an estimation of cancer risk within each category, which has been summarised in **Table 4**.


#### **Table 4.**

*The Bethesda system for reporting cytopathology: diagnostic categories and risk of malignancy [38].*

PTC, MTC and ATC can be diagnosed by cytopathology preoperatively. However, cytopathology cannot differentiate between FTC and follicular adenoma as histopathological findings of vascular and capsular invasion distinguish these entities.

## **9. Markers and molecular testing**

FNA specimens can also be investigated for molecular markers, mutations and rearrangements to assess the risk of malignancy, prognosis and decide further management strategies in cases of indeterminate cytology.

Thyroglobulin and calcitonin in the washout fluid from FNA of cervical lymph nodes can serve as potential markers for metastatic well differentiated thyroid carcinoma and MTC respectively. TG levels of <1 ng/ml in the washout fluid is reassuring, with higher levels corresponding to increasing probability of N1 disease. This is particularly useful in cases in which lymph nodes are cystic, cases with inadequate cytological evaluation and sono-cytological discordance [1].

The 2 most common molecular testing strategies are **mutational analysis** and **gene expression analysis (GEC)**, in which genetic information can be derived from the sample obtained in the original fine-needle aspiration.

Mutational analysis involves isolating DNA from thyroid follicular cells in the specimen and performing gene sequencing. For example, RET-PTC and AKAP9/ BRAF rearrangements, BRAF mutations can be associated with PTC and ATC of PTC origin. PTCs with BRAF mutation tend to be more aggressive, with greater propensity for extrathyroidal invasion and a more advanced clinical stage. FTCs are commonly associated with PAX8/PPARγ fusion in 20–50% of cases, followed by RAS mutations. The presence of markers like calcitonin and RET protein are suggestive of MTC. RET mutations are associated with fMTC, MEN2A and MEN 2B [22]. The seven gene mutation and rearrangement panel comprising of BRAF, NRAS, HRAS and KRAS point mutations, and rearrangements of RET/PTC1 and 3, and PAX8/PPARγ has a high specificity of 86–100% and a PPV of 84–100%, but poor sensitivity of 44–100%. It is being used as a **rule in test** for thyroid malignancy. However, while mutations in *RAS* genes (*HRAS*, *KRAS*, *NRAS*) are present in thyroid cancers, they are also present in nonmalignant thyroid neoplasms and in noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), and are therefore less specific. Furthermore, if no mutations are found, a thyroid malignancy with a mutation that was not assessed could still be present (~4%); therefore, mutational testing may lead to both false-negative and false-positive results, especially if *RAS* mutations are found.

The second type of molecular testing, gene expression classifier (GEC), uses a proprietary algorithm to analyse the expression of specific genes, the Afirma gene expression classifier (167 GEC), i.e. the mRNA expression of 167 genes, evaluates for the presence of a benign gene expression profile, with a high sensitivity of 92% and NPV of 93%, but low PPV and specificity of 48–53%. Hence it is used as a **rule out test** to identify benign nodules that do not require surgery. However one needs to bear in mind that nodules with a benign GEC result still have a 5% risk of malignancy [28]. MicroRNA analysis is a more recent method for molecular testing for which limited data is available.

#### **10. Management**

#### **10.1 Toxic adenoma and toxic multinodular goitre**

Patients with toxic adenoma and toxic multinodular goitre (Toxic MNG) can be managed with either radioactive iodine ablation (RAIA) or surgery with surgery

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• Advanced patient age

• Small goitre size

following scenarios:

• Comorbidities with increased surgical risk

• RAIU sufficient to allow therapy

• Previously operated or irradiated necks

• Lack of access to a high volume thyroid surgeon

• Symptomatic compression or large goitres >80 g

• Need for rapid correction of the thyrotoxic state

• Documented or suspected thyroid malignancy

• Coexisting hyperparathyroidism requiring surgery

**10.2 Management of thyroid nodule based on FNA findings**

drugs (ATDs) can be considered as an alternative [39].

• Large thyroid nodules, especially if >4 cm

• Substernal or retrosternal extension

• Relatively low uptake of RAI

because they are cytologically benign.

being preferred for Toxic MNG and RAIA for Toxic adenoma. For patients with toxic adenoma, the risk of treatment failure is <1% after surgical resection (ipsilateral thyroid lobectomy or isthmusectomy), whereas the risk of persistent hyperthyroidism and recurrent hyperthyroidism with radioiodine therapy is 6–18 and 3–5.5%, respectively. For patients with toxic multinodular goitre, the risk of treatment failure is <1% following surgery (near-total/total thyroidectomy), compared

Radioiodine therapy may additionally be preferred in the following scenarios:

Radioiodine therapy is contraindicated in pregnancy, lactation, coexisting

Surgery (near total/total thyroidectomy for multinodular goitre, ipsilateral thyroid lobectomy or isthmusectomy for toxic adenoma) can be preferred in the

In patients who are poor candidates for either therapies, long term anti-thyroid

If a nodule is found benign on cytology, no further immediate diagnostic studies or treatment is required. Infact more than 90% of detected thyroid nodules need no intervention because they have no ultrasound features to suggest malignancy or

Nodules with high suspicion pattern on ultrasound can be followed up with a repeat ultrasound and FNA within 12 months, whereas nodules with low to intermediate suspicion can have a repeat ultrasound at 12–24 months. If sonographic

thyroid cancer, inability to comply with radiation safety guidelines.

with 20% risk of need for retreatment following radioiodine therapy.

#### *Thyroid Nodule: Approach and Management DOI: http://dx.doi.org/10.5772/intechopen.91627*

*Goiter - Causes and Treatment*

**9. Markers and molecular testing**

management strategies in cases of indeterminate cytology.

cytological evaluation and sono-cytological discordance [1].

the sample obtained in the original fine-needle aspiration.

PTC, MTC and ATC can be diagnosed by cytopathology preoperatively. However, cytopathology cannot differentiate between FTC and follicular adenoma as histopathological findings of vascular and capsular invasion distinguish these entities.

FNA specimens can also be investigated for molecular markers, mutations and rearrangements to assess the risk of malignancy, prognosis and decide further

Thyroglobulin and calcitonin in the washout fluid from FNA of cervical lymph nodes can serve as potential markers for metastatic well differentiated thyroid carcinoma and MTC respectively. TG levels of <1 ng/ml in the washout fluid is reassuring, with higher levels corresponding to increasing probability of N1 disease. This is particularly useful in cases in which lymph nodes are cystic, cases with inadequate

The 2 most common molecular testing strategies are **mutational analysis** and **gene expression analysis (GEC)**, in which genetic information can be derived from

Mutational analysis involves isolating DNA from thyroid follicular cells in the specimen and performing gene sequencing. For example, RET-PTC and AKAP9/ BRAF rearrangements, BRAF mutations can be associated with PTC and ATC of PTC origin. PTCs with BRAF mutation tend to be more aggressive, with greater propensity for extrathyroidal invasion and a more advanced clinical stage. FTCs are commonly associated with PAX8/PPARγ fusion in 20–50% of cases, followed by RAS mutations. The presence of markers like calcitonin and RET protein are suggestive of MTC. RET mutations are associated with fMTC, MEN2A and MEN 2B [22]. The seven gene mutation and rearrangement panel comprising of BRAF, NRAS, HRAS and KRAS point mutations, and rearrangements of RET/PTC1 and 3, and PAX8/PPARγ has a high specificity of 86–100% and a PPV of 84–100%, but poor sensitivity of 44–100%. It is being used as a **rule in test** for thyroid malignancy. However, while mutations in *RAS* genes (*HRAS*, *KRAS*, *NRAS*) are present in thyroid cancers, they are also present in nonmalignant thyroid neoplasms and in noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), and are therefore less specific. Furthermore, if no mutations are found, a thyroid malignancy with a mutation that was not assessed could still be present (~4%); therefore, mutational testing may lead to both false-negative and false-positive results, especially if *RAS* mutations are found. The second type of molecular testing, gene expression classifier (GEC), uses a proprietary algorithm to analyse the expression of specific genes, the Afirma gene expression classifier (167 GEC), i.e. the mRNA expression of 167 genes, evaluates for the presence of a benign gene expression profile, with a high sensitivity of 92% and NPV of 93%, but low PPV and specificity of 48–53%. Hence it is used as a **rule out test** to identify benign nodules that do not require surgery. However one needs to bear in mind that nodules with a benign GEC result still have a 5% risk of malignancy [28]. MicroRNA analysis is a more recent method for molecular testing for

**90**

which limited data is available.

**10.1 Toxic adenoma and toxic multinodular goitre**

Patients with toxic adenoma and toxic multinodular goitre (Toxic MNG) can be managed with either radioactive iodine ablation (RAIA) or surgery with surgery

**10. Management**

being preferred for Toxic MNG and RAIA for Toxic adenoma. For patients with toxic adenoma, the risk of treatment failure is <1% after surgical resection (ipsilateral thyroid lobectomy or isthmusectomy), whereas the risk of persistent hyperthyroidism and recurrent hyperthyroidism with radioiodine therapy is 6–18 and 3–5.5%, respectively. For patients with toxic multinodular goitre, the risk of treatment failure is <1% following surgery (near-total/total thyroidectomy), compared with 20% risk of need for retreatment following radioiodine therapy.

Radioiodine therapy may additionally be preferred in the following scenarios:


Radioiodine therapy is contraindicated in pregnancy, lactation, coexisting thyroid cancer, inability to comply with radiation safety guidelines.

Surgery (near total/total thyroidectomy for multinodular goitre, ipsilateral thyroid lobectomy or isthmusectomy for toxic adenoma) can be preferred in the following scenarios:


In patients who are poor candidates for either therapies, long term anti-thyroid drugs (ATDs) can be considered as an alternative [39].

## **10.2 Management of thyroid nodule based on FNA findings**

If a nodule is found benign on cytology, no further immediate diagnostic studies or treatment is required. Infact more than 90% of detected thyroid nodules need no intervention because they have no ultrasound features to suggest malignancy or because they are cytologically benign.

Nodules with high suspicion pattern on ultrasound can be followed up with a repeat ultrasound and FNA within 12 months, whereas nodules with low to intermediate suspicion can have a repeat ultrasound at 12–24 months. If sonographic

evidence of growth (>20% increase in atleast two nodule dimensions, with a minimal increase of 2 mm, increase in volume by 50%) or appearance of a suspicious sonographic pattern, FNA should be repeated or monitoring continued with repeat ultrasound, with repeat FNA in case of continued growth. Nodules with very low suspicion pattern can have a repeat ultrasound at ≥24 months if >1 cm, rest do not require a routine sonographic follow up. If a nodule has a second benign cytology on repeat ultrasound guided FNA, then further surveillance with ultrasound is not required. Surgery may be considered in growing nodules >4 cm, presence of compressive symptoms or cosmetic concern. There is no role of levothyroxine suppression therapy in benign thyroid nodules.

For nodules with AUS/FLUS cytology, repeat FNA and molecular testing may be used to supplement malignancy risk assessment in addition to clinical and sonographic features. Mutational testing for BRAF in AUS/FLUS samples has high specificity, but low sensitivity for cancer. Testing for the seven gene panel of mutations and rearrangements (BRAF, NRAS, KRAS, HRAS, RET/PTC1, RET/PTC3, PAX8/PPARγ) offer a significantly higher sensitivity of 63–80%. On the other hand, molecular testing using the 167 GEC (gene expression classifier) in AUS/FLUS cytology has yielded a sensitivity and NPV of 90 and 95%, respectively, but only 53% specificity and 38% PPV for cancer. If repeat FNA and molecular testing are not performed or both are inconclusive, either surveillance or diagnostic surgical excision may be carried out based on clinical and sonographic risk factors and patient preference.

If cytology is suggestive of FN/SFN, diagnostic surgical excision is the longestablished standard of care. Clinical, sonographic pattern and molecular testing may be used to supplement the malignancy risk assessment. Testing for the seven gene panel of mutations in FN/SFN cytology has a sensitivity of 57–75%, specificity of 97–100%, PPV of 87–100%, NPV of 79–86%. Molecular testing with GEC is reported to have a 94% NPV, and a 37% PPV in the FN/SFN subgroup. If molecular testing is unavailable, a diagnostic surgical excision is the preferred treatment modality. No further treatment is required if the histopathology of surgical specimen is suggestive of a follicular adenoma. However, if the histopathology is suggestive of FTC, then a completion thyroidectomy may be required.

If the cytology is suspicious of papillary carcinoma (SUSP), surgical management is similar to that of malignant cytology, depending on clinical risk factors, sonographic characteristics and mutational testing if available. BRAF testing is estimated to have 36% sensitivity and 100% specificity, whereas testing with seven gene panel is reported to have 50–68% sensitivity, 86–96% specificity, 80–95% PPV and 70–75% NPV in this subgroup. On the other hand, GEC testing has a PPV (76%) similar to cytology, and a NPV of 85%, hence is not indicated in this cytological diagnosis. Molecular testing may be done if expected to alter the surgical decision making.

For a nodule with initial non diagnostic cytology, repeat FNA should be done with ultrasound guidance, and with on-site cytological evaluation if available. If the results are repeatedly non diagnostic, surgery should be considered for histopathological diagnosis in the presence of clinical and sonographic risk factors for malignancy, or growth of the nodule >20% in two dimensions detected during ultrasound surveillance.

Surgical management in cytologically indeterminate nodules (AUS/FLUS, FN/ SFN, SUSP) can be either hemithyroidectomy or near total or total thyroidectomy based on clinical risk factors (nodule >4 cm, family history, history of radiation) and findings on sonography, cytology and molecular testing.

If cytology is diagnostic of a primary thyroid malignancy, then thyroid surgery is the treatment of choice. The choice of surgery depends on the stage of the

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*Thyroid Nodule: Approach and Management DOI: http://dx.doi.org/10.5772/intechopen.91627*

involved lateral neck nodes.

high surgical risk or limited life expectancy [1].

tive necrosis and small vessel thrombosis.

is still suppressed.

for the remainder of gestation.

**11. Conclusion**

**10.3 Management in specific situations: pregnancy**

differentiated thyroid cancer. In tumours ≥4 cm, or with gross extrathyroidal invasion or clinically apparent nodal metastasis or distant metastasis, near total or total thyroidectomy is the treatment of choice. Therapeutic central compartment neck dissection should accompany the procedure in case of clinical involvement of central nodes. Therapeutic lateral neck compartmental neck dissection should be undertaken in case of biopsy proven metastatic lateral cervical lymphadenopathy. Prophylactic central compartment neck dissection can be considered in cases of papillary thyroid carcinoma with advanced primary tumour (T3/T4), or clinically

For thyroid cancers >1 cm and < 4 cm, with no gross extrathyroidal invasion/ nodal or distant metastasis, either lobectomy or near-total/total thyroidectomy can be considered. In tumours <1 cm, without extrathyroidal extension and nodal involvement, the initial surgical procedure should be a lobectomy, unless there are clear indications to remove the contralateral lobe. Active surveillance can be chosen in very low risk tumours like micropapillary carcinoma (tumour ≤1 cm), patients at

Newer minimally invasive methods like percutaneous ethanol ablation, radiofrequency, laser, microwave ablation, and high-intensity focused ultrasound have been tried and may be considered for treating clinically relevant benign thyroid nodules [40]. Recurrent cystic thyroid nodules with benign cytology can be considered for percutaneous ethanol injection (PEI) or surgical excision. Ethanol acts by coagula-

Thyroid nodules may enlarge slightly during pregnancy, though this does not imply malignant transformation. Patients with suppressed TSH beyond 16 weeks of pregnancy should be monitored until after delivery and cessation of lactation, followed by a radionuclide scan to assess the functional status of the nodule if TSH

In euthyroid and hypothyroid patients, FNA should be done if clinically and sonographically indicated similar to non-pregnant patients. If PTC is diagnosed by cytology during pregnancy, surgery should be considered during pregnancy only if there is substantial growth (>20% increase in atleast two nodule dimensions, with a minimal increase of 2 mm, increase in volume by 50%) before 24–26 weeks of gestation, or if ultrasound reveals cervical nodes suspicious of metastatic disease. The surgery should be carried out in second trimester before 24 weeks to minimise the risk of miscarriage. If the disease remains stable by mid gestation, or diagnosed in second half of the pregnancy, surgery may be deferred until after delivery. As higher TSH levels may correlate with a more advanced stage of cancer, thyroid hormone therapy can be initiated if TSH > 2 mIU/L, with a target TSH of 0.3–2 mIU/L

Thyroid nodules pose a common clinical problem to physicians and surgeons alike. The primary concern in the evaluation of thyroid nodules is exclusion of malignancy while bearing in mind that most thyroid nodules are benign. With the advent and easy availability of high-resolution ultrasound, reliable of characterisation is possible while deciding on further testing for FNA. FNA is the single most valuable cost effective and reliable investigation for risk stratification, complemented by clinical risk factors. New molecular markers can aid in risk stratification

#### *Thyroid Nodule: Approach and Management DOI: http://dx.doi.org/10.5772/intechopen.91627*

*Goiter - Causes and Treatment*

patient preference.

decision making.

ultrasound surveillance.

suppression therapy in benign thyroid nodules.

evidence of growth (>20% increase in atleast two nodule dimensions, with a minimal increase of 2 mm, increase in volume by 50%) or appearance of a suspicious sonographic pattern, FNA should be repeated or monitoring continued with repeat ultrasound, with repeat FNA in case of continued growth. Nodules with very low suspicion pattern can have a repeat ultrasound at ≥24 months if >1 cm, rest do not require a routine sonographic follow up. If a nodule has a second benign cytology on repeat ultrasound guided FNA, then further surveillance with ultrasound is not required. Surgery may be considered in growing nodules >4 cm, presence of compressive symptoms or cosmetic concern. There is no role of levothyroxine

For nodules with AUS/FLUS cytology, repeat FNA and molecular testing may be used to supplement malignancy risk assessment in addition to clinical and sonographic features. Mutational testing for BRAF in AUS/FLUS samples has high specificity, but low sensitivity for cancer. Testing for the seven gene panel of mutations and rearrangements (BRAF, NRAS, KRAS, HRAS, RET/PTC1, RET/PTC3, PAX8/PPARγ) offer a significantly higher sensitivity of 63–80%. On the other hand, molecular testing using the 167 GEC (gene expression classifier) in AUS/FLUS cytology has yielded a sensitivity and NPV of 90 and 95%, respectively, but only 53% specificity and 38% PPV for cancer. If repeat FNA and molecular testing are not performed or both are inconclusive, either surveillance or diagnostic surgical excision may be carried out based on clinical and sonographic risk factors and

If cytology is suggestive of FN/SFN, diagnostic surgical excision is the longestablished standard of care. Clinical, sonographic pattern and molecular testing may be used to supplement the malignancy risk assessment. Testing for the seven gene panel of mutations in FN/SFN cytology has a sensitivity of 57–75%, specificity of 97–100%, PPV of 87–100%, NPV of 79–86%. Molecular testing with GEC is reported to have a 94% NPV, and a 37% PPV in the FN/SFN subgroup. If molecular testing is unavailable, a diagnostic surgical excision is the preferred treatment modality. No further treatment is required if the histopathology of surgical specimen is suggestive of a follicular adenoma. However, if the histopathology is sugges-

If the cytology is suspicious of papillary carcinoma (SUSP), surgical management is similar to that of malignant cytology, depending on clinical risk factors, sonographic characteristics and mutational testing if available. BRAF testing is estimated to have 36% sensitivity and 100% specificity, whereas testing with seven gene panel is reported to have 50–68% sensitivity, 86–96% specificity, 80–95% PPV and 70–75% NPV in this subgroup. On the other hand, GEC testing has a PPV (76%) similar to cytology, and a NPV of 85%, hence is not indicated in this cytological diagnosis. Molecular testing may be done if expected to alter the surgical

For a nodule with initial non diagnostic cytology, repeat FNA should be done with ultrasound guidance, and with on-site cytological evaluation if available. If the results are repeatedly non diagnostic, surgery should be considered for histopathological diagnosis in the presence of clinical and sonographic risk factors for malignancy, or growth of the nodule >20% in two dimensions detected during

Surgical management in cytologically indeterminate nodules (AUS/FLUS, FN/ SFN, SUSP) can be either hemithyroidectomy or near total or total thyroidectomy based on clinical risk factors (nodule >4 cm, family history, history of radiation)

If cytology is diagnostic of a primary thyroid malignancy, then thyroid surgery is the treatment of choice. The choice of surgery depends on the stage of the

tive of FTC, then a completion thyroidectomy may be required.

and findings on sonography, cytology and molecular testing.

**92**

differentiated thyroid cancer. In tumours ≥4 cm, or with gross extrathyroidal invasion or clinically apparent nodal metastasis or distant metastasis, near total or total thyroidectomy is the treatment of choice. Therapeutic central compartment neck dissection should accompany the procedure in case of clinical involvement of central nodes. Therapeutic lateral neck compartmental neck dissection should be undertaken in case of biopsy proven metastatic lateral cervical lymphadenopathy. Prophylactic central compartment neck dissection can be considered in cases of papillary thyroid carcinoma with advanced primary tumour (T3/T4), or clinically involved lateral neck nodes.

For thyroid cancers >1 cm and < 4 cm, with no gross extrathyroidal invasion/ nodal or distant metastasis, either lobectomy or near-total/total thyroidectomy can be considered. In tumours <1 cm, without extrathyroidal extension and nodal involvement, the initial surgical procedure should be a lobectomy, unless there are clear indications to remove the contralateral lobe. Active surveillance can be chosen in very low risk tumours like micropapillary carcinoma (tumour ≤1 cm), patients at high surgical risk or limited life expectancy [1].

Newer minimally invasive methods like percutaneous ethanol ablation, radiofrequency, laser, microwave ablation, and high-intensity focused ultrasound have been tried and may be considered for treating clinically relevant benign thyroid nodules [40]. Recurrent cystic thyroid nodules with benign cytology can be considered for percutaneous ethanol injection (PEI) or surgical excision. Ethanol acts by coagulative necrosis and small vessel thrombosis.

#### **10.3 Management in specific situations: pregnancy**

Thyroid nodules may enlarge slightly during pregnancy, though this does not imply malignant transformation. Patients with suppressed TSH beyond 16 weeks of pregnancy should be monitored until after delivery and cessation of lactation, followed by a radionuclide scan to assess the functional status of the nodule if TSH is still suppressed.

In euthyroid and hypothyroid patients, FNA should be done if clinically and sonographically indicated similar to non-pregnant patients. If PTC is diagnosed by cytology during pregnancy, surgery should be considered during pregnancy only if there is substantial growth (>20% increase in atleast two nodule dimensions, with a minimal increase of 2 mm, increase in volume by 50%) before 24–26 weeks of gestation, or if ultrasound reveals cervical nodes suspicious of metastatic disease. The surgery should be carried out in second trimester before 24 weeks to minimise the risk of miscarriage. If the disease remains stable by mid gestation, or diagnosed in second half of the pregnancy, surgery may be deferred until after delivery. As higher TSH levels may correlate with a more advanced stage of cancer, thyroid hormone therapy can be initiated if TSH > 2 mIU/L, with a target TSH of 0.3–2 mIU/L for the remainder of gestation.

### **11. Conclusion**

Thyroid nodules pose a common clinical problem to physicians and surgeons alike. The primary concern in the evaluation of thyroid nodules is exclusion of malignancy while bearing in mind that most thyroid nodules are benign. With the advent and easy availability of high-resolution ultrasound, reliable of characterisation is possible while deciding on further testing for FNA. FNA is the single most valuable cost effective and reliable investigation for risk stratification, complemented by clinical risk factors. New molecular markers can aid in risk stratification in nodules with indeterminate cytology. Diagnostic surgical excision can be done in these patients if associated with high risk clinical and sonographic features. Patients with malignant cytology should undergo surgery. Evidence based practices should be followed while keeping in mind patient preferences thus giving individualized precision medical care for patients with thyroid nodule.
