Ultrasonography, FNA, mutations, hormones and thyroid nodule obsession in the twenty-first century: a cytopathologist’s plea for reason in the age of thyroid storm

Excerpt

Once, the physician had only observing eyes, listening ears, skilled fingers and the humble stethoscope. Then, came the roentgenogram and limited use of the ultrasound machine [1]. Next came computerized tomography (CT), high-resolution imaging and a bourgeoning use of thyroid ultrasonography (US) instigated by CT, MRI and carotid screening incidentalomas. This US explosion has led us to a new overwhelming question. Is it good? Thyroid US-related publications have amplified from 7 in 1965–1970, to over 600 in the early 2000’s [1]. A 2014 PubMed search of “ultrasonography of the thyroid” yields more than 6,000 titles. This amount of publications is minuscule compared to the number of thyroid ultrasound examinations and US-guided FNA performed yearly. Radiologists, endocrinologists, otolaryngologists, surgeons and pathologists wield US machines and FNA needles. Will thyroid US screening and FNA soon be offered at our local shopping malls? Guidelines do not support generalized US thyroid screening [2]; however, referral of incidentalomas for US is recommended [2, 3]. In 2010, we compared our institute’s thyroid FNA performed in 1997–1998 with those performed in 2009–2010 [4] (see Table 1). During the 97–98 years, thyroid FNA (256) represented 9 % (256/2718) of our total FNA, and only 7 % were performed under US; thus, most nodules were palpable. Only 2 (1 %) of patients had multiple sites aspirated although 22 had repeat FNA. In the 2009–2010 years, 205 patients had thyroid FNA. Thyroid composed 22 % of our total FNA (281/1269). Concomitantly, our 2009–2010/1997–1998 ratios for lung (112/270) and lymph node or soft tissue FNA (472/1003) markedly decreased. In 2009–2010, 96 % of thyroid FNA were performed under US, and 68 (33 %) of the 205 patients had 2 or 3 nodules aspirated. In 2011, our total non-thyroid FNA decreased further and thyroid FNA rate was 32 %. An upward age trend was also found. In the 1997–1998 years, 40 % were older than 50 years increasing to 60 % in 2009–2010. How many of these were incidentalomas? Stringently defined as nodules found on imaging of patients without past history of hypothyroidism, palpable nodules or signs or symptoms potentially related to thyroid, 83/205 (40 %) patients had FNA for incidentalomas. The reasons for discovery included: CT for non-thyroid mass or cancer (19), CT, angiogram or MRI for pain, trauma. (34), health fair (4) and miscellaneous other reasons (26). Ten (12 %) of the incidentalomas were resected. Five (50 %) were adenomas, and five (50 %) non-neoplastic benign. None were clinically aggressive papillary carcinomas; however, two incidental micropapillary carcinomas were found within benign lesions. …