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Adults with indeterminate thyroid nodules may receive excessive surgery
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Adults with indeterminate thyroid nodules may receive inappropriate initial extent of surgery, suggesting that tools are needed to identify benign and malignant disease before deciding on surgery, study data show.
“Providers try to predict how much surgery is necessary for an indeterminate thyroid nodule by their estimation of its risk for being a cancer,” David F. Schneider, MD, MS, of the department of surgery, University of Wisconsin, told Endocrine Today. “Even the high-volume providers in our study performed an oncologically incorrect amount of surgery 30% of the time.”
Schneider and colleagues evaluated 639 adults (mean age, 52 years; 78.5% women) with indeterminate thyroid nodules (median nodule size, 2.3 cm) within the University of Wisconsin Surgery Database who underwent a thyroid operation between May 1994 and April 2015. Researchers sought to determine the accuracy and factors associated with the extent of initial thyroidectomy for indeterminate thyroid nodules.
The extent of surgery was categorized as “oncologically inadequate” if participants required a completion thyroidectomy or “oncologically excessive” if a total thyroidectomy was performed and final diagnosis did not reveal a malignant nodule of at least 1 cm in size.
Follicular neoplasm was the most common indeterminate cytology diagnosis (45.1%), followed by Hürthle cell neoplasm (20.3%), atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS; 18.9%), and suspicion of papillary thyroid cancer (PTC; 15.7%).
Thyroid lobectomy was the most commonly performed initial surgery (58.8%), and 24.7% of the nodules were found to contain a cancer ( 1 cm) on final pathology as well as an additional 70 microcarcinomas (< 1 cm).
Overall, a completion thyroidectomy was required in 9.3% of participants who underwent initial lobectomy, and 19% of participants underwent an initial total thyroidectomy for benign nodules. According to the researchers, 28.3% of the participants did not receive the appropriate initial surgery from an oncologic standpoint.
Cancers of at least 1 cm in size were presented in 18.8% of diagnoses of follicular neoplasm, 13.2% of Hürthle cell neoplasm, 28.9% AUS or FLUS and 78% of suspicion for PTC.
Overall, initial excessive extent of surgery was significantly associated with female sex (OR = 2.1; 95% CI, 1-4.45). Appropriate initial lobectomy was significantly associated with being older than 45 years (OR = 2.58; 95% CI, 1.16-5.74). Initially correct total thyroidectomy was associated with intraoperative frozen section (OR = 9.71; 95% CI, 2.45-38.56) and suspicion for PTC (OR = 5.68; 95% CI, 2.1-15.33).
“There are an ever-increasing number of adjuncts trying to help surgeons and endocrinologists preoperatively diagnose indeterminate nodules as cancer or benign,” Schneider told Endocrine Today. “Our study shows that surgeons have some baseline accuracy in trying to make this distinction. While we were biased toward oncologic overtreatment (doing a total thyroidectomy up front), others might tend toward more undertreatment (lobectomy and then completion thyroidectomy for cancer). It probably has to do with experience level, volume, local practices, etc. Before using other adjuncts like molecular testing, it’s important for institutions to understand their baseline accuracy in predicting cancer. This will help them evaluate and choose an adjunct that fits their specific needs.”
Schneider added that the study was performed using the 2009 American Thyroid Association guideline, and it “would be interesting to evaluate the accuracy of decision-making under the new 2015 guidelines where lobectomy is considered adequate treatment for many low-risk cancers.”
“We are currently conducting a prospective study specifically looking at patient and physician decision-making as it was hard to reconstruct this decision-making in this retrospective study,” Schneider told Endocrine Today. “Finally, I think looking at the interaction between physician judgement and adjuncts like molecular testing impacts decision-making, patient satisfaction and cost-effectiveness.” – by Amber Cox
For more information:
David F. Schneider, MD, MS, can be reached at schneiderd@surgery.wisc.edu.
Disclosure: Schneider reports no relevant financial disclosures. The study was funded by two grants from NIH.
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