Overtreatment of thyroid nodules

In fact, everyone is familiar with the disease of thyroid nodules. Many people suffer from this disease for various reasons. However, after suffering from a disease like thyroid nodules, many patients will receive excessive treatment. What is overtreatment of thyroid nodules? In other words, patients with thyroid nodules that can be treated with medication will choose surgical treatment, which is overtreatment.

Thyroid nodules are very common in the normal population. In the past, due to limited medical conditions, people could only discover them when their necks thickened. Since ultrasound examination has been widely used in physical examinations, the detection rate of thyroid nodules has rapidly increased from 4% to 19%~67%. That is to say, 1 in 4 people has thyroid nodules, which are more common in women and the elderly.

Among thyroid nodules, 80% to 90% are nodular goiter, which is a disease of thyroid tissue hyperplasia and degeneration, not a tumor and has no surgical indications.

Only 5% to 10% of thyroid cancers may require surgical treatment.

In addition, about 10% of other benign nodular diseases, such as Hashimoto's thyroiditis, usually do not require surgery.

At present, over-treatment of thyroid nodules is a common phenomenon in China.

A statistical report on thyroid disease surgery in Changchun City, Jilin Province shows that among 9,216 patients with thyroid nodules who underwent surgical treatment, only 10% had malignant tumors, while benign nodules such as nodular goiters and adenomas accounted for about 90%.

Since the detection rate of thyroid nodules can be as high as 19% to 67%, it should not and is impossible for China, with a population of 1.3 billion, to perform surgery on every patient with thyroid nodules. However, due to the low level of ultrasound and cytology diagnosis in most hospitals in my country, it is impossible to distinguish the benign or malignant nature of nodules before surgery, so some doctors perform surgery on all patients with thyroid nodules, which not only wastes a lot of medical resources, but also causes varying degrees of damage to the patient's appearance and function.

Therefore, according to the 2015 edition of the "Guidelines for the Diagnosis and Treatment of Thyroid Nodules and Differentiated Thyroid Cancer in Adults" (referred to as the "2015 Guidelines") of the American Thyroid Association (ATA), a reasonable diagnosis and treatment process should be formulated in combination with the actual situation of each hospital, and diagnosis and treatment should be strictly followed to reduce unnecessary surgeries and other treatments.

Ultrasound diagnosis

High-definition thyroid ultrasound examination is the most basic and important diagnostic and treatment step in the process, with the highest cost-effectiveness. In most cases, the nature of the nodule can be preliminarily determined by understanding the location, shape, size, number, nodule edge status, internal structure, echo characteristics, blood flow conditions and cervical lymph node conditions of the nodule.

The 2015 Guidelines divide the malignancy risk of nodules in ultrasound images into five levels, which is worth learning from. Based on the characteristics of the nodule ultrasound image, suitable patients can also be selected for fine needle aspiration biopsy (FNA). At present, the accuracy rate of ultrasound diagnosis of benign lesions at the Cancer Hospital of the Chinese Academy of Medical Sciences can reach 86.0%, and the accuracy rate of malignant lesions is 82%.

Thyroid nodule FNA

Fine needle aspiration biopsy (FNA) of thyroid nodules is the most accurate and cost-effective diagnostic method for preoperative evaluation of the nature of thyroid nodules and is listed as a routine method in all foreign guidelines. There are approximately 300,000 new cases of thyroid nodules in the United States each year, and approximately 96% undergo biopsy.

In China, biopsy examinations are rarely performed due to outdated physician concepts, limited level of cytopathology diagnosis, patients' excessive concerns about thyroid nodules, and doubts about the safety of FNA.

The Cancer Hospital of the Chinese Academy of Medical Sciences has been performing thyroid FNA since October 2005. The sensitivity of differentiating benign and malignant thyroid nodules has reached 85.4%, the specificity is 86.9%, and the positive predictive value is 90.5%, and the diagnostic level is close to the international standard. It can be seen that by accumulating experience, the diagnostic level of FNA and pathological cytology can be significantly improved.

In addition, concerns about the safety of FNA are unnecessary: ​​literature reports that approximately 300,000 patients undergo thyroid FNA examinations in the United States each year. As of January 2010, there have been only 19 reports of tumor implantation caused by thyroid puncture.

Currently, the patients recommended for FNA examination are mainly those with nodules larger than 1 cm.

Diagnosis and treatment

In the diagnosis and treatment process, after completing the FNA examination, the choice of treatment is also based on evidence. According to the Papanicolaou Cytopathology Society's diagnostic strategy for thyroid FNA, FNA diagnostic results are divided into 6 levels: malignant, suspected malignant, undiagnosable, atypical cells, follicular tumors, and benign.

Usually benign nodules can be checked regularly without the need for surgery. Large sample data confirm that the probability of thyroid cancer developing in patients with benign puncture results during long-term follow-up is only 0.6% to 3%, and most of them can be discovered in subsequent follow-up and receive timely treatment.

In addition, due to uncertain effectiveness, levothyroxine is not recommended for inhibiting nodule growth, and it may instead cause adverse reactions in the heart and bones.

Of course, not all benign nodules do not require any treatment. A small number of patients have large thyroid nodules and should consider surgery if the following conditions occur:

① Compression of the trachea affects breathing;

② Affects the appearance of the neck;

③ Retrosternal goiter, etc.

Nodules that are suspicious of malignancy or malignancy should usually be treated surgically. The results of the study showed that among patients with malignant puncture results, 97.6% were confirmed to have thyroid malignant tumors by pathology after surgery, and among patients with suspected malignant puncture results, 83.3% were confirmed to have malignant tumors. Once a malignant tumor is confirmed, it will be treated and followed up according to the principles of thyroid cancer.

However, it is worth discussing whether all thyroid microcancers (maximum diameter less than or equal to 10 mm) require surgical treatment.

An ultrasound screening specifically for the female thyroid gland found that 3.5% of women had thyroid cancer, mainly thyroid microcancer.

Autopsies of corpses revealed that the proportion of normal people "carrying" thyroid microcancer can be as high as 0.5% to 5.2%.

Therefore, can the vast majority of thyroid microcancers remain "dormant" for a long time without developing and posing a threat?

A recent Japanese study answered this question:

In a study of 1235 patients with thyroid microcarcinoma who were selectively followed up and not treated with surgery (mean follow-up, 60 months, range, 18-227 months), only 43 patients (3.5%) had clinical progression of the disease (tumor diameter greater than 12 mm or clear lymph node metastasis), and no patient developed lung metastasis or died.

Although this result still needs more research to verify, it suggests that for suitable patients with thyroid microcancer, observation and follow-up is also a treatment option. At present, newly discovered thyroid cancer microcancers at home and abroad account for a large proportion, reaching about 40%. For such a large population, using surgical treatment may lead to another misunderstanding of overtreatment.

The standardized diagnosis and treatment process of thyroid nodules introduced above will help avoid overtreatment of thyroid nodules. However, it must be recognized that the levels of different regions and hospitals in the country vary greatly, and it is necessary to formulate practical diagnosis and treatment plans based on their actual medical levels. Some large hospitals in Beijing, Shanghai, Guangzhou and other cities with the necessary conditions can try their best to align themselves with internationally advanced diagnosis and treatment methods, while hospitals that lack the means of pathological cytological diagnosis can rely on ultrasound and intraoperative freezing to assist in diagnosis and treatment.