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

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Abstract
The optimum diagnostic and therapeutic strategy for 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 patients in clinical centres throughout Europe by means of a questionnaire. The questionnaire was circulated to all clinical members of the European Thyroid Association (ETA). A case report was followed by diagnostic investigations and choice of therapy in the index case (a 42-year old woman with a solitary 2 x 3 cm thyroid nodule and no clinical suspicion of malignancy). Eleven variations of the basic case report were proposed in order to evaluate how each alteration would affect management. 151 members replied to the letter and 110 individuals from 20 countries completed the questionnaire (corresponding to approximately two-thirds 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 with nodular thyroid disease within the previous 6 months. 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. Almost 50% included determination of serum thyroid autoantibodies (TPOab: 47%, Tgab: 26%) and 43% measured serum calcitonin. Thyroid scintigraphy was used by 66% (99mTc: 86%, 123I: 10%, 131I: 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 the individually chosen diagnostic tests indicating a benign solitary thyroid nodule, a nonsurgical strategy was advocated by 77%. Despite controversies on L-T4 treatment this treatment was supported by more than 40% of the clinicians. Surgery was advocated by 23% and the preferred technique was hemithyroidectomy (70%). Clinical factors raising suspicion of thyroid malignancy (e.g. family history of thyroid cancer, history of external radiation, rapid 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. The favoured diagnostic strategy in the workup of patients with a solitary thyroid nodule include determinations of serum TSH combined with serum T4 and/or free T4 followed by FNAB and US together with scintigraphy. A nonsurgical strategy was favoured by the majority supporting the use of L-T4 as the first choice. In case of clinical factors raising the likelihood of malignancy, the majority recommended diagnostic thyroidectomy despite FNAB suggesting a benign condition.