Most fine-needle aspiration thyroid biopsies can be ‘safely delayed’ during COVID-19
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Most fine-needle aspiration procedures for thyroid nodules can be safely delayed for 6 months or longer during the COVID-19 pandemic; data show such delays do not influence the long-term prognosis for common forms of thyroid cancer, according to an editorial published in Clinical Thyroidology.
“There is little evidence that early detection and treatment of differentiated thyroid cancer significantly alters disease outcomes, as the overall mortality rate for differentiated thyroid cancer has remained 0.5%, despite a steady rise in incidence as neck imaging has become more widespread,” Sherman Mitchell Harman, MD, PhD, chief of the endocrine division, medicine service at the Phoenix VA Health Care System, and colleagues wrote in the editorial. The group recommended that fine-needle aspiration (FNA) biopsy for most asymptomatic thyroid nodules, taking into account the sonographic characteristics and patients’ clinical picture, be deferred to a later time when risk of exposure to COVID-19 is more manageable and resource restriction is no longer a concern.
“With the VA guideline during the COVID-19 pandemic advising that patient visits should be converted to remote video or phone encounters to the extent consistent with good patient care, and the advisory that all elective procedures should be delayed for the duration of the crisis, we needed to make a rational decision regarding which FNA procedures should be considered urgent and which would be considered elective and safely delayed,” Harman told Healio. “This article grew out of our review of the relevant literature followed by a meeting of all of our attending physicians to discuss the issues and reach consensus. As chief of the Division, I wrote up a narrative description of the discussion and the conclusions we reached. We then wondered whether the document we had created for our own needs might be useful for other endocrinologists facing the same issues and questions. We therefore decided to re-write the account of our deliberations as an editorial, and submit it for publication in the hope that it might provide a helpful approach for our endocrine colleagues nationally and internationally.”
Harman, who said endocrinologists at his institution perform approximately eight FNA procedures every week, said his team developed several key takeaways for thyroidologists:
The vast majority of FNA procedures for thyroid nodules can be safely delayed for 6 months or longer.
Patients with suspected medullary thyroid cancer (MTC), which is relatively rare, should undergo measurement of serum calcitonin and be referred directly for surgery without FNA if calcitonin level is unequivocally elevated.
FNA can be considered urgent and performed when calcitonin level is equivocal; this approach would entail ordering calcitonin measurements far more often than is usually done in practice in the U.S.
Patients with anaplastic thyroid carcinoma, characterized by rapid growth, tenderness, and early compromise of critical structures in the neck resulting in dysphagia and/or dyspnea, could be referred for surgery without requiring a preliminary FNA.
“Finally, we recognized that patients who have been informed that they may be harboring a thyroid malignancy should have the opportunity to confer with an endocrinologist in order to be made aware of the low probability that any incidentally discovered nodule is malignant and to be reassured that a reasonable delay is unlikely to worsen prognosis, the goal being to alleviate their very understandable anxiety,” Harman said.
The researchers also noted that, when the need for an urgent thyroid FNA arises, safety for both the patients and the operators must be addressed, including screening patients for symptoms and undergoing the available nucleic acid test.
“It is crucial to carefully weigh the risks of COVID-19 exposure, availability of resources, and urgency of these procedures for each patient in our individual practice settings,” the researchers wrote. – by Regina Schaffer
For more information:
Sherman Mitchell Harman, MD, PhD, can be reached at the Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012; email: sherman.harman@va.gov.
Disclosures: The authors report no relevant financial disclosures.
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