Better Diagnostics and Treatment
In contrast to what is shown in Figure 2 (1), thyroid scintigraphy is relevant in nodules larger than 1 cm when the TSH concentration is normal. If a hot nodule is present or the scintigram shows an autonomous nodule, then malignancy can be excluded with a probability bordering on certainty (2). In such cases, fine-needle aspiration cytology (FNAC) is not required. As multicenter study showed that most autonomous nodules are accompanied by a normal TSH concentration, although a focal raised concentration is shown by the scintigram (3). Before performing FNAC in a sonographically suspect finding, technetium-99m pertechnetate scintigraphy should be undertaken.
Unfortunately, a negligible proportion of thyroid cancers present as sonographically normal. Especially multinodular goiter (where not all nodules can be aspirated) therefore leaves us all a desire for a procedure with a high predictive value. FNAC is important, but its usefulness in excluding malignancy is limited (10–20% false-negatives). Technetium-99m-MIBI tumor scintigraphy of the thyroid can rule out malignancy with a probability of 97% if the findings are negative (4).
On the basis of the data analyzed by Wienhold et al., the unsatisfactory preoperative risk stratification of thyroid nodules can be assumed, if at all, only for uninodular goiter (it is not obvious from the coding whether local symptoms/mechanical relevance is present). And in uninodular goiter too, a significant displacement of the trachea or swallowing difficulties can be reason enough for performing surgical resection. Furthermore it should not remain unmentioned that in the article, out of 9000 patients with uninodular goiter, only 4.5% had surgery. A large number of diagnostic thyroid operations can therefore not be deduced from the data presented.
Prof. Dr. med. Holger Palmedo
Kompetenznetz Schilddrüse Bonn Rhein-Sieg,
Überörtliche Gemeinschaftspraxis für Radiologie und Nuklearmedizin, PET-CT-Zentrum Johanniterkrankenhaus Bonn
Prof. Dr. med. Andreas Türler
Evangelische Kliniken Bonn gGmbH, Johanniter-Krankenhaus; Kompetenzzentrum für Schilddrüsen- & Nebenschilddrüsenchirurgie (DGAV), Bonn
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Wienhold R, Scholz M, Adler JB, Günster C, Paschke R: The management of thyroid nodules—a retrospective analysis of health insurance data. Dtsch Arztebl Int 2013; 110(49): 827–34. VOLLTEXT|
|2.||Gharib H, Papini E, Paschke R, et al.: American Association of Clinical Endicrinologists, AME and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. J Endocrinol Invest 2010 33: 287–91 CrossRef MEDLINE|
|3.||Görges R, Kandror T, Kuschnerus S, et al.: Scintigraphically hot thyroid nodules mainly go hand in hand with a normal TSH. Nuklearmedizin 2011; 50: 179–88 CrossRef MEDLINE|
|4.||Wale A, Miles KA, Young B, et al.: Combined 99mTc-methoxyisobutylisonitrile scintigraphy and fine-needle aspiration cytology offers an accurate and potentially cost-effective investigative strategy for the assessment of solitary or dominant thyroid nodules. Eur J Nucl Med Mol Imaging 2014; 41: 105–15 CrossRef MEDLINE|