Intended for healthcare professionals

Clinical Review State of the Art Review

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

BMJ 2020; 368 doi: (Published 07 January 2020) Cite this as: BMJ 2020;368:l6670
  1. Naykky Singh Ospina, assistant professor of medicine, endocrinologist1,
  2. Nicole M Iñiguez-Ariza, assistant professor of medicine, endocrinologist2,
  3. M Regina Castro, associate professor of medicine, endocrinologist3
  1. 1Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
  2. 2Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
  3. 3Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
  1. Correspondence to: N Singh Ospina naykky.singhospina{at}


Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient’s values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All authors contributed to developing the outline for this article. NSO and NIA wrote the first draft of the manuscript. All authors reviewed and appraised the manuscript. NSO is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: A 69 year old woman incidentally found to have a thyroid nodule on imaging who underwent thyroid biopsy was invited to serve as a patient reviewer for the BMJ. The patient was supportive of including small clinical vignettes in the final version of the manuscript of an example of how different patients may value diagnostic and treatment options differently.

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