CLINICAL THYROIDOLOGY FOR PATIENTS
A publication of the American Thyroid Association
Summaries for Patients from Clinical Thyroidology by Ernest Mazzaferri, MD MACP
Table of Contents
NODULAR GOITER
FNAB Fine-needle aspiration biopsy is an out-patient method used to biopsy thyroid nodules with a very small needle, often under ultrasound guidance. Although this is the standard approach to the diagnosis of thyroid nodules, a few malignant nodules (~1%) yield benign cytology results, which are false-negative tests.
What is the study about? Aggressive thyroid cancers may be missed in patients with multinodular goiter not undergoing periodic follow-up with neck ultrasonography
The full article title: “Fate of the non-operated, non-toxic goitre in a defined population.” It is in the March 2008 issue of the British Journal of Surgery (volume 95 Issue 3 Pages 338-43. The authors are A Winbladh and J Järhult. To obtain the abstract of this study the internet link is: http://www.ncbi.nlm.nih.gov/
pubmed/17929233?dopt=Citation
What is the problem being studied? This is a study of the medical effectiveness and hospital cost of a longterm “wait and see” follow-up strategy for patients with benign nodular goiter that had undergone fine-needle aspiration biopsy.
What was the aim of the study? The study was undertaken to estimate the cost-effectiveness and risk of future significant thyroid disease in patients with benign non-toxic goiter after the initial clinical evaluation.
Who was studied? The study patients were 261 of 587 individuals referred to a Swedish Surgical Department for consultation regarding nontoxic goiter. Neither goiter nor thyroid cancer is endemic in this area.
How was the study done? Almost 90% of the patients had an FNAB, but none had a neck ultrasonography. The median duration of follow-up from the first diagnosis to telephone interview or second hospital referral was almost 11 years.
What were the results of the follow-up Study? In all, 46% of the patients were referred on a second occasion to the same hospital, mainly because of goiter enlargement or local symptoms, for which 48% had surgery. Most had benign goiter (77%), benign tumors or Hashimoto’s thyroiditis, but a few (5%) had thyroid cancer. Five patients developed thyroid cancer during follow-up; two died of anaplastic thyroid cancer almost 13 years after inclusion in the study and another died of an aggressive papillary thyroid cancer with brain metastases 7 years after a goiter had been diagnosed as benign. In-hospital cost of thyroid surgery for nodular goiter in Sweden is 3400€, and the authors’ hospital saved 700 400€ over 15 years as a result of the policy of expectant waiting for patients with benign FNAB results
How does this compare with other studies? Two evidence-based reviews and the American Thyroid Association guidelines all recommend annual follow-up of patients with benign nodules or nodular goiter, with physical exam, neck ultrasonography, and serum TSH.
Most cost-effectiveness studies include many patient and societal parameters in addition to direct costs.
The guidelines and references for the above noted studies can be found on the internet at the following sites:
Thyroid nodule guidelines:
http://www.thyroid.org/professionals/publications/documents/Guidelinesthy2006.pdf
Research articles:
http://www.ncbi.nlm.nih.gov/pubmed/18311576?dopt=Citation http://www.ncbi.nlm.nih.gov/pubmed/18305998?dopt=Citation http://www.thyroid.org/professionals/publications/documents/Guidelinesthy2006.pdf
What are the Implications of this study of this study? Most patients with benign goiter should undergo yearly evaluations with serum TSH and neck ultrasonography.
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