Background: While thyroid nodules are frequent in endocrine clinical practice, patients are often asymptomatic and euthyroid, and death is rare in cases of malignancy. Objectives: To evaluate the perception of current international guidelines regarding thyroid nodule management among Italian endocrinologists, and to compare daily clinical practice with suggested recommendations. Methods: Italian Association of Clinical Endocrinologists (AME) members were invited to participate in a Web-based survey. Results: A total of 566 physicians responded. About 50% had read the full text of the guidelines. Over half appreciated the suggested ultrasound (US) risk categories. Fine-needle aspiration (FNA) was obtained more frequently than recommended. Follow-up of a cytologically benign nodule was largely performed according to the guidelines. Molecular testing would be most commonly requested when cytology reports showed atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) (TIR3A for Italian System). Iodine and/or levothyroxine were largely prescribed for cytologically benign asymptomatic nodules. Laser/radiofrequency ablation and percutaneous ethanol injection were commonly considered as alternatives to surgery (46.2 and 71.4%, respectively). Conclusions: Efforts are needed to make the guidelines more user-friendly and to encourage the use of codified risk categories in thyroid US reports. FNA indications remain a matter of debate as FNA is obtained in clinical practice more often than is recommended. Current US follow-up modalities for a benign nodule are correct, but probably could be performed less frequently without any harm. Molecular testing, if accessible, would be helpful in guiding clinicians' strategies in cases of AUS/FLUS-TIR3A cytologic results. Nonsurgical procedures are favorably embraced.

Keywords:
Thyroid nodule, Fine-needle aspiration, Ultrasound, Cytology, Guidelines
1.
Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA: The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol (Oxf) 1977;7:481-493.
2.
Guth S, Theune U, Aberle J, Galach A, Bamberger CM: Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination. Eur J Clin Invest 2009;39:699-706.
3.
Russ G, Leboulleux S, Leenhardt L, Hegedüs L: Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J 2014;3:154-63.
4.
Leenhardt L, Grosclaude P, Cherie-Challine L; Thyroid Cancer Committee: Increased incidence of thyroid carcinoma in France: a true epidemic or thyroid nodule management effects? Report from the French Thyroid Cancer Committee. Thyroid 2004;14:1056-1060.
5.
Davies L, Welch HG: Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006;295:2164-2167.
6.
Rossing M, Nygaard B, Nielsen FC, Bennedbæk FN: High prevalence of papillary thyroid microcarcinoma in Danish patients: a prospective study of 854 consecutive patients with a cold thyroid nodule undergoing fine-needle aspiration. Eur Thyroid J 2012;1:110-117.
7.
Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedüs L, Paschke R, Valcavi R, Vitti P; AACE/ACE/AME Task Force on Thyroid Nodules: American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 2016;22:622-639.
8.
Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L: 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016;26:1-133.
9.
Burch HB, Burman KD, Cooper DS, Hennessey JV, Vietor NO: A 2015 survey of clinical practice patterns in the management of thyroid nodules. J Clin Endocrinol Metab 2016;101:2853-2862.
10.
Durante C, Costante G, Lucisano G, Bruno R, Meringolo D, Paciaroni A, Puxeddu E, Torlontano M, Tumino S, Attard M, Lamartina L, Nicolucci A, Filetti S: The natural history of benign thyroid nodules. JAMA 2015;313:926-935.
11.
Negro R: What happens in a 5-year follow-up of benign thyroid nodules. J Thyroid Res 2014;2014:459791.
12.
Ali SZ, Cibas ES (eds): The Bethesda System for Reporting Thyroid Cytopathology: Definitions, Criteria and Explanatory Notes. New York, Springer, 2010.
13.
Baloch ZW, LiVolsi VA, Asa SL, et al: Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol 2008;36:425-437.
14.
Nardi F, Basolo F, Crescenzi A, et al: Italian consensus for the classification and reporting of thyroid cytology. J Endocrinol Invest 2014;37:593-599.
15.
Nikiforov YE, Ohori NP, Hodak SP, et al: Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. J Clin Endocrinol Metab 2011;96:3390-3397.
16.
Nikiforov YE, Steward DL, Robinson-Smith TM, et al: Molecular testing for mutations in improving the fine-needle aspiration diagnosis of thyroid nodules. J Clin Endocrinol Metab 2009;94:2092-2098.
17.
Cantara S, Capezzone M, Marchisotta S, et al: Impact of proto-oncogene mutation detection in cytological specimens from thyroid nodules improves the diagnostic accuracy of cytology. J Clin Endocrinol Metab 2010;95:1365-1369.
18.
Alexander EK, Kennedy GC, Baloch ZW, et al: Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med 2012;367:705-715.
19.
Eszlinger M, Hegedüs L, Paschke R: Ruling in or ruling out thyroid malignancy by molecular diagnostics of thyroid nodules. Best Pract Res Clin Endocrinol Metab 2014;28:545-557.
20.
Lee S, Shin JH, Oh YL, Hahn SY: Subcategorization of Bethesda System Category III by ultrasonography. Thyroid 2016;26:836-842.
21.
Bandeira-Echtler E, Bergerhoff K, Richter B: Levothyroxine or minimally invasive therapies for benign thyroid nodules. Cochrane Database Syst Rev 2014;6:CD004098.
22.
Klein Hesselink EN, Lefrandt JD, Schuurmans EP, Burgerhof JG, Groen B, Gansevoort RT, van der Horst-Schrivers AN, Dullaart RP, Van Gelder IC, Brouwers AH, Rienstra M, Links TP: Increased risk of atrial fibrillation after treatment for differentiated thyroid carcinoma. J Clin Endocrinol Metab 2015;100:4563-4569.
23.
Wang LY, Smith AW, Palmer FL, Tuttle RM, Mahrous A, Nixon IJ, Patel SG, Ganly I, Fagin JA, Boucai L: Thyrotropin suppression increases the risk of osteoporosis without decreasing recurrence in ATA low- and intermediate-risk patients with differentiated thyroid carcinoma. Thyroid 2015;25:300-307.
24.
Bennedbæk FN, Hegedüs L: Treatment of recurrent thyroid cysts with ethanol: a randomized double-blind controlled trial. J Clin Endocrinol Metab 2003;88:5773-5777.
25.
Valcavi R, Frasoldati A: Ultrasound-guided percutaneous ethanol injection therapy in thyroid cystic nodules. Endocr Pract 2004;10:269-275.
26.
Raggiunti B, Fiore G, Mongia A, Balducci G, Ballone E, Capone F: A 7-year follow-up of patients with thyroid cysts and pseudocysts treated with percutaneous ethanol injection: volume change and cost analysis. J Ultrasound 2009;12:107-111.
27.
Reverter JL, Alonso N, Avila M, Lucas A, Mauricio D, Puig-Domingo M: Evaluation of efficacy, safety, pain perception and health-related quality of life of percutaneous ethanol injection as first-line treatment in symptomatic thyroid cysts. BMC Endocr Disord 2015;15:73.
28.
Guglielmi R, Pacella CM, Bianchini A, Bizzarri G, Rinaldi R, Graziano FM, Petrucci L, Toscano V, Palma E, Poggi M, Papini E: Percutaneous ethanol injection treatment in benign thyroid lesions: role and efficacy. Thyroid 2004;14:125-131.
29.
Papini E, Rago T, Gambelunghe G, Valcavi R, Bizzarri G, Vitti P, De Feo P, Riganti F, Misischi I, Di Stasio E, Pacella CM: Long-term efficacy of ultrasound-guided laser ablation for benign solid thyroid nodules. Results of a three-year multicenter prospective randomized trial. J Clin Endocrinol Metab 2014;99:3653-3659.
30.
Deandrea M, Sung JY, Limone P, Mormile A, Garino F, Ragazzoni F, Kim KS, Lee D, Baek JH: Efficacy and safety of radiofrequency ablation versus observation for nonfunctioning benign thyroid nodules: a randomized controlled international collaborative trial. Thyroid 2015;25:890-896.
31.
Negro R, Salem TM, Greco G: Laser ablation is more effective for spongiform than solid thyroid nodules. a four-year retrospective follow up study. Int J Hyperthermia 2016;12: 1-18.
32.
Papini E, Pacella CM, Misischi I, Guglielmi R, Bizzarri G, Døssing H, Hegedüs L: The advent of ultrasound-guided ablation techniques in nodular thyroid disease: towards a patient-tailored approach. Best Pract Res Clin Endocrinol Metab 2014;28:601-618.
33.
Gharib H, Hegedüs L, Pacella CM, Baek JH, Papini E: Clinical review: nonsurgical, image-guided, minimally invasive therapy for thyroid nodules. J Clin Endocrinol Metab 2013;98:3949-3957.
© 2016 European Thyroid Association Published by S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.