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January 27, 2015

Large Thyroid Nodules Have Higher Risk of Cancer Even if Needle Biopsyis Normal

A recent 2015 study revealed that large thyroid nodules (over 3cm) have a higher risk of cancer and that needle biopsies are not very accurate in diagnosing cancer in such large nodules. This is hardly the first study to demonstrate this.

In a 2009 study, surgeons at the University of Wisconsin found that fine needle aspiration biopsy (FNAB) in 26 of 52 FNAB reported as benign (50.0%) turned out to be either neoplastic (22) or malignant (4) on final pathologic analysis after thyroidectomy. Among patients with nondiagnostic FNAB results, the risk of malignant neoplasms was 27.3%. Even for smaller thyroid masses, FNAB is still not 100% accurate with a falsely negative rate of around 10%.

In the 2015 study (meta-analysis based on 15 other studies), a total of 13,180 patients were analyzed who underwent thyroid nodule biopsies. What they found was that the best-reported studies suggests sensitivity, false-negative rates, and frequency of true negatives among benign needle biopsy results are worse in large nodules (over 3cm).


These findings all suggest that thyroidectomy may be the best course to take regardless of needle biopsy results (if performed) in large thyroid nodules.

So what does this mean for a patient with a thyroid mass?

1) The ONLY way to know 100% whether a patient has thyroid cancer or not is to remove the thyroid.
2) IF the needle biopsy shows thyroid cancer, total thyroidectomy is recommended.
3) IF the needle biopsy does not show thyroid cancer, thyroid cancer can STILL be there; it's just that the needle biopsy was wrong; and the risk of a wrong results is higher the larger the nodule, especially if over 3cm in size. Thyroid lobectomy should still be considered.

Of course, one needs to talk with your local surgeon on what the next step is.

Just keep in mind that the needle biopsy is not 100% accurate!


Reference:
Accuracy of Fine-Needle Aspiration Biopsy for Predicting Neoplasm or Carcinoma in Thyroid Nodules 4 cm or Larger. Arch Surg. 2009;144(7):649-655. doi:10.1001/archsurg.2009.116.

False negatives in thyroid cytology: impact of large nodule size and follicular variant of papillary carcinoma. Laryngoscope. 2013 May;123(5):1305-9. doi: 10.1002/lary.23861. Epub 2013 Jan 4.

Impact of thyroid nodule size on prevalence and post-test probability of malignancy: A systematic review. Laryngoscope. 2015 Jan;125(1):263-72. doi: 10.1002/lary.24784. Epub 2014 Jun 26.


Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

1 comment:

  1. I had total thyroidectomy in 2005 and since then have many problems breathing at night while sleeping. They did a sleep endoscopy in 2011 and found very prominent lingual tonsils, but more significantly, near total collapse of the epiglottis while in a sleep state. CPAP only made things worse with up 25 AHI with over 90% CPAP compliance on very high pressure. My surgeon told me my recurrent laryngeal nerves were preserved during surgery and he found nothing amiss in followup. I had a steel surgical staple placed during surgery to control a bleeding vessel, and they removed part of my thymus due to lymphadenopathy found. I had Hurthle cell neoplasm on FNA before surgery and the diagnosis was Hurthle cell benign type on postop path, but I wonder if I should have something tested because I have a lot of throat soreness and mouth inflammation in the back of my tongue constantly with some bleeding.

    Thanks for posting this informative video Dr. Chang. s/ Edward.

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