Management of Nondiagnostic Thyroid Fine-Needle Aspiration Biopsy: Survey of Endocrinologists

doi:10.4158/ep.10.4.317

Endocrine Practice

Volume 10, Issue 4, July 2004, Pages 317-323

https://doi.org/10.4158/ep.10.4.317 Get rights and content

ABSTRACT

Objective

To evaluate the approach of endocrinologists in the setting of nondiagnostic thyroid fine-needle aspiration (FNA) biopsies.

Methods

In 2002, we surveyed physicians attending the national annual meetings of the American Association of Clinical Endocrinologists and the Endocrine Society of North America, using a 13-item questionnaire. The responses were tallied and analyzed.

Results

Of the 143 respondents, 139 were endocrinologists, with a male:female ratio of 2.5:1. Most respondents were involved in a medical practice in North America, but Europe, Asia, New Zealand, and Australia were also represented. Of those performing thyroid FNA biopsy, 31% used thyroid ultrasound guidance. Among the survey respondents, 16%, 49%, 20%, and 15% performed less than 2, 2 to 5, 6 to 10, and more than 10 thyroid FNA biopsies per month, respectively. Among the respondents, 13.5%, 44%, 28.5%, 10%, and 4% had nondiagnostic rates of less than 5%, 5 to 10%, 11 to 20%, 21 to 30%, and more than 30%, respectively. The approach of the respondents to an initially nondiagnostic FNA was repeated FNA biopsy in 87%, observation in 7%, levothyroxine suppression in 4%, and thyroid scintigraphy in 2%. Respondents believed that the most cost-effective approach in a patient with nondiagnostic FNA was repeated biopsy (82%), monitoring the size of the thyroid nodule (17%), and surgical referral (< 1%). No one was willing to repeat the thyroid biopsy more than three times.

Conclusion

On the basis of findings in our survey, most endocrinologists repeat thyroid FNA at least once when confronted with a nondiagnostic result. No published studies have demonstrated the cost-effectiveness of this approach versus proceeding to surgical intervention or observation. We hope that this survey will encourage further studies on this issue. (Endocr Pract. 2004;10: 317-323)

Section snippets

INTRODUCTION

Palpable thyroid nodules are common, affecting 4 to 7% of the general population (1). Recent data based on use of thyroid ultrasonography and autopsy studies suggest that the prevalence currently approaches 50% 2., 3..

The initial diagnostic evaluation of a thyroid nodule involves measuring a thyrotropin (thyroid-stimulating hormone) level and performing a thyroid fine-needle aspiration (FNA) biopsy if the level is not suppressed 1., 4., 5.. Thyroid FNA biopsy is the most cost-effective method

AIMS AND OBJECTIVES

We surveyed the views of practicing endocrinologists about their approach to a nondiagnostic thyroid FNA biopsy. In addition, we evaluated the association among the reported frequency of performance of thyroid FNA, the FNA nondiagnostic rate, the use of thyroid ultrasonography, and the initial approach to the management of a nondiagnostic thyroid FNA biopsy.

METHODS

We approached some of the endocrinologists attending the thyroid symposia at the 2002 national annual meetings of the American Association of Clinical Endocrinologists (AACE) and the Endocrine Society of North America with a 13-item questionnaire (see Appendix). Questionnaires were distributed to 173 physicians who indicated they were willing to participate in the survey, of whom 143 completed and returned the forms.

The chi-square test and Fisher’s exact test were used for statistical analysis.

RESULTS

Of the 143 respondents, 139 were endocrinologists, with a male:female ratio of 2.5:1. The remaining four respondents were surgeons. Of the 133 respondents to the geographic question, 120 (90%) indicated that their practice was in North America. The other 13 respondents were from Europe, Asia, New Zealand, or Australia. The median duration of practice was 12 years (range, 2.5 months to 42 years).

Among the respondents, 139 (97%) routinely managed thyroid nodules, and 125 performed thyroid FNA. Of

DISCUSSION

Management of thyroid nodules is a common component of endocrine practice. When the cytologic findings are inadequate (unsatisfactory, insufficient, or nondiagnostic), the physician will be faced with a series of questions, including the value of a repeated thyroid FNA biopsy, the duration of observation, the timing and selection of patients for surgical referral, and the value of thyroid scintigraphy.

Because no published studies have been systematically designed to study these issues

CONCLUSION

Management of thyroid nodules constitutes a major part of the medical practice of endocrinologists. Frequently, thyroid nodule FNA biopsies are nondiagnostic. The optimal approach to further management of such cases remains a challenge. Our survey, the first of its kind, sheds some light on the current approach of endocrinologists to a nondiagnostic thyroid FNA biopsy. Most respondents proceed with a repeated FNA biopsy when faced with a nondiagnostic thyroid FNA result. We hope that our survey

ACKNOWLEDGMENT

We thank Dr. Mario Skugor, staff endocrinologist at the Cleveland Clinic, who helped with administration of some of the questionnaires. We also thank the administrative staff of the AACE and the Endocrine Society for coordinating the return of the questionnaires in some instances. This study was presented in part as an abstract at the 85th annual meeting of the Endocrine Society, June 2003, in Philadelphia, Pennsylvania.

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Thyroid nodules are very common lesions. Despite that the great majority is benign, in a significant percentage of them there is an underlying malignancy. Malignant thyroid nodules should be managed surgically, while the more common benign thyroid nodules may be managed conservatively. A systemic and careful diagnostic evaluation is needed to recognize nodules (overtly malignant or with malignant potential), and to avoid unnecessary surgery in a large percentage of patients with benign disease. Fine-needle aspiration (FNA) has a central role in the diagnostic investigation of the patient with thyroid nodules. FNA is a safe, useful, and cost-effective procedure. To increase accuracy, FNA can be performed under ultrasonographic guidance (if needed). Its results may be particularly helpful in determining the indication for surgery. In contrast, the role of FNA in selecting the extent of surgery is limited today. This is due to the fact that during the last decade there is a clear trend toward radical surgical management of thyroid nodular disease (both benign and malignant) by total/near-total thyroidectomy.
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A retrospective study of patients who underwent thyroid surgery for palpable thyroid nodules at the department of Otolaryngology Head and Neck surgery, Kaohsiung Medical University Hospital, Taiwan.
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We have also shown that a second repeated FNA (FNA #3) can provide a diagnosis in 50% of cases, although the absolute numbers were small. Of note in a recent survey of clinical endocrinologists (43), the majority were willing to repeat FNAs up to 3 times before referring a patient for surgical treatment. Our institutional nondiagnostic rate of 5% is consistent with that described in many published reports (4,6,7).
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Original ArticleManagement of Nondiagnostic Thyroid Fine-Needle Aspiration Biopsy: Survey of Endocrinologists

ABSTRACT

Objective

Methods

Results

Conclusion

Section snippets

INTRODUCTION

AIMS AND OBJECTIVES

METHODS

RESULTS

DISCUSSION

CONCLUSION

ACKNOWLEDGMENT

Endocrinol Metab Clin North Am.

Endocrinol Metab Clin North Am.

Endocrinol Metab Clin North Am.

Endocrinol Metab Clin North Am.

Am J Med.

Mayo Clin Proc.

Clin Lab Med.

Am J Med.

Am J Med.

Am J Med.

Endocrinol Metab Clin North Am.

Am J Surg.

Endocrinol Metab Clin North Am.

Management of a solitary thyroid nodule

N Engl J Med.

Thyroid nodules

Am Fam Physician.

The thyroid nodule

Ann Intern Med

Fine-needle aspiration biopsy of the thyroid: an appraisal

Ann Intern Med.

Accuracy of fine-needle aspiration of thyroid

Arch Pathol Lab Med.

Nondiagnostic thyroid fine-needle aspiration cytology: management dilemmas

Thyroid.

Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules

J Clin Endocrinol Metab.

Fine needle aspiration cytology of the thyroid, 1980 to 1986

Acta Cytol.

Fine needle aspiration biopsy cytology in the diagnosis of thyroid cancer: comparative study of 213 operated patients

Br J Surg.

Sources of diagnostic error in fine needle aspiration of the thyroid

Cancer.

Cystic thyroid nodules: the dilemma of malignant lesions

Arch Intern Med

Original Article
Management of Nondiagnostic Thyroid Fine-Needle Aspiration Biopsy: Survey of Endocrinologists