Discrepancy Between Clinical Reality and Guidelines
The authors deserve thanks for pointing out the substantial discrepancy between clinical reality in Germany and older US guidelines (1). I have some additional comments.
If reality and guidelines differ that widely, then it is worth checking the guidelines as well as the clinical reality.
Recent evidence for therapeutic options was not included. The LISA study (2) was published in 2011—after the publication of the two US guidelines (2009 and 2011) (3, 4). This study reported a significant reduction in the size of thyroid nodules for L-thyroxine alone (7.3%) versus L-thyroxine plus iodide (17.3%) compared with placebo. (However, whether these effects are relevant or cost effective has not been the subject of discussion thus far.)
The authors assume that a 1 cm diameter of an echo-less nodule is a useful intervention threshold—but this is still under discussion.
The value of fine-needle aspiration cytology is also still under discussion, in view of the very low mortality due to thyroid cancer in an assumed incidence of micro-cancers in up to 35% of the population. This raises the question of the cost-benefit-effectiveness of an approach similar to screening—as in prostate cancer.
The authors furthermore adopt from the cited guidelines without any discussion the recommendation to perform scintigraphy in multinodular goiter for the purposes of further differentiation. In view of the fact that almost all nodules are cold, and that a malignancy may also be concealed by a hot nodule, this seems rather ineffective. In view of the radiation load, an analysis of cost:benefit and benefit:harm is urgently indicated.
Postoperative follow-up examinations, which the authors lamented as being undertaken too rarely, should also be studied regarding their cost:benefit ratio. Postoperative hypocalcemia and hyperthyroidism or hypothyroidism certainly require follow-up and treatment, whereas recurrent asymptomatic increase in size after reduction surgery rather does not.
In conclusion: the time has come for evidence based German recommendations. These should evaluate critically especially the indications for scintigraphy, fine-needle aspiration cytology, and surgery.
Dr. med. Uwe Popert
Abteilung Allgemeinmedizin der Universität Göttingen
Sprecher der DEGAM-Sektion Versorgung
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.||Grussendorf M, Reiners C, Paschke R, Wegscheider K; LISA Investigators. J Clin Endocrinol Metab. Reduction of thyroid nodule volume by levothyroxine and iodine alone and in combination: a randomized, placebo-controlled trial. 2011; 96: 2786–95 MEDLINE|
|3.||Gharib H, Papini E, Paschke R, et al.: American Association of Clinical Endocrinologists, Italian Association of Clinical Endocrinologists and European Thyroid Association: Medical guidelines for clinical practice for the diagnosis and management of thyroid Nodules. Endocr Pract, Hot Thyroidology, J Endocrin Invest 2010; 33 Suppl 5: 1–56 CrossRef MEDLINE|
|4.||Cooper DS, Doherty GM, Haugen BR, Kloos, et al.: Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009; 19: 1167–214 CrossRef MEDLINE|