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Thyroid Disorders
Guideline-oriented Diagnosis of Thyroid Nodules
Ralf Paschke, MD,
1
Enrico Papini, MD
2
and Hossein Gharib, MD, MACP, MACE
3
1. Professor of Internal Medicine and Endocrinology, III Medical Department, University of Leipzig; 2. Professor of Endocrinology, University of Rome
‘La Sapienza’ Medical School; 3. Professor of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine
Abstract
Thyroid nodules are very common. Their etiology is due to the interaction between genetic and environmental factors. In 2006, two major
society-sponsored guidelines and one major consensus statement for thyroid diagnosis and management were published by the American
Association of Clinical Endocrinologists/Associazione Medici Endocrinologi (AACE/AME), the American Thyroid Association (ATA), and the
European Thyroid Association (ETA). A careful review of these guidelines reveals that despite many similarities, significant differences are also
present, likely reflecting differences in practice patterns, interpretation of existing data, and availability of resources in different regions. The
methodology of the guidelines is similar, but a few differences in the rating scales make a rapid comparison of the strength of both evidence
and recommendations difficult for use in current clinical practice. Some recommendations are based mostly on expert opinion. The
same recommendation may be based on different evidence; on the other hand, sometimes the same evidence may induce a different
recommendation. A survey performed during an interactive symposium at the 32nd annual meeting of the ETA in Leipzig in Germany, was
carried out to investigate whether these guidelines were able to affect the divergent management strategies for thyroid nodules that have
previously been documented. The thyroid nodule guidelines obviously provide useful information and recommendations for practice and have
a positive impact on patient care; however, guidelines should be considered as suggestions rather than a rigid formula for practice. With further
accumulating evidence, these guidelines will need revision and updating.
Keywords
Thyroid nodule, diagnosis, treatment, guidelines, evidence-based
Disclosure: The authors have no conflicts of interest to declare.
Received: April 27, 2009 Accepted: July 10, 2009
Correspondence: Ralf Paschke, MD, III Medical Department, University of Leipzig, Ph.-Rosenthal-Str. 27, D-04103 Leipzig, Germany. E: pasr@medizin.uni-leipzig.de
Etiology, Epidemiology, and Risks increased production of H
2
O
2
will lead to an increased rate of
Thyroid nodules are very common. Moreover, with the increasing use of mutagenesis; depending on which gene is hit, this will lead to small
sensitive imaging techniques, an increasing proportion of thyroid clones of hot or cold thyroid cells, which will then give rise to hot or cold
nodules are now detected incidentally. A prospective study comparing thyroid nodules or, less frequently, thyroid carcinomas.
clinical examination and ultrasound showed that 46% of nodules >1cm
detected by ultrasound escaped detection by clinical examination.
1
In areas not affected by nuclear fall-out, the annual incidence of
Autopsy and prospective ultrasound studies in North America detected thyroid cancer has been reported to range between 1.2 and 2.6 cases
asymptomatic thyroid nodules in 50 and 67%, respectively.
2,3
A per 100,000 in men and 2 and 3.8 cases per 100,000 in women,
population study in Germany—a previously iodine-deficient and with higher incidences in countries such as Sweden, France, Japan,
currently borderline iodine-sufficient country—detected thyroid nodules and the US.
7
An increase of thyroid cancer incidence from 3.6 per
by ultrasound in 20% of the population 20–79 years of age. The 100,000 in 1973 to 8.7 per 100,000 in 2002 has recently been reported
prevalence increased with advancing age to 52 and 29%, respectively, in the US.
8
A similar increase of thyroid cancer incidence from 1983
for women and men 70–74 years of age.
4
to 2000 was reported in France,
9
and the incidence of thyroid
cancer in Germany in 2002 was 6.7 and 3.2 per 100,000 women
According to current knowledge, the etiology of thyroid nodules can be and men, respectively.
10
However, most of these increases in
summarized as outlined in Figure 1 (modified from Krohn et al.
5
and thyroid cancer incidence are due to an increased detection of small
Krohn et al.
6
). Susceptibility to developing a thyroid nodule or goiter papillary cancers.
8,9
mainly in response to iodine deficiency is genetically determined. In
genetically susceptible individuals with maladaptation to iodine In autopsy studies, clinically silent thyroid papillary microcarcinomas
deficiency, the increased thyroid epithelial cell proliferation and the (<1cm diameter) have been reported in up to 36% depending on the
112 © TOUCH BRIEFINGS 2009
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