COVID-19: Defer 'Bread and Butter' Procedure for Thyroid Nodules

Nancy A. Melville

April 27, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

With a few notable exceptions, the majority of fine needle aspiration (FNA) biopsies of thyroid nodules should be delayed until the risk of COVID-19, and the burden on resources, has lessened, according to expert consensus.

"Our group recommends that FNA biopsy of most asymptomatic thyroid nodules — taking into account the sonographic characteristics and patients' clinical picture — be deferred to a later time, when risk of exposure to COVID-19 is more manageable and resource restriction is no longer a concern," say the endocrinologists, writing in a guest editorial in Clinical Thyroidology.

All elective procedures have been canceled under guidance of the US Centers for Disease Control and Prevention (CDC), in conjunction with the US Surgeon General, in response to the COVID-19 pandemic. However, thyroid nodule FNAs, though elective, fall into the category of being considered medically necessary and potentially prolonging life expectancy

Yet with approximately 90% of asymptomatic thyroid nodules turning out to be benign, and little evidence that early detection and treatment affects disease outcomes, there is a strong argument for deferral in most cases, stress Ming Lee and colleagues, from the endocrinology division at Phoenix VA Health Care System (PVAHCS), Arizona, who convened a multidisciplinary meeting to address the urgent issue.

Patients should instead be interviewed by an endocrinologist (preferably via telehealth) to collect their clinical history as well as assess their perception of the disease and risk of malignancy, senior author S. Mitchell Harman, MD, chief of PVAHCS, told Medscape Medical News.

"The principal guiding factor should be the objectively assessed likelihood of malignancy of the individual patient's nodule(s)," he said.

"In my opinion, we should also factor in the patient's level of anxiety, since some patients are more sanguine about risk than others and our goal is to provide relief of anxiety as well as to determine need for, and course of, subsequent treatment," Harman added. 

Vast Majority of Malignant Thyroid Nodules Are DTC, Which Is 'Indolent'

Lee and colleagues note that, even of the 10% of thyroid nodules that do prove to be malignant, the vast majority of these (90%) are differentiated thyroid cancers (DTC). In general, patients with DTC "follow an indolent course and have excellent outcomes."

"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.

And although prior FNA is helpful to obtain a cytologic diagnosis, as this may change the extent of surgery, it may not always be essential.

Broadly, symptomatic patients with compressive symptoms threatening vital structures can be directly referred to a surgeon, with the timing for surgery jointly decided based on the severity of symptoms, rapidity of disease progression, local COVID-19 status, and available resources.

"During the pandemic, we believe that the vast majority of thyroid FNAs should be considered optional, and extent of surgery can be determined by pathological analysis of frozen sections intraoperatively," they write.

"The value of FNA in these situations is less compelling in the current COVID-19 setting, as the basis of decision for surgery has been already determined," the authors explain.

If Urgent FNA Needed, Screen Patient for COVID-19 and Use PPE

Should the need for an urgent thyroid FNA occur, patients should be screened and tested for COVID-19 by a clinician wearing personal protective equipment (PPE), say Lee and colleagues.

"It is crucial to carefully weigh the risks of COVID-19 exposure, availability of resources, and urgency of these procedures for each patient in our individual practice settings," they note.

As restrictions eventually loosen, precautions will still be necessary to some degree, Harman said.

"I do not consider FNA a 'high-risk' procedure in the era of COVID-19, since it does not routinely result in profuse aerosolization of respiratory fluids," he told Medscape Medical News.

"However, patients do sometimes cough or choke due to pressure on the neck and the operator is, of necessity, very close to the patient's face. Therefore, when we resume FNA, patients will be screened for symptoms of COVID-19 infection and both the operator and the patient will be masked," Harman continued.

"We routinely wear gloves, [and] whether the operator will wear a surgical or an N95 mask, disposable gown, etc, will depend on CDC guidance and guidance received from our VA infectious disease experts as it is applied specifically to each patient evaluation."

The authors have reported no relevant financial relationships.

Clin Thyroidol. Published online April 15, 2020. Editorial

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