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Navigating the Debate on Managing Large (≥4 cm) Thyroid Nodules.

Samantha N Steinmetz-Wood1, Amanda G Kennedy2, Bradley J Tompkins2

  • 1University of Vermont Medical Center, Burlington, VT, USA.

International Journal of Endocrinology
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Summary

Approximately 13% of surgeries for large thyroid nodules (≥4cm) may be unnecessary. This study highlights opportunities to improve patient care and reduce costs by re-evaluating surgical indications for benign biopsy results.

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Area of Science:

  • Endocrinology
  • Surgical Oncology
  • Diagnostic Cytopathology

Background:

  • Discordant practice guidelines for managing large thyroid nodules (≥4cm) can lead to unnecessary surgeries and increased healthcare costs.
  • Recent data indicate similar false-negative rates in fine needle aspiration (FNA) biopsies for both small (<4cm) and large (≥4cm) nodules.
  • Monitoring may be a suitable alternative to surgery for large nodules with benign FNA biopsy results.

Purpose of the Study:

  • To investigate the management of thyroid nodules measuring ≥4cm.
  • To determine the proportion of surgeries that were not diagnostically necessary for these large nodules.
  • To identify potential predictors for unnecessary surgeries.

Main Methods:

  • Retrospective cohort study of patients with thyroid nodules ≥4cm who underwent FNA biopsy between November 2014 and October 2019.
  • Surgery was deemed unnecessary if FNA results were benign and no specific high-risk factors (compressive symptoms, family history of thyroid cancer, neck irradiation, toxic nodule, substernal extension) were present.
  • Statistical analysis included Wilcoxon rank sum tests, chi-square, and Fisher's exact tests.

Main Results:

  • Out of 177 patients with nodules ≥4cm, 54.2% underwent surgery.
  • Surgical patients were younger (51.5 vs. 62 years) and more likely to report obstructive symptoms (34.4% vs. 12.1%).
  • 13% (23/177) of surgeries were potentially unnecessary for diagnostic purposes, with benign FNA results and negative surgical pathology.

Conclusions:

  • Nearly half of patients with large thyroid nodules underwent surgery.
  • A significant proportion (13%) of these surgeries may not have been necessary for diagnostic reasons.
  • Findings suggest opportunities to optimize management strategies for large thyroid nodules, potentially reducing costs and improving patient care.