15th International Thyroid Congress, 85th Annual Meeting of the American Thyroid Association:
Survey Found Marked Variability in Endocrinologists’ Management of Thyroid Nodules
Presented at the meeting by Nicole Vietor, MD
A 2015 survey of endocrinologists’ practice patterns regarding management of thyroid nodules showed marked variability, particularly for selection of the nodule for fine-needle aspiration (FNA), explained Nicole Vietor, MD, at the 15th International Thyroid Congress and 85th Annual Meeting of the American Thyroid Association (ITC/ATA). The findings suggest that more FNAs are performed that what is currently recommended in clinical guidelines, Dr. Vietor said.
“Wide variation was found regarding when to perform FNAs in pregnant women with thyroid nodules,” said Dr. Vietor, who is an Endocrinology Fellow at Walter Reed National Military Medical Center in Bethesda, MD. In addition, variability was found in management of FNA results of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), follicular neoplasm, and suspicious for malignancy.
Several clinical practice guidelines have been published on the management of thyroid nodules, including the American Association of Clinical Endocrinologists (AACE) guidelines from 2010, and the American Thyroid Association (ATA) guidelines from 2015. This study was designed to assess whether clinicians’ current practice patterns on management of thyroid nodules are concordant with clinical guidelines.
Dr. Vietor and colleagues surveyed 897 members (60% male) of the Endocrine Society (80%), AACE (56%), and ATA (44%) using a web-based survey that included 36 questions pertaining to the diagnosis and management of thyroid nodules.
A majority of the members (63%) were from North America, 10% were from Latin America, 12% from Europe, 6.5% from Asia, 5.6% from the Middle East and Africa, and 2% from Oceana. Most of the respondents (87%) were adult endocrinologists.
The questionnaire included an index case of a 52-year-old woman found to have an incidental 1.5 cm thyroid nodule, no personal or family history of thyroid disease, and no evidence of cervical lymphadenopathy. Nearly all respondents (99.4%) said they would initially evaluate the patient by measuring serum thyroid stimulating hormone, in accordance with clinical guidelines. More than half of the respondents reported that they would use thyroid ultrasound (52.1% in clinic; 57.2% in radiology), 68.5% would assess cervical lymph nodes, 8.4% would use a serum calcitonin test, and 4.5% would obtain a thyroid scintigraphy scan at the initial evaluation.
Demographic differences were found for the percentage of respondents who would obtain a calcitonin test for any thyroid nodule, with respondents from Europe being more inclined to obtain a calcitonin test (32%) and those from North America being the least likely (2.3%), Dr. Vietor said.
Most Participants Use Ultrasound Guidance for Fine-Needle Aspirations
The majority of FNAs (56.6%) are performed by endocrinologists, followed by radiologists (32%) and pathologists (6%). Consistent with current guidelines, a majority of respondents (83%) use ultrasound to guide FNA. Slightly more than half of respondents (57%) use analgesia for FNAs, most commonly local injection.
When presented with six different nodules of varying sizes and varying ultrasound characteristics, “the majority (93%) would perform FNA with a 1.5 cm hypoechoic nodule; however, there were varying answers for the rest of the nodules,” Dr. Vietor said. “If you look at the 2015 ATA guidelines, the 1.5 cm solid hypoechoic nodule is the only nodule that would be recommended for FNA. It is interesting there is some discordance between clinical practice and the current practice guidelines,” Dr. Vietor said.
Variability Found in FNAs for Elderly and Pregnant Cases
In other cases, the majority of respondents (64%) reported being less likely to recommend FNA in an elderly patient with a 1.5 cm hypoechoic nodule without suspicious ultrasound features, and 34% would postpone FNA until after pregnancy in a woman at 8 weeks gestation with a 1.5-cm nodule.
In a case involving a multinodular goiter with 5 solid hypoechoic nodules all greater than 1 cm in diameter, nearly half of respondents (46%) said they would perform FNA of the representative 2 to 3 largest nodules, but the results were varied in the remainder of the group, Dr. Vietor said. “Some respondents would perform a FNA on the single largest nodule; some would perform a FNA of all the nodules over 1 cm, some opted for no FNA, and a minority of participants would obtain a thyroid scan,” she said.
Variances in Management by FNA Result
For patients with FNA results of AUS/FLUS, 39% of respondents would use molecular analysis for further evaluation, 32% would perform repeat cytology, and 24% would recommend a lobectomy. For patients with follicular neoplasm, 47% of respondents would recommend a lobectomy, 29% would use molecular analysis, and 15% would recommend a total thyroidectomy. For patients with FNA results suspicious for malignancy, 43% would refer patients for lobectomy, 43% would refer to total thyroidectomy, and 10% would choose molecular analysis.
Regional differences in the evaluation of thyroid nodules also were found. For example, routine use of molecular analysis varied widely with a high of 73% among respondents from North America to a low of 34% among respondents from the Middle East and Africa.
Dr. Vietor concluded that management of thyroid nodules showed high variability in this survey, with regional differences found with regard to performing FNAs and molecular analysis.