Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey

BACKGROUND AND OBJECTIVE The optimum diagnostic and therapeutic strategy fo r the euthyroid patient with a solitary thyroid nodule is still a matter of debate. The aim was to assess the attitudes towards management of such pat ients in clinical centres throughout Europe by means of a questionnaire. DESIGN The questionnaire was circulated to all clinical members of the Euro pean Thyroid Association (ETA). A case report was followed by diagnostic in vestigations and choice of therapy in the index case (a 42-year old woman w ith a solitary 2 x 3 cm thyroid nodule and no clinical suspicion of maligna ncy). Eleven variations of the basic case report were proposed in order to evaluate how each alteration would affect management. MATERIAL 151 members replied to the letter and 110 individuals from 20 coun tries completed the questionnaire (corresponding to approximately two-third s of the clinical members of the ETA). They represented clinicians who had diagnosed and treated more than 50 (76%) or less than 50 (24%) patients wit h nodular thyroid disease within the previous 6 months. RESULTS Based on the index case, basal serum TSH was the routine choice of 99% and serum T4 and/or free T4 were included by 70% of the respondents. Al most 50% included determination of serum thyroid autoantibodies (TPOab: 47% , Tgab:26%) and 43% measured serum calcitonin. Thyroid scintigraphy was use d by 66% (Tc-99m: 86%, I-123: 10%, I-131: 4%), ultrasonography (US) by 80% (size: 75%, grey scale: 57%, Doppler: 33%), Scintigraphy in addition to US was used by 58%. Fine-needle aspiration biopsy (FNAB) was routinely used by 99% of the respondents, and performed under US-guidance by 42%, Based on t he individually chosen diagnostic tests indicating a benign solitary thyroi d nodule, a nonsurgical strategy was advocated by 77%. Despite controversie s on L-T4 treatment this treatment was supported by more than 40% of the cl inicians. Surgery was advocated by 23% and the preferred technique was hemi thyroidectomy (70%). Clinical factors raising suspicion of thyroid malignan cy (e.g, family history of thyroid cancer, history of external radiation, r apid nodule growth and a large nodule of 5 cm) lead the majority (70-91%; P < 0.000001) to disregard FNAB results and to choose a surgical strategy. CONCLUSIONS The favoured diagnostic strategy in the workup of patients with a solitary thyroid nodule include determinations of serum TSH combined wit h serum T4 and/or free T4 followed by FNAB and US together with scintigraph y. A nonsurgical strategy was favoured by the majority supporting the use o f L-T4 as the first choice. In case of clinical factors raising the likelih ood of malignancy, the majority recommended diagnostic thyroidectomy despit e FNAB suggesting a benign condition.