Guideline Compliance in Surgery for Thyroid Nodules – A Retrospective Study

Abstract

Introduction

Diagnostic guidelines for thyroid nodules focus on malignancy risk assessment to avoid unnecessary diagnostic operations. These guidelines recommend a combination of tests in form of a diagnostic algorithm. The present study analyzed the recommended algorithm and its implementation by different medical professionals.

Methods

Preoperative diagnostic procedures, laboratory tests and histopathological findings of patients who underwent thyroid surgery between 2006 and 2013 were analyzed. The results were stratified by the assignation by specialized endocrinologists (ENP), general practitioners (GP) or Goethe-University Hospital Frankfurt (UKF).

Results

677 patients were enrolled, of these 62% were assigned by UKF, 18.5% by an ENP and 19.5% by a GP. Ultrasonography rate was significantly higher in UKF (97.6%) compared to patients assigned by GP (90.9%, p<0.0001). Rates for fine-needle aspiration cytology ranged between 47.6% in UKF and 23.2% in ENP (p<0.0001). In over 93% of the patients an analysis of thyroid-stimulating hormone and triiodothyronine/thyroxin was realized. The overall malignancy rate was 11.82%. The malignancy rate was significantly higher if a FNA biopsy was performed (16.35 vs. 8.94%; p=0.0048).

Conclusions

A higher malignancy rate could only be seen if the preoperative diagnostic workup included FNA. Besides this, the grade of algorithm adherence showed no effect on the malignancy rate.

Key words

thyroid cancer - thyroid nodules - diagnostic algorithm - diagnostic operations - guidelines

• References

• 1 Wienhold R, Scholz M, Adler JB. et al. The management of thyroid nodules: a retrospective analysis of health insurance data. Dtsch Arztebl Int 2013; 110: 827-834
• 2 Dogan L, Karaman N, Yilmaz KB. et al. Total thyroidectomy for the surgical treatment of multinodular goiter. Surg Today 2011; 41: 323-327
• 3 Wiest PW, Hartshorne MF, Inskip PD. et al. Thyroid palpation versus high-resolution thyroid ultrasonography in the detection of nodules. J Ultrasound Med 1998; 17: 487-496
• 4 Morris LF, Ragavendra N, Yeh MW. Evidence-based assessment of the role of ultrasonography in the management of benign thyroid nodules. World J Surg 2008; 32: 1253-1263
• 5 Bojunga J, Herrmann E, Meyer G. et al. Real-time elastography for the differentiation of benign and malignant thyroid nodules: a meta-analysis. Thyroid 2010; 20: 1145-1150
• 6 McLeod DS, Watters KF, Carpenter AD. et al. Thyrotropin and thyroid cancer diagnosis: a systematic review and dose-response meta-analysis. J Clin Endocrinol Metab 2012; 97: 2682-2692
• 7 Elisei R, Bottici V, Luchetti F. et al. Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders. J Clin Endocrinol Metab 2004; 89: 163-168
• 8 Guarino E, Tarantini B, Pilli T. et al. Presurgical serum thyroglobulin has no prognostic value in papillary thyroid cancer. Thyroid 2005; 15: 1041-1045
• 9 Pacini F, Burroni L, Ciuoli C. et al. Management of thyroid nodules: a clinicopathological, evidence-based approach. Eur J Nucl Med Mol Imaging 2004; 31: 1443-1449
• 10 Ogilvie JB, Piatigorsky EJ, Clark OH. Current status of fine needle aspiration for thyroid nodules. Adv Surg 2006; 40: 223-238
• 11 Tee YY, Lowe AJ, Brand CA. et al. Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review. Ann Surg 2007; 246: 714-720
• 12 Pacini F, Schlumberger M, Dralle H. et al. European Thyroid Cancer Taskforce: European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol 2006; 154: 787-803
• 13 Garib H, Papini E, Valcavi R. et al. AACE/AME Task Force one Thyroid Nodules, American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 2006; 12: 63-102
• 14 Garib H, Papini E, Paschke R. et al. AACE/AME/ETA Task force on Thyroid Nodules, American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 2010; 16: 468-475
• 15 (Muster) Weiterbildungsordung der Bundesärztekammer von 2003 mit den Erweiterungen und Ergänzungen 2013 [(Model) Specialty Training Regulations 2003 as amended on 28/06/2013]; (Model) Specialty Training Regulations 2003 as amended on 28/06/2013 http://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/MWBO_Englisch_210113_FINFI_aktualaktual171214.pdf Accessed 24 June 2016
• 16 Tangpricha V, Harriam SD, Chipkin SR. Compliance with guidelines for thyroid nodule evaluation. Endocr Pract 1999; 5: 119-123
• 17 Dralle H, Stang A, Sekulla C. et al. Surgery for benign goiter in Germany: fewer operations, changed resectional strategy, fewer complications. Chirurg 2014; 85: 236-245
• 18 Schiro AJ, Pinchot SN, Chen H. et al. Clinical efficacy of fine-needle aspiration biopsy of thyroid nodules in males. J Surg Res 2010; 159: 645-650
• 19 Frate MC, Benson CB, Doubilet PM. et al. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab 2006; 91: 3411-3417
• 20 Dralle H, Sekulla C, Haerting J. et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136: 1310-1322
• 21 Dralle H. Thyroid incidentaloma. Overdiagnosis and overtreatment of healthy persons with thyroid illness?. Chirurg 2007; 78: 677-686
• 22 Rosato L, Avenia N, Bernante P. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 2004; 28: 271-276
• 23 Raguin T, Schneegans O, Rodier JF. et al. Value of fine-needle aspiration in evaluating large thyroid nodules. Head Neck 2016; [Epub ahead of print]
• 24 Giuffrida D, Gharib H. Current diagnosis and management of medullary thyroid carcinoma. Ann Oncol 1998; 9: 695-701
• 25 Elisei R, Romei C. Calcitonin estimation in patients with nodular goiter and its significance for early detection of MTC: european comments to the guidelines of the American Thyroid Association. Thyroid Res 2013; 14 (Suppl. 01) S2