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Thyroid Disorders
routine CT measurement can detect early and unsuspected MTC.
28
Early approaches for the diagnostic work-up of a patient with a thyroid nodule
diagnosis and prompt thyroidectomy result in decreased morbidity and is described in Figure 2. The clinical work-up of a patient with a thyroid
increased survival. However, there seems to be no consensus on this nodule should always be based on the assessment of possible
issue. Outside Europe, the enthusiasm for ordering routine CT has not predictors of malignancy (see Table 3) and the assessment of symptoms
been high except for a recent publication suggesting cost-effectiveness.
44
of hyperthyroidism.
The AACE/AME guidelines do not endorse routine CT measurement,
recommending the test only if FNA is suspicious for MTC or family history The thyroid nodule guidelines obviously provide useful information and
is positive for MTC/MEN2. The ATA guidelines do not recommend routine recommendations for practice, and have a positive impact on patient
CT measurement. The ETA recommends CT measurement in the initial care. However, guidelines should be considered as suggestions rather
diagnostic evaluation of thyroid nodules. than a rigid formula for practice. We always have to rely on the art of
practical medicine. The arbitrary application of guidelines to the
Recent expert opinion underlines this difference in practice on opposite individual patient can lead to problems for the individual patient. The
sides of the Atlantic: Borget et al., writing from France, state that “based recent thyroid guidelines underscore regional practice differences based
on their assumption, plasma CT determination in the assessment of partly on different disease epidemiologies, but they also illustrate many
thyroid nodule patient would appear to be highly favorable compared similarities. With further accumulating evidence, these guidelines will
with a number of other accepted health interventions.”
45
By contrast, need revision and updating. n
Podak and Burman, writing from the US, observe that “the issue of CT
testing in patients with thyroid disease remains controversial. It does
Ralf Paschke, MD, is a Professor of Internal Medicine and
not seem that the use of basal CT levels in the routine screening of
Endocrinology at the University of Leipzig. He headed the
patients with nodular thyroid disease is warranted without the ability to Department of Internal Medicine III for eight years. His
use gastrin stimulation as a confirmatory test.”
46
Thus, European thyroid
major research interests include the thyroid-stimulating
hormone (TSH) receptor, the genetics of goiter, and thyroid
specialists seem to acknowledge this ongoing controversy in thyroid
nodules and hyperthyroidism. He hosted the 2007 annual
practice, with 49% using and 43% not using routine CT measurement. meeting of the European Thyroid Association (ETA) in
However, it is it surprising that as many as 43% do not order CT
Leipzig and has served on several Editorial Boards.
measurement, considering that the overwhelming majority of them
today are likely practicing in Europe. Therefore, apparently despite the Enrico Papini, MD, is Head of the Department of
recommendation from the ETA for routine CT determination, many
Endocrine and Metabolic Diseases at the Ospedale
Regina Apostolorum, Albano in Rome and a Professor of
members still consider this matter unresolved. The positive predictive
Endocrinology at the University of Rome ‘La Sapienza’
value of routine CT measurements for medullary thyroid carcinoma in Medical School. His main areas of clinical and research
patients with thyroid nodules ranges from 10 to 40% in most studies and
interest include thyroid cancer and nodular goiter, the
thyroid gland, and type 2 diabetes. Professor Papini is
is >90% in two studies from one group.
47
Recent studies have shown
Past President of the Italian Association of Clinical
that the different CT assays have different reference ranges, that the Endocrinologists (AME).
threshold should in fact be 20 instead of 5pg/ml, as used in many
Hossein Gharib, MD, MACP, MACE, is a Professor of Medicine
previous studies, that CT levels are influenced by sex, body mass index
in the Division of Endocrinology, Diabetes, Metabolism, and
(BMI), and age and that alcohol and smoking are associated with falsely Nutrition at the Mayo Clinic College of Medicine in
elevated CT levels.
48 Rochester. He is also President of the American College of
Endocrinology (ACE). An international authority on thyroid
disorders, he has lectured at over 250 national and
It is obviously difficult to describe the diagnostic work-up of a patient international meetings and has authored or co-authored
with a thyroid nodule in a uniformly applicable algorithm. An attempt at
more than 250 academic papers.
an overview that tries to provide an integrated view of the diagnostic
1. Brander A, et al., J Clin Ultrasound, 1992;20:37–42. 18. Bahre M, et al., Acta Endocrinol (Copenh), 1988;117:145–53. 34. Frates MC, et al., Radiology, 2005;237:794–800.
2. Ezzat S, et al., Arch Intern Med, 1994;154:1838–40. 19. Krohn K, et al., J Pathol, 2000;192:37–42. 35. Frates MC, et al., J Clin Endocrinol Metab, 2006;91:3411–17.
3. Mortensen JD, et al., J Clin Endocrinol Metab, 1955;15:1270–80. 20. Laurberg P, et al., J Intern Med, 1991;229:415–20. 36. Rago T, et al., Clin Endocrinol (Oxf), 2007;66:13–20.
4. Volzke H, et al., Thyroid, 2003;13:803–10. 21. Emrich D, et al., Eur J Nucl Med, 1993;20:410–14. 37. Pacini F, et al., Eur J Nucl Med Mol Imaging, 2004;31:1443–9.
5. Krohn K, et al., Endocr Rev, 2005;26:504–24. 22. Bennedbaek FN, et al., Clin Endocrinol (Oxf), 1999;50:357–63. 38. Gharib H, Papini E, Endocrinol Metab Clin North Am,
6. Krohn K, et al., Nat Clin Pract Endocrinol Metab, 2007;3:713–20. 23. Bennedbaek FN, Hegedus L, J Clin Endocrinol Metab, 2000;85: 2007;36:707–35, vi.
7. Nagataki S, Nystrom E, Thyroid, 2002;12:889–96. 2493–8. 39. Wiersinga WM, Eur J Endocrinol, 1995;132:661–2.
8. Davies L, Welch HG, JAMA, 2006;295:2164–7. 24. Fuhrer D, et al., Exp Clin Endocrinol Diabetes, 2005;113:152–9. 40. Lucas A, et al., Eur J Endocrinol, 1995;132:677–80.
9. Colonna M, et al., Eur J Cancer, 2007;43:891–900. 25. Paschke R, et al., Dtsch Med Wochenschr, 2005;130:1831–6. 41. Chehade JM, et al., Endocr Pract, 2001;7:237–43.
10. Krebs in Deutschland, 2006, Gesellschaft der 26. American Association of Clinical Endocrinologists and 42. Richter B, et al., Endocrinol Metab Clin North Am, 2002;31:
epidemiologischen Krebsregister in Deutschland e.V.(GEKID) Associazione Medici Endocrinologi, Endocr Pract, 699–722.
in Zusammenarbeit mit dem Robert Koch Institut (RKI). 2006;12:63–102. 43. Paphavasit A, et al., Arch Surg, 1997;132:674–8.
11. Harach HR, et al., Cancer, 1985;56:531–8. 27. Cooper DS, et al., Thyroid, 2006;16:109–42. 44. Cheung K, et al., J Clin Endocrinol Metab, 2008;93:2173–80.
12. Brauer VF, et al., Dtsch Med Wochenschr, 2003;128:2381–7. 28. Pacini F, et al., Eur J Endocrinol, 2006;154:787–803. 45. Borget I, et al., J Clin Endocrinol Metab, 2007;92:425–7.
13. Lang W, et al., Am J Clin Pathol, 1988;90:72–6. 29. Gharib H, et al., Eur J Endocrinol, 2008;159: 493–505. 46. Hodak SP, Burman KD, J Clin Endocrinol Metab, 2004;89:511–14.
14. Martinez-Tello FJ, et al., Cancer, 1993;71:4022–9. 30. Diehl LA, et al., J Clin Endocrinol Metab, 2005;90:117–23. 47. Costante G, Durante C, Francis Z, et al., Nat Clin Pract Endocrinol
15. Roti E, et al., J Clin Endocrinol Metab, 2006;91:2171–8. 31. Marqusee E, et al., Ann Intern Med, 2000;133:696–700. Metab, 2009;5:35–44.
16. Knudsen N, et al., Eur J Endocrinol, 2000;142:224–30. 32. Tan GH, et al., Arch Intern Med, 1995;155:2418–23. 48. d’Herbomez M, et al., Eur J Endocrinol, 2007;157:749–55.
17. Belfiore A, et al., Cancer, 1987;60:3096–3102. 33. Hagag P, et al., Thyroid, 1998;8:989–95.
116 US ENDOCRINOLOGY
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