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“There is little evidence that early detection and treatment of DTC significantly alters disease outcomes as the overall mortality rate for DTC has remained low, at around 0.5%,” they write.
They also note that ultrasound features of thyroid nodules can help guide priority for the future timing of an FNA procedure, but should not be the sole basis for deciding on immediate thyroid FNA or surgery.
Exceptions to the Rule
Exceptions for considering FNA include more urgent thyroid disease diagnoses, including those that are symptomatic.
Suspected Medullary Thyroid Cancer
“Regarding medullary thyroid cancer (MTC), early diagnosis and surgery do significantly improve outcomes, therefore, delaying FNA of nodules harboring MTC could be potentially injurious,” the authors say.
They suggest, however, measuring calcitonin levels instead, which they note “is still controversial” in the United States, but “we feel it would be justified in patients with thyroid nodules that would usually be indicated for FNA.”
Those with a family history of MTC, or nodules located in the posterior upper third of lateral lobes (the usual location of MTC), should have calcitonin levels measured.
If calcitonin levels are above 10 pg/mL, “FNA should be offered as early as possible.”
“Significantly elevated serum calcitonin levels (eg, > 100 pg/mL) should be considered an indication for surgery without cytologic confirmation by FNA,” they add.
Anaplastic Thyroid Cancer
Anaplastic thyroid cancer, though rare, “is one of the few occasions when thyroid surgery should be performed on an urgent basis, as this condition can worsen very rapidly.”
“Patients typically present with a rapidly enlarging thyroid mass that is associated with compressive symptoms, such as dysphagia and dyspnea,” they observe.
In this instance, although FNA is part of the pre-operative workup, it is often nondiagnostic and could require additional sampling.
“At the time of this pandemic, it is reasonable that after a multidisciplinary discussion, such patients with the appropriate clinical scenario be referred for thyroid surgery, with or without prior FNA, based on the team’s judgment,” the authors recommend.
Longstanding Thyroid Masses
These are usually large and/or closely associated with vital structures, such as the trachea and esophagus, and when such masses cause compressive symptoms, thyroid surgery is typically warranted.
