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Rapid Responses: Rapid Responses published:
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Are thyroid function tests helpful in the diagnosis of nodular thyroid disease?
- G L Sayer (13 August 2001)
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Management of nodular thyroid disease. Is there a role for ultrasound guided FNAC?
- Ricard Simo (29 August 2001)
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Measurement of hTERT in the Management of Thyroid Nodules
- K L Kirkpatrick, K Mokbel (2 September 2001)
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Author's reply
- M Keston Jones (13 September 2001)
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G L Sayer, SpR in General Surgery Kings College Hospital
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In his review of the management of nodular thyroid disease Dr M Keston Jones states that testing of thyroid function is still one of the cornerstones of investigation. He also states that overt thyroid dysfunction effectively rules out the possibility of malignancy. The use of thyroid function tests will not however help in the discrimination or otherwise of a nodule as it gives no description of the thyroid nodule itself. It is also clear that there are instances of malignancy occurring in patients with hyperthyroidism and a palpable thyroid nodule. Kraimps JL (1) et al report that in patients with a cold nodule and Graves disease that the incidence of maligancy is as high as 15% and should be taken as an indication for total thyroidectomy although in this group the nodules were largely non-palpable. More impressively Carnell NE and Valente WA report that 19% of palpable cold nodules were malignant in a retrospective review of 468 patients with Graves disease. It therefore seems that in some instances abnormal thyroid function may be a positive discriminator for malignacy whilst in the most euthyroid patients it will give no further diagnostic information. 1.Br J Surg 2000 Aug;87(8):1111-3
2.Thyroid 1998 Aug;8(8):647-52
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Ricard Simo, Consultant Otorhinolaryngologist Head and Neck Surgeon University Hospital Lewisham
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Management of nodular thyroid disease. Is there a role for ultrasound guided FNAC? And the role of the experienced cytopathologist? EDITOR. I read with interest the editorial of M Keston Jones regarding the management of nodular thyroid disease. I fully agree with all the individual statements on his editorial with the conclusion that the optimum diagnostic strategy for the euthyroid patient is still a matter of debate (1). He discussed the value of fine needle aspiration cytology (FNAC) and the role of ultrasound in an individual bases and there are limitations with both investigations, especially if done separately However, he did not mention the potential value of these investigations when combined . There is reasonable evidence that ultrasound guided FNAC has a definite role to play in the management strategy of nodular thyroid disease. In multinodular goitres especially, sampling errors occur most frequently with very small (<1cm) or large (>4cm.) nodules. Also if the nodules are haemorrhagic there as increased incidence of false negatives. These errors can be minimised if ultrasound is used to guide FNAC (2). Ultrasound will assist the FNAC very efficiently decreasing sampling errors, especially in posteriorly located nodules and therefore increasing sensitivity and specificity (3). Ultrasound also has a very important role in the follow-up of these patients, as the size of the nodules can be objectively measured and exact comparisons can be made. One other very important aspect not addressed in Keston Jones’ article, is the role of a cytopathologist who is experienced in the interpretation of thyroid cytological samples. Unfortunately there is no evidence published comparing different cytopathologists accuracies but there is a general consensus that the experience of the cytopathologist is a essential factor for diagnostic accuracy . It is, the duty of the clinicians requesting cytology to give maximum information regarding the history and clinical characteristics of the nodule. An ultrasound done at the same time of the FNAC will add very useful information for the final cytological interpretation. Ricard Simo 1.- Keston Jones, M. Management of nodular thyroid disease, British Medical Journal. 2001, 293-294, (11th August) 2.- Walsh, R.M., Watkinson, J.C., Franklyn, J. The management of the solitary thyroid nodule: a review. Clinical Otolaryngology, 1999, 24, 388-397 3.- Shaha, A.R. Controversies in the Management of Thyroid Nod |
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K L Kirkpatrick, Research Fellow Breast and Endocrine Surgery, Consultant Surgeon St. Bartholomew's Hospital, London, St. George's Hospital Tooting, K Mokbel
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Editor We agree with Dr M Keston Jones1 that thyroid nodules represent a diagnostic challenge. Particular difficulty exists with follicular neoplasms, where the observation of invasion is needed to differentiate adenomas from carcinomas, precluding diagnosis from fine needle aspiration cytology. We have recently reviewed the published research2 and believe that measurement of the catalytic subunit of telomerase (human telomerase reverse transcriptase, hTERT) in fine needle aspirate specimens would be helpful in the accurate diagnosis of follicular carcinoma. Eleven papers have been published since 1997 exploring telomerase or hTERT expression in a total of 159 follicular neoplasms using the TRAP enzyme assay or Reverse -Transcription Polymerase Chain Reaction (RT-PCR). These have shown a combined sensitivity and specificity of 82.9% and 82.2% in the diagnosis of malignancy. Although these figures do not yet give sufficient accuracy to enable operative planning, in our own unit we have investigated hTERT expression in human breast cancers with the newer quantitative RT-PCR. We have found that we can achieve 100% specificity and 93% sensitivity for malignancy diagnosis using a cut-off level of 5000 mRNA copy numbers per microgram of RNA3 . It is likely that the use of quantitative RT-PCR will enable hTERT expression levels to aid pre-operative diagnosis for thyroid nodules. 1 M Keston Jones. Management of nodular thyroid disease. BMJ 2001;323:293-294(11 August) 2 K Kirkpatrick, M Hanson, K Mokbel. The role of telomerase and hTERT in the diagnosis of follicular neoplasms of the thyroid. Submitted to Current Medical Research and Opinion. 3 K Kirkpatrick, W Ogunkulade, C Laban, M Ghilchick, K Mokbel. Quantitative hTERT Expression in Human Breast Cancer. Accepted for presentation at San Antonio Breast Cancer Symposium 2001. |
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M Keston Jones, Consultant Physician Singleton Hospital
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Editorial: Management of Nodular Thyroid Disease M Keston Jones (BMJ, 2001, 323, 293-294) Editor – The comments made by Sayer are not relevant to the management of nodular thyroid disease. It is recognised that nodules occurring in diffuse, Graves’ goitres have an increased risk of malignancy and that cancers arising in these goitres may be more aggressive in their behaviour.1 . A nodule arising in a patient with Graves’ disease would certainly give rise to concern and the patient would undergo fine needle aspiration cytology (FNAC). In a hyperthyroid patient with nodular thyroid disease the situation is quite different and the risk of malignancy is low 2, 3 . FNAC does not need to be performed routinely in these patients unless clinical features suggestive of malignancy are present. These features include a history of neck irradiation, rapid growth, family history, hard consistency, local lymphadenopathy and recurrent laryngeal nerve palsy in the absence of previous surgery. It is unusual for patients with nodular thyroid disease to exhibit hyper or hypothyroidism. An abnormal thyroid function test decreases the risk of thyroid cancer in these patients. 1. BELFIORE A, GAROFALO MR, GIUFFRIDA D, RUNELLO F, FILETTI S, FIUMARA A, et al Increased aggressiveness of Thyroid Cancer in Patients with Graves’ Disease Jl. Clin. Endocrinol & Metab, 1990, 830-835 2. BELFIORE A, LA ROSA GL Fine-Needle Aspiration Biopsy of the Thyroid Endocrinol. Metab. Clin. North Am, 2001, 30, 361-400 3. American Association of Clinical Endocrinologists (1996) AACE Clinical Practice Guidelines for the Diagnosis and Management of Thyroid Nodules Endocrine Practice 1996, 2, 80-84 M Keston Jones, consultant physician
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