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Large thyroid nodules: should size alone matter?

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European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Background

The management of thyroid nodules ≥ 4 cm is controversial due to conflicting evidence on the prevalence of malignancy and diagnostic accuracy of fine-needle aspiration cytology (FNAC). Some literature recommends routine excision of large thyroid nodules due to high cytology false negative rates (FNR). We aim to investigate the diagnostic accuracy of FNAC, prevalence of malignancy in large (≥ 4 cm) thyroid nodules compared to nodules < 4 cm, and the clinical and ultrasound characteristics of those large nodules with false negative cytology.

Methods

This was a retrospective case-log review in a tertiary referral hospital. All thyroid nodules subjected to Ultrasound (US)-guided FNAC by the Interventional Radiology department between December 2011 and November 2017 were included. Data on patient demographics, thyroid US features, cytology findings, and surgical histology were collected and analyzed. Sensitivity, specificity, and FNR were calculated based on FNAC results and final post-operative histology. Factors associated with a false negative result were analyzed using univariate and multivariate analyses.

Results

A total of 4982 nodules were studied, including 4419 < 4 cm and 563 ≥ 4 cm. Malignancy rates were similar in both groups. For nodules ≥ 4 cm, FNAC sensitivity was 40%, specificity 100%, and FNR 6.6% compared to 4.2% in nodules < 4 cm. Within malignant nodules, there was a significantly higher proportion of follicular and Hurthle cell carcinomas in nodules ≥ 4 cm. Amongst nodules ≥ 4 cm, multivariate analysis revealed male gender to be an independent predictor of FNR (OR 3.32; 95% CI 1.29–8.59).

Conclusion

Larger nodules ≥ 4 cm have a similar malignancy rate as nodules < 4 cm, and FNAC FNR is low at 6.6%. Management of large thyroid nodules should be individualized based on their clinical, sonographic and cytological features rather than routine surgery.

Level of evidence

3.

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Availability of data and material

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy concerns, but are available from the corresponding author on reasonable request.

Code availability

Not applicable.

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Funding

The authors did not receive support from any organization for the submitted work.

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Authors and Affiliations

  1. Department of Otorhinolaryngology—Head and Neck Surgery, Singapore General Hospital, Singapore, Singapore

    Joyce Zhi’en Tang & Kimberley Liqin Kiong

  2. Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore, Singapore

    Jasmine Ming Er Chua, Tian Kai Woon & Bien Soo Tan

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  1. Joyce Zhi’en Tang
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  3. Tian Kai Woon
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Contributions

KLK conceptualized the study, and TKW put the dataset together. JZT and KLK analyzed the data together. JZT was a major contributor in writing the manuscript. All authors read and were involved in manuscript revisions, and all approved the final manuscript.

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Correspondence to Joyce Zhi’en Tang.

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The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

Approval for this study was obtained from Singhealth Institutional Review Board (IRB reference: 2014/238/C).

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Not applicable. This paper is based on a database and no identifiable information is included, hence no consent was taken from subjects for participation.

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Tang, J.Z., Chua, J.M.E., Woon, T.K. et al. Large thyroid nodules: should size alone matter?. Eur Arch Otorhinolaryngol 279, 3139–3146 (2022). https://doi.org/10.1007/s00405-021-07151-3

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  • DOI: https://doi.org/10.1007/s00405-021-07151-3

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