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Management of Thyroid Nodules
- Hossein Gharib, MD; and
- John R. Goellner, MD
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IN RESPONSE:
Dr. Daniels expresses concern about the cost of thyroid nodule evaluation when fine-needle aspiration biopsy is the first test. He advocates thyroid scan as an initial procedure and believes that when a thyroid scan is not used as an initial test, patients with hot nodules may be misleadingly subjected to thyroid surgery.
Van Herle and colleagues [1] reviewed the cost-effectiveness of the evaluation of a thyroid nodule and carefully outlined the sequence of test procedures that is most cost-effective when applied to patients with solitary or dominant thyroid nodules. Both fine-needle aspiration biopsy followed by a scan and a scan followed by fine-needle aspiration biopsy were highly sensitive (93%) as well as highly specific (91%). However, the strategy using fine-needle aspiration biopsy as the first diagnostic test had the lowest cost and was the most cost-effective. The strategy that used a scan first and then fine-needle aspiration biopsy was the most expensive and least cost-effective [1]. In this analysis, the cost of surgery was excluded and analysis was restricted to the cost of diagnostic tests. Our own experience supports these data.
Fewer than 5% of nodules appear hot on thyroid scanning; fewer than 5% of these hot nodules are suspicious according to results of fine-needle aspiration biopsy [2]. This would mean that, in fact, a small fraction of patients with hot nodules may have unnecessary thyroidectomy. Most of this small group of patients will have a benign cytologic diagnosis and should be monitored.
We continue to use fine-needle aspiration biopsy as the initial diagnostic test, reserving radionuclide scanning for situations in which cytology is nondiagnostic. We consider our approach reasonable and cost-effective.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright 2004 by the American College of Physicians
