Management of the solitary thyroid nodule: Results of a North American survey

The present survey evaluated current trends in the management of the nontox ic solitary thyroid nodule by expert endocrinologists in North America and compared their results with a similar European Thyroid Association survey. A questionnaire was circulated to all clinical members of the American Thyr oid Association. An index case (a 42-yr-old woman with a solitary 2 x 3-cm thyroid nodule and no clinical suspicion of malignancy) and 11 variations w ere provided to evaluate how each alteration would affect management. One h undred and seventy-eight members replied and 142 responses were retained fo r analysis, corresponding to a response rate of 43% of clinically active me mbers. Based on the index case, basal serum TSH was the routine choice of 9 9%, and serum T-4 and/or free T-4 were included by 61% of the respondents. Thyroid peroxidase antibodies and serum calcitonin were included by 30% and 5%, respectively. Thyroid scintigraphy was used by 23% (I-123, 63%; Tc-99m , 31%; I-131, 6%), and ultrasonography was used by 34%. Fine needle aspirat ion biopsy was routinely used by all and was guided by palpation in 87%. Ba sed on the individually chosen diagnostic tests indicating a benign solitar y thyroid nodule in a euthyroid subject, L-T-4 treatment was advocated by 4 7%, no specific treatment and follow-up was advocated by 52%, and surgery w as advocated by 1%. Clinical factors suggesting thyroid malignancy (e.g. ra pid nodule growth and a large nodule of 5 cm) lead a significant number of clinicians (40 - 50%; P < 0.00001) to disregard biopsy results and to choos e a surgical strategy. Nevertheless, North American endocrinologists heavil y rely on fine needle aspiration biopsy results. Compared to the European T hyroid Association survey, North American endocrinologists use imaging [sci ntigraphy, 23% vs. 66% (P < 0.0001); ultrasonography, 34% us. 80% (P < 0.00 01)] and serum calcitonin (5% us. 43%; P < 0.0001) less frequently. A nonsu rgical strategy prevails in North America, and despite controversies on the effect of L-T-4, this treatment is supported by more than 40% in both Euro pe and North America.