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Thyroid Disorders
Figure 2: Flow Chart for the Diagnostic Evaluation of If cytology showed ‘suspicious for malignancy – follicular neoplasm’,
Thyroid Nodules
80% would recommend surgical excision of the nodule. Management
of a nodule with indeterminate cytology still generates controversy.
The cancer risk among these specimens ranges from 15 to 75%, and
Patient with thyroid nodule(s)
is approximately 15% for follicular neoplasms. Immunohistochemical
markers have neither regularly nor reliably separated benign fromClinical history
Physical examination of the thyroid and the neck
malignant lesions.
38
Repeat biopsy is not helpful and can even lead
to confusion, because if re-aspiration is benign, the clinician has to
reconcile between a benign and a suspicious result. The AACE/AME
FT3, FT4, TSH
Neck US
(TPO Ab)
guidelines consider surgical excision as the best management;
(solid/mixed)
Calcitonin
repeat biopsy or large-needle biopsy is not recommended. The ATA
guidelines discourage the use of molecular markers and prefer a
Diameter Diameter >1cm Low TSH or
Normal
<1cm or multinodular radioiodine thyroid scan to rule out nodule hyperfunction when
TSH
No suspicion <1cm suspicious goitre
cytology is suspicious. The ETA guidelines find immuno-
cytochemistry neither sensitive nor specific, believing surgical
Thyroid
scan
treatment is the best approach.
‘Cold’ or
Follow-up FNAC
isocaptant If the cytology is ‘follicular neoplasm’, lobectomy and post-operative
nodule(s)
histological review was recommended by 24%, near-total
thyroidectomy by 34% and lobectomy and intraoperative frozen
Malignant,
Benign nodule suspicious or Surgery section exam by 36% of the European thyroid specialists. The
follicular neoplasm
AACE/AME guidelines recommend surgical treatment but do not
specify the extent of surgery. The ATA guidelines suggest thyroid
This figure presents an attempt at an overview that tries to give an integrated view of the
diagnostic approaches for the diagnostic workup of a patient with a thyroid nodule.
lobectomy for an isolated, indeterminate solitary nodule, whereas the
FNAC = fine-needle aspiration cytology; TPO Ab = thyroid peroxidase antibody;
ETA recommends lobectomy for a solitary nodule and a near-total
TSH = thyroid-stimulating hormone; US = ultrasound.
28
Source: Pacini F, Schlumberger M, Dralle H, et al.
thyroidectomy for a multinodular goitre when cytology is suspicious.
Table 3: Factors Suggesting Increased Risk
Moreover, the ETA does not endorse frozen section because of the
of Malignancy high frequency of false-negative results.
History of head and neck irradiation
Several recent reports suggest that in experienced hands
Family history of MTC or MEN2
intraoperative frozen section can accurately separate benign from
Age <20 or >70 years
malignant follicular or Hurthle cell neoplasms. For example,
Male sex
Paphavasit and colleagues report that intraoperative frozen section
Growing nodule
was correct in 78% of patients, with sensitivity, specificity, positive
Firm or hard consistency
Cervical adenopathy
predictive value, negative predictive value and accuracy of 78, 99, 90,
Fixed nodule
98 and 98%, respectively.
43
It is therefore not surprising that European
Persistent hoarseness, dysphonia, dysphagia or dyspnoea
thyroid experts seem evenly divided between the surgical options
noted above. While there is no majority of opinion here, these
MEN2 = multiple endocrine neoplasia type 2; MTC = mycobacterium tuberculosis complex.
Source: American Association of Clinical Endocrinologists and Associazione Medici differences likely represent the availability of surgical and pathology
26
Endocrinologi, 2006.
expertise available to each participant in his/her clinic or location.
For the example patient – a 40-year-old woman with a single 2.5cm
nodule that is benign, colloid by FNA and solid by ultrasound and with For the example patient, 49% of the European thyroid specialists
serum TSH 0.6mIU/l – 65% would not recommend T4 suppressive would measure a baseline serum calcitonin (CT) level, whereas
therapy. Whereas previously most endocrinologists would have used 43% would not. This is in fact the most controversial question. Serum
T4 to suppress TSH in this case, current guidelines do not recommend CT is a useful marker for C-cell disease and correlates well with
this practice. Therefore, it is gratifying that 65% of the European thyroid tumour burden. MTC accounts for only 5% of thyroid malignancies;
specialists agreed with the guidelines and chose not to use T4 therapy. however, recent reports show that the prevalence of MTC ranges
The AACE/AME guidelines state that routine T4 therapy in patients with from 0.4 to 1.4% in unselected patients with nodular thyroid disease.
benign thyroid nodules is not appropriate, but it may be considered in Data from non-randomised, prospective studies, mostly from
iodine deficiency. Only 12% of this group voted to use T4 if the patient European countries, suggest that routine CT measurement can
was in an iodine-deficient area. The ATA guidelines do not recommend detect early and unsuspected MTC.
28
Early diagnosis and prompt
suppression therapy for benign nodules. A recent meta-analysis of thyroidectomy result in decreased morbidity and increased survival.
nine studies including 596 patients showed that nodule volume However, there seems to be no consensus on this issue. Outside
decreased significantly in only fewer than 20% of the treated group. Europe, the enthusiasm for ordering routine CT has not been high
Moreover, T4 suppressive therapy led to a non-significant except for a recent publication suggesting cost-effectiveness.
44
The
improvement in the rate of response to therapy (defined as ≥50% AACE/AME guidelines do not endorse routine CT measurement,
nodule volume reduction by ultrasound): pooled relative risk (RR) 1.83, recommending the test only if FNA is suspicious for MTC or family
95% confidence interval (CI) 0.9–3.73.
42
In summary, neither the history is positive for MTC/MEN2. The ATA guidelines do not
guidelines nor the majority of European thyroid specialists recommend routine CT measurement. The ETA recommends CT
recommend T4 to suppress benign thyroid nodules. measurement in the initial diagnostic evaluation of thyroid nodules.
62 EUROPEAN ENDOCRINOLOGY
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