In the initial assessment of thyroid nodules, thyrotropin (TSH) has very low sensitivity for assessing functional thyroid nodules (FTNs). The false negativity in FTNs and the false positivity in non-FTNs misinterpreted by TSH will raise unnecessary assessment costs. Therefore, the aim of this study is to explore the values of the TSH and color flow Doppler sonography (CFDS) combined strategies in reducing the unnecessary assessment costs.
2383 patients with thyroid nodules were retrospectively analyzed, including 107 FTNs and 2276 non-FTNs. Four strategies including TSH, CFDS, Combination 1 (TSH+/CFDS+, TSH+/CFDS−, and TSH−/CFDS+ defined as positive; TSH−/CFDS− defined as negative) and Combination 2 (TSH+/CFDS+ defined as positive; TSH+/CFDS−, TSH−/CFDS+, and TSH−/CFDS− defined as negative) were separately used for initial assessment. The four strategies were compared using the testing cost ratio of fine-needle aspiration (FNA) to thyroid scintigraphy (TS) (marked as CFNA/TS) as main outcome measure.
Compared with TSH, Combination 1 prevented 15.89 % of FTNs from unnecessary FNA, but increased the number of non-FTNs subjected to unnecessary 99mTc-TS by 9.31 %. Combination 2 prevented 5.32 % of non-FTNs from unnecessary TS, but increased the number of FTNs subjected to unnecessary FNA by 18.69 %. When CFNA/TS was <6.05, the lowest total cost was found in Combination 2. The TSH and Combination 1 were optimal at 6.05 ≤ CFNA/TS ≤ 12.47 and CFNA/TS > 12.47, respectively.
The combined strategies can be used to supplement TSH in the initial assessment of thyroid nodules in iodine-adequate areas, depending on the testing costs of FNA and TS.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Gharib H, Papini E, Valcavi R, Baskin HJ, Crescenzi A, Dottorini ME, et al. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2006;12:63–102.
American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167–214.
Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. Endocr Pract. 2010;16:468–75.
Hurtado-López LM, Monroy-Lozano BE, Martínez-Duncker C. TSH alone is not sufficient to exclude all patients with a functioning thyroid nodule from undergoing testing to exclude thyroid cancer. Eur J Nucl Med Mol Imaging. 2008;35:1173–8.
Chami R, Moreno-Reyes R, Corvilain B. TSH measurement is not an appropriate screening test for autonomous functioning thyroid nodules: a retrospective study of 368 patients. Eur J Endocrinol. 2014;170:593–9.
Walfish PG, Strawbridge HT, Rosen IB. Management implications from routine needle biopsy of hyperfunctioning thyroid nodules. Surgery. 1985;98:1179–88.
Wang HH. Reporting thyroid fine-needle aspiration: literature review and a proposal. Diagn Cytopathol. 2006;34:67–76.
Rieu M, Bekka S, Sambor B, Berrod JL, Fombeur JP. Prevalence of subclinical hyperthyroidism and relationship between thyroid hormonal status and thyroid ultrasonographic parameters in patients with non-toxic nodular goitre. Clin Endocrinol (Oxf). 1993;39:67–71.
Fiore E, Rago T, Provenzale MA, Scutari M, Ugolini C, Basolo F, et al. Lower levels of TSH are associated with a lower risk of papillary thyroid cancer in patients with thyroid nodular disease: thyroid autonomy may play a protective role. Endocr Relat Cancer. 2009;16:1251–60.
Gimondo P, Pizzi C, Gimondo S, Messina G. Ultrasonography, with Doppler color, and cytologic correlations in Plummer’s disease. Radiol Med. 1998;95:193–8.
Lupi A, Cerisara D, Orsolon P, De Antoni G. Vianello Dri A. Thyroid nodules and Doppler ultrasonography. A new element for an old puzzle? Minerva Endocrinol. 1999;24:7–10.
Becker D, Lohner W, Martus P, Hahn EG. Color doppler ultrasonographic detection of focal thyroid nodules. Ultraschall Med. 1999;20:41–6.
Bogazzi F, Bartalena L, Brogioni S, Burelli A, Manetti L, Tanda ML, et al. Thyroid vascularity and blood flow are not dependent on serum thyroid hormone levels: studies in vivo by color flow doppler sonography. Eur J Endocrinol. 1999;140:452–6.
Erdoğan MF, Anil C, Cesur M, Başkal N, Erdoğan G. Color flow Doppler sonography for the etiologic diagnosis of hyperthyroidism. Thyroid. 2007;17:223–8.
Smith-Bindman R, Lebda P, Feldstein VA, Sellami D, Goldstein RB, Brasic N, et al. Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. JAMA Intern Med. 2013;173:1788–96.
Rago T, Vitti P, Chiovato L, Mazzeo S, De Liperi A, Miccoli P, et al. Role of conventional ultrasonography and color flow-doppler sonography in predicting malignancy in ‘cold’ thyroid nodules. Eur J Endocrinol. 1998;138:41–6.
Tatar IG, Kurt A, Yilmaz KB, Doğan M, Hekimoglu B, Hucumenoglu S. The role of elastosonography, gray-scale and colour flow Doppler sonography in prediction of malignancy in thyroid nodules. Radiol Oncol. 2014;48:348–53.
Ianni F, Perotti G, Prete A, Paragliola RM, Ricciato MP, Carrozza C, et al. Thyroid scintigraphy: an old tool is still the gold standard for an effective diagnosis of autonomously functioning thyroid nodules. J Endocrinol Invesig. 2013;36:233–6.
Bransom CJ, Talbot CH, Henry L, Elemenoglou J. Solitary toxic adenoma of the thyroid gland. Br J Surg. 1979;66:592–5.
Kumar A, Ahuja MM, Chattopadhyay TK, Padhy AK, Gupta AK, Kapila K, et al. Fine needle aspiration cytology, sonography and radionuclide scanning in solitary thyroid nodule. J Assoc Physicians India. 1992;40:302–6.
Committee on China National Center for Food Safety Risk Assessment. Salt Iodization and Risk Assessment of Iodine Status in Chinese Population. Beijing: National Health and Family Planning Commission of the People’s Republic of China. 2010. http://www.moh.gov.cn/cmsresources/mohwsjdj/cmsrsdocument/doc9250.pdf. Accessed 26 Aug 2014.
Belfiore A, Sava L, Runello F, Tomaselli L, Vigneri R. Solitary autonomously functioning thyroid nodules and iodine deficiency. J Clin Endocrinol Metab. 1983;56:283–7.
Baltisberger BL, Minder CE, Bürgi H. Decrease of incidence of toxic nodular goitre in a region of Switzerland after full correction of mild iodine deficiency. Eur J Endocrinol. 1995;132:546–9.
Reinhardt MJ, Högerle S, Trupkovic T, Krause TM, Moser E. Influence of urinary iodine excretion on thyroid technetium-99m pertechnetate uptake with and without TSH suppression: what happens when iodine supply increases? Eur J Nucl Med. 1998;25:1475–81.
Georgopoulos NA, Sykiotis GP, Sgourou A, Papachatzopoulou A, Markou KB, Kyriazopoulou V, et al. Autonomously functioning thyroid nodules in a former iodine-deficient area commonly harbor gain-of-function mutations in the thyrotropin signaling pathway. Eur J Endocrinol. 2003;149:287–92.
Bastin S, Bolland MJ, Croxson MS. Role of ultrasound in the assessment of nodular thyroid disease. J Med Imaging Radiat Oncol. 2009;53:177–87.
WHO. Iodine status worldwide: WHO global database on iodine deficiency. Geneva: World Health Organization. 2004. http://whqlibdoc.who.int/publications/2004/9241592001.pdf. Accessed Aug 2014.
De Nicola H, Szejnfeld J, Logullo AF, Wolosker AM, Souza LR, Chiferi V Jr. Flow pattern and vascular resistive index as predictors of malignancy risk in thyroid follicular neoplasms. J Ultrasound Med. 2005;24:897–904.
Sharma R, Chakravarty KL, Tripathi M, Kaushik A, Bharti P, Sahoo M, et al. Role of 99mTc-Tetrofosmin delayed scintigraphy and color Doppler sonography in characterization of solitary thyroid nodules. Nucl Med Commun. 2007;28:847–51.
Fu X, Guo L, Zhang H, Ran W, Fu P, Li Z, et al. “Focal thyroid inferno” on color Doppler ultrasonography: a specific feature of focal Hashimoto’s thyroiditis. Eur J Radiol. 2012;81:3319–25.
H. Cai and Y. Qiao contributed equally.
About this article
Cite this article
Cai, H., Qiao, Y., Huang, X. et al. Cost-effective initial assessment strategies for thyroid nodules in iodine-adequate areas. Ann Nucl Med 31, 12–18 (2017). https://doi.org/10.1007/s12149-016-1124-5
- Thyroid nodule
- Initial assessment
- Color flow Doppler sonography