Year : 2016 | Volume
: 13 | Issue : 3 | Page : 99--100
Improving decision-making in thyroid nodules
Krishna G Seshadri
Editor in Chief, Thyroid Research in Practice, Sri Balaji Vidhyapeeth, Pondicherry, India
Krishna G Seshadri
Editor in Chief, Thyroid Research in Practice, Sri Balaji Vidhyapeeth, Pondicherry
|How to cite this article:|
Seshadri KG. Improving decision-making in thyroid nodules.Thyroid Res Pract 2016;13:99-100
|How to cite this URL:|
Seshadri KG. Improving decision-making in thyroid nodules. Thyroid Res Pract [serial online] 2016 [cited 2020 Feb 28 ];13:99-100
Available from: http://www.thetrp.net/text.asp?2016/13/3/99/193126
Despite significant leaps in our understanding, thyroid nodules continue to remain an enigma to clinicians. Palpable nodules are common and present in approximately 5% of women and 1% of men in iodine sufficient areas. If high-resolution ultrasound were used, up to 68% of randomly selected individuals may have nodules.  The clinician's task in nodule is finding the proverbial needle in the haystack and saving the vast majority of patients who have benign disease from the scalpel, while accurately identifying the important minority who need intervention.
Over the years, fine-needle aspiration cytology (FNAC) has become an important tool in our ability to discriminate patients who will not need surgery from those who will. In this issue of the journal, Alwahaibi et al.  describe a 10-year retrospective of FNACs of the thyroid from a single institution in Oman. Their experience epitomizes those of many experiences and provides insights into how we can do a better job in helping patients with nodules find reassurance and comfort.
The period of the author's study extends through a decade in which significant advances in technology occurred which enabled a paradigm shift in the management of thyroid nodules leading to a revision of recommended practices. Detailed information on the use and decision-making is not available in the article, but it would be interesting to compare their first 5 years with the second.
Five processes have emerged from a decade of understanding that can help us in better decision-making. First is closer and collaborative work between the radiologist, cytologist, and the clinician - endocrinologist in managing patients with thyroid nodules. Second is the use of ultrasound as an important component in decision-making. Clearly, the single most important advance in the last decade in the care of patients with thyroid nodules is the availability of high-resolution ultrasound. A sonologist experienced with thyroid ultrasound and willing to meticulously document findings using a standard reporting system such as the Thyroid Imaging Reporting and Data System (TIRADS)/American Thyroid Association risk category is a significant asset.  Ultrasound guidance during FNAC is the third game changer. While this may not be required for all nodules, most clinicians with this expertise prefer this tool to target areas of suspicion. In addition, there is evidence that it reduces false negative rates.  Fourth is a cytologist on site who ensures that samples drawn from the FNACs are adequate. This is an important safeguard to reduce the number of inadequate samples that plagued Alwahaibi et al. Fifth is the use of a standardized score such as a Bethesda scoring system which reduces ambiguity in reporting.  There is a significant correlation between the Bethesda scoring system and histopathology. Of note is a significant correlation between ultrasonography risk scores such as the TIRADS and the Bethesda scores; discordance between the two allows clinicians to flag patients who require a relook.
Ancillary testing and molecular methods while interesting and exciting have not improved by much our ability to tell cancer from a "non." This is simply because that many of these tests "rule in" malignancy but are very poor in "ruling out." This is where going back to the basics and using available resources and technology optimally for the welfare of the patient makes a big impact. Allowing a small number of people in an institution to do this over and over again is the surest step to ensuring that a majority of patients get the right clinical decision. To paraphrase Aristotle, we are what we repeatedly do. Excellence is, therefore, a habit and not a virtue.
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