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Guideline-orientated Diagnosis of Thyroid Nodules
Recent expert opinion underlines this difference in practice on The thyroid nodule guidelines obviously provide useful information and
opposite sides of the Atlantic: Borget et al., writing from France, state recommendations for practice, and have a positive impact on patient
that “based on their assumption, plasma CT determination in the care. However, guidelines should be considered as suggestions rather
assessment of thyroid nodule patient would appear to be highly than a rigid formula for practice. We always have to rely on the art of
favourable compared with a number of other accepted health practical medicine. The arbitrary application of guidelines to the
interventions”.
45
By contrast, Podak and Burman, writing from the US, individual patient can lead to problems for the individual patient. The
observe that “the issue of CT testing in patients with thyroid disease recent thyroid guidelines underscore regional practice differences
remains controversial. It does not seem that the use of basal CT based partly on different disease epidemiologies, but they also illustrate
levels in the routine screening of patients with nodular thyroid many similarities. With further accumulating evidence, these guidelines
disease is warranted without the ability to use gastrin stimulation as will need revision and updating. n
a confirmatory test”.
46
Thus, European thyroid specialists seem to
acknowledge this ongoing controversy in thyroid practice, with 49%
Ralf Paschke is a Professor of Internal Medicine and
using and 43% not using routine CT measurement. However, it is it
Endocrinology at the University of Leipzig. He headed the
surprising that as many as 43% do not order CT measurement, Department of Internal Medicine III for eight years. His
considering that the overwhelming majority of them today are likely
major research interests include the thyroid-stimulating
hormone (TSH) receptor, the genetics of goitre and thyroid
practising in Europe. Therefore, apparently despite the
nodules and hyperthyroidism. He hosted the 2007 annual
recommendation from the ETA for routine CT determination, many meeting of the European Thyroid Association (ETA) in
members still consider this issue unresolved. The positive predictive
Leipzig and has served on the Editorial Boards of the
Journal of Clinical Endocrinology and Metabolism, Thyroid
value of routine CT measurements for medullary thyroid carcinoma
and Molecular and Cellular Endocrinology.
in patients with thyroid nodules ranges from 10 to 40% in most
studies and is >90% in two studies from one group.
47
Recent studies
Enrico Papini is Head of the Department of Endocrine and
have shown that the different CT assays have different reference
Metabolic Diseases at the Ospedale Regina Apostolorum,
Albano in Rome and a Professor of Endocrinology at the
ranges, that the threshold should in fact be 20 instead of 5pg/ml, as
University of Rome ‘La Sapienza’ Medical School. His main
used in many previous studies, that CT levels are influenced by sex,
areas of clinical and research interest include thyroid
body mass index (BMI) and age and that alcohol and smoking are
cancer and nodular goitre, the thyroid gland and type 2
diabetes. Professor Papini is Past President of the Italian
associated with falsely elevated CT levels.
48
Association of Clinical Endocrinologists (AME).
It is obviously difficult to describe the diagnostic work-up of a patient
Hossein Gharib is a Professor of Medicine in the Division
with a thyroid nodule in a uniformly applicable algorithm. An attempt
of Endocrinology, Diabetes, Metabolism and Nutrition at
the Mayo Clinic College of Medicine in Rochester. He is
at an overview that tries to provide an integrated view of the
also President of the American College of Endocrinology
diagnostic approaches for the diagnostic work-up of a patient with a
(ACE). An international authority on thyroid disorders, he
thyroid nodule is described in
has lectured at over 250 national and international
Figure 2. The clinical work-up of a
meetings and has authored or co-authored more than
patient with a thyroid nodule should always be based on the
250 academic papers, including peer-reviewed journal
assessment of possible predictors of malignancy (see
articles, scientific meeting abstracts and book chapters.
Table 3) and
the assessment of symptoms of hyperthyroidism.
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5. Krohn K, Fuhrer D, Bayer Y, et al., Endocr Rev, 21. Emrich D, Erlenmaier U, Pohl M, Luig H, Eur J Nucl Med, 2007;66:13–20.
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6. Krohn K, et al., Nat Clin Pract Endocrinol Metab, 2007;3:713–20. 22. Bennedbaek FN, Perrild H, Hegedus L, Clin Endocrinol (Oxf), 2004;31:1443–9.
7. Nagataki S, Nystrom E, Thyroid, 2002;12:889–96. 1999;50:357–63. 38. Gharib H, Papini E, Endocrinol Metab Clin North Am,
8. Davies L, Welch HG, JAMA, 2006;295:2164–7. 23. Bennedbaek FN, Hegedus L, J Clin Endocrinol Metab, 2007;36:707–35, vi.
9. Colonna M, Guizard AV, Schvartz C, et al., Eur J Cancer, 2000;85:2493–8. 39. Wiersinga WM, Eur J Endocrinol, 1995;132:661–2.
2007;43:891–900. 24. Fuhrer D, Mugge C, Paschke R, Exp Clin Endocrinol Diabetes, 40. Lucas A, Llatjos M, Salinas I, et al., Eur J Endocrinol,
10. Krebs in Deutschland, 2006, Gesellschaft der 2005;113:152–9. 1995;132:677–80.
epidemiologischen Krebsregister in Deutschland 25. Paschke R, Reiners C, Fuhrer D, et al., Dtsch Med Wochenschr, 41. Chehade JM, Silverberg AB, Kim J, et al., Endocr Pract,
e.V.(GEKID) in Zusammenarbeit mit dem Robert Koch 2005;130:1831–6. 2001;7:237–43.
Institut (RKI). 26. American Association of Clinical Endocrinologists and 42. Richter B, Neises G, Clar C, Endocrinol Metab Clin North Am,
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2003;128:2381–7. 2006;16:109–42. 44. Cheung K, et al., J Clin Endocrinol Metab, 2008;93:
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72–6. 2006;154:787–803. 45. Borget I, De Pouvourville G, Schlumberger M, J Clin
14. Martinez-Tello FJ, Martinez-Cabruja R, Fernandez-Martin J, 29. Gharib H, Papini E, Paschke R, Eur J Endocrinol, Endocrinol Metab, 2007;92:425–7.
et al., Cancer, 1993;71:4022–9. 2008;159:493–505. 46. Hodak SP, Burman KD, J Clin Endocrinol Metab,
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EUROPEAN ENDOCRINOLOGY 63
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