Benbassat, Carlos1,3; Koren, Shlomit 1,3; Steinshneider, Miriam1,3; Or, Karen 1; Kummer, Esther 1; Muallem Kalmovich, Limor2,3
1 Endocrine Institute, Assaf Harofeh Medical Center, Zerifin, Israel
2 Department of ENT, Assaf Harofeh Medical Center, Zerifin, Israel
3 Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Background: New thyroid nodules ATA guidelines recommend considering hemithyroidectomy in PTC tumors < 4 cm. We sought to investigate physicians practice in light of those guidelines.
Methods: A questionnaire was e-mailed to endocrinologists and ENT surgeons including demographic data and an index case: A 26 y.o women with a 3 cm Bethesda 3 nodule.
Results: Response rate was 62% (134/216), 93 endocrinologists, 41 surgeons. 46.2% would repeat FNA, 24.6% would order molecular analysis and 22.4% would refer to surgery. Should repeated FNA remain B3, 49% would proceed to surgery. If FNA was B6, 58.5% would operate (TT) ,41.5% hemithyroidectomy (HT). In pathologically confirmed PTC, 41.6 % would recommend completion, followed by RAI (65.4%). While 53% would recommend HT for tumors < 4 cm, 35% would recommend TT > 2 cm. Variables favoring TT were family history (89%) and irradiation exposure (95%). Only 17% and 25% would prefer TT in the presence of small benign contralateral tumor or Hashimoto. In patients with normal US and undetectable Tg 1y after TT and RAI, 63% would perform Tg stimulation but only 12% would do iodine scan. For two LNs (13 and 9 mm) recurrence after TT and RAI, 56% would reoperate. Main differences between endocrinologists and ENT: iodine after completion thyroidectomy (9.3 vs 25.7%), HT for 4 cm tumor (52 vs 46%) and impact of Hashimoto and age (18 vs 37% and 18 vs 36%, respectively).
Conclusion: Despite new ATA guidelines, the approach to < 4 cm monofocal low risk PTC remains controversial.