Q&A

To Cut or Not to Cut? Evaluating Surgical Criteria for Benign & Nondiagnostic Thyroid Nodules

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Now What?
While FNA most definitively distinguishes between benign and malignant nodules, the test is limited. An indeterminate, or nondiagnostic, finding occurs in 10% to 15% of cases and is more likely in nodules with a large cystic component.1

Even a benign finding on FNA of a larger nodule should be viewed with caution, since aspiration is unlikely to pinpoint small insidious malignant cells nestled among a larger collection of benign tissue.3 In many situations, a patient receives FNA results and asks, “What should we do now?”

Nondiagnostic nodules
When FNA is indeterminate, the next step depends on the characteristics of the nodule. For a solid nodule, repeat FNA is recommended.4,5 For nodules with repeatedly nondiagnostic FNAs, the American Academy of Clinical Endocrinologists and the American Thyroid Association recommend that a solid nodule be considered for surgical removal unless the nodule has “clearly favorable clinical and US features.”4,5

Surgical excision should be considered for cysts that recur, those that are larger (> 4 cm), and those that are repeatedly nondiagnostic on FNA. Personal and family history should be taken into account when nodules that are nondiagnostic on FNA demonstrate suspicious characteristics on US.6

An analysis by Renshaw determined that risk for malignancy in a nodule with a single nondiagnostic FNA was about 20%. For nodules that underwent repeat FNA, the risk was 0% for those that were again nondiagnostic. This significant difference led the author to conclude that “patients with two sequential nondiagnostic thyroid aspirates have a very low risk of malignancy.”7

Consider the time commitment, financial burden, and emotional cost for the patient of repeated evaluation with thyroid US and possibly FNA. In recurrent cases, the risks associated with surgery begin to be outweighed by the cost and burden of prolonged observation.

Benign nodules
With a biopsy-proven benign nodule, observation is recommended unless certain criteria are present: local neck compressive/obstructive symptoms that can be confidently attributed to a thyroid nodule; patient preference (eg, due to anxiety or aesthetics); or higher index of suspicion (eg, history of previous radiation exposure, progressive nodule growth, or suspicious characteristics on US).4,5

If surgical removal of a benign thyroid nodule is recommended, it is imperative to discuss the risks with patients. In addition to traditional surgery risks, thyroidectomy is associated with transient or permanent postoperative hypoparathyroidism, as well as vocal hoarseness or changes in vocal quality due to the proximity of the recurrent laryngeal nerve. Additionally, patients should be advised of the potential for surgical hypothyroidism with hemithyroidectomy and certain irreversible hypothyroidism with total thyroidectomy.

After a discussion of the risks and cost of observation versus surgery, an informed decision between provider and patient can ultimately be reached.

Would thyroidectomy be recommended for Felicia? After a thorough discussion, it is decided that surgery is not indicated at this time. Relevant factors include the benign thyroid US characteristics, lack of clinical neck compressive symptoms, and patient preference.

According to the American Thyroid Association guidelines, Felicia’s risk for malignancy for the nodule in question is < 3%, since it is a partially cystic nodule without any suspicious sonographic features. By foregoing surgery, Felicia will need repeated imaging studies and possibly repeat serologic studies and FNA in the future.

References
1. Stang MT, Carty SE. Recent developments in predicting thyroid malignancy. Curr Opin Oncol. 2008;21(1):11-17.
2. Hambleton C, Kandil E. Appropriate and accurate diagnosis of thyroid nodules: a review of thyroid fine-needle aspiration. Int J Clin Exp Med. 2013;6(6):413-422.
3. American Cancer Society. Thyroid cancer (2014). www.cancer.org/acs/groups/cid/documents/webcontent/003144-pdf.pdf. Accessed June 29, 2016.
4. Gharib H, Papini E, Garber J, et al; AACE/AME/ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules—2016 Update. Endocrine Pract. 2016;22(suppl 1):1-60.
5. Haugen BR, Alexander EK, Bible KC, et al; The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016; 26(1):1-133.
6. Yeung MJ, Serpell JW. Management of the solitary thyroid nodule. Oncologist. 2008; 13(2):105-112.
7. Renshaw A. Significance of repeatedly nondiagnostic thyroid fine-needle aspirations. Am J Clin Pathol. 2011;135(5):750-752.

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