Beast Node: Examining the Many Scenarios for Treating Thyroid Nodules

[Editor’s Note: A version of this feature appeared in the March issue, prior to the spread of COVID-19 forcing the cancellation of ENDO 2020 in San Francisco.] 

By and large, endocrinologists treating thyroid nodules seem to be adopting two general principles: Avoid overtreating and include the patient in deciding next steps. Another common theme among them is how eagerly they anticipate discussing whether to “whack it, zap it, or leave it alone”.

Here, four clinicians with expertise in thyroid management detail their geographic- and demographic-specific approaches to treating thyroid nodules:

Less Is More. Says surgeon Julie Ann Sosa, MD MA FACS, of the University of California, San Francisco, “As a thyroid surgeon, I would say that there has been a general pivot toward a ‘less is more’ approach around many of our management approaches. I subscribe to these, along with a patient-centered stance that empowers the patient to arbitrate decision making where there is evidential equipoise.”

In her practice, Sosa frequently encounters patients with thyroid, parathyroid, and adrenal diseases, and her specific clinical and research interests are focused in thyroid cancer. She characterizes her approach to practice this way: “I try always to be evidence-based in my approach to thyroid disease, and especially so around hyperthyroidism, thyroid nodules, and thyroid cancer, as these are all areas where there are now robust practice guidelines. I have had the privilege to participate in the guidelines-writing process for the American Thyroid Association for hyperthyroidism and thyroid nodules and differentiated thyroid cancer, so evidence and recommendations are always in the back of my mind,” she says. Despite her scientific perspective, she is eager to debate, saying of the upcoming session, “I’m looking forward to it! It will be fun to share the stage with friends and distinguished colleagues, and I’m looking forward to spirited discussion and hopefully even a little provocative disagreement!”

Small Talk. Sebastiano Filetti, MD of the Sapienza University of Rome in Italy feels strongly that communication is critical. “In general, all treatments should be part of patient-centered care. Decision-making should be based on evidence, the patient’s best interest, and the physician’s professional judgment. Communication of potential risks and expected benefits needs to be frank, complete, and transparent. In this way, the final treatment plan can take into account patients’ preferences and needs,” he says of his approach. In his practice, thyroiditis and thyroid nodules are common, and both are frequent in the general population. “In the majority of the cases, nodules are benign disorders (or — even if malignant — are non-threatening) and require very little or no medicalization at all. For the same reason, there is no need to screen for such conditions,” he says.

He continues about his focus on clear communication: “I feel it will be an exceptional opportunity to spread some clear messages. First, all choices need to be clearly and completely discussed with the patients. Furthermore, there is an urgent need to reduce the resort to surgery for small disease and to reduce the extent of surgery, if it is done. Finally, we should reduce the number of biopsies; there is no need to biopsy small, subcentimeter, non-threatening nodules, even if suspicious for malignancy (except in case of lymph node metastases, or suspicion of extra-thyroidal extension).”

Getting the Picture. Mary C. Frates, MD of the Brigham and Women’s Hospital, Boston, Mass., a radiologist specializing in ultrasound, brings the imaging versus the treatment perspective to the group. Her area of clinical research is the thyroid gland. “I will offer some thoughts regarding the imaging of thyroid disease, including benign and malignant nodules as well as thyroiditis,” she explains. “I hope to emphasize for the audience which imaging findings should raise concern and require additional evaluation.”

Treat the Patient, not Imaging Findings. Indeed, according to Marius N. Stan, MD of the Mayo Clinic in Rochester, Minn., “We see thyroid structural ‘abnormalities’ on a number of imaging tests these days. We have to be careful in interpreting their clinical significance and avoid treating an image.” Stan sees a variety of thyroid conditions, ranging from autoimmune thyroid disease, to abnormal thyroid function tests related to other medical therapies, to papillary thyroid carcinoma, to incidentally discovered thyroid nodules. He explains that because most nodules are benign, non-toxic, and non-compressive, they can be observed, and surgical intervention avoided. “I don’t consider size to be an absolute criterion in that respect,” he continues. “However, when intervention is needed, I aim to select a pathway that preserves as much as possible the thyroid function.”

His patients, he explains, seem to prefer the treatment approach that is as selective as possible regarding the extent of thyroid resection or ablation that will result (e.g., open surgery, radioactive iodine, or ultrasound-guided ablation). “Therefore,” he says, “I try to offer that selectivity if I’m convinced that it has a good likelihood of providing resolutions or long-term control of their main thyroid problem.”

So, whack it, zap it, or leave it alone? That depends, but it’s well worth taking a look.

— Horvath is a Baltimore, Md.-based freelance writer. She wrote February’s cover story about the potential effects on the offspring of expectant mothers who vape.

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