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The appropriate diagnostic evaluation of the patient presenting with nodular
thyroid disease remains controversial, despite the frequency of the problem.
Several alternative strategies have been proposed ranging from immediate
surgery of all lesions to selective surgery after one or more of a series
of investigations including radionuclide imaging, ultrasound scanning,
a trial of thyroid hormone suppression and fine needle or large needle
biopsy. Molitch et al. (l0) have applied decision analysis to examination
of the value of these different strategies, balancing possible long term
benefits of increased life expectancy after surgery against the risk of
operative complications, and the value of imperfect diagnostic techniques
that alter surgical selection. In view of the good prognosis for most patients
with differentiated thyroid cancer it is not surprising that only small
differences can be demonstrated between the predicted value of each strategy
for investigation and management. At age 20, aspiration cytology provides
a benefit of 0.05% of life expectancy over thyroid hormone suppression,
which in turn outweighs immediate surgery by 0.16%.
Considerations other than life expectancy therefore need to be taken account of and fine needle aspiration cytology, as a sole investigation, followed by selective surgery, is emerging as an appropriate scheme for patient management. This scheme has resulted in a reduction in the number of radionuclide and ultrasound scans and the number of operations performed in many clinics. In our own series, surgery was performed for removal of neoplastic tissue in 40% of cases, compared with a predicted rate of 9.6% if all solitary nodules have been removed. Al-Sayer et al. (36) and Hamberger et al. (44) have reported a 25% reduction in frequency of operation for single thyroid swellings and an increase in the proportion of operations for neoplastic disease from 31 to 50% after routine use of aspiration cytology. This approach not only spares many patients with benign disease unnecessary surgery but leads to substantial financial savings. In centres where large numbers of patients with solitary nodules are seen and where expert cytological skills are available, fine needle aspiration cytology is to be recommended for routine use in the diagnostic evaluation of such patients. In these circumstances we would recommend that patients with malignant or suspicious cytological findings, or where clinical suspicion is high, be referred for selective surgery. Definition of an optimum management strategy does depend, however, on the long term follow up of patients with negative results by such centres. |
