from the algorithm to the individual diagnosis

Personal view - short reports

Histopathological discrimination of follicular adenoma from well-differentiated follicular carcinoma

Saxen et al. have published their work in 1978. They demonstrated that there is a significant problem in the histopathological differentiation of follicular adenoma from well-differentiated follicular carcinoma. This excellently designed study was made for almost 40 years, and no one in the thyroid literature confuted it.
One can conceive that we are now over this problem, and it is only marginal. However, several reports in the new century confirmed that this problem is valid even nowadays (among others Hirokawa et al. 2002, Ghossein 2010, Duggal et el. 2011)
What does it mean in the everyday practice? Around 25% of follicular lesions are diagnosed differently by histopathologist.

Sonographic denomination of discrete lesions

The term nodule is differently defined by clinicians, radiologist and histopathologist; this reflects the difference in the texture of the thyroid in palpation, echogenicity and histopathology. Every thyroid disorders may present in the form of focal ultrasound alterations, but the term nodule has to be reserved for benign hyperplastic nodules and benign and malignant thyroid tumors. The most frequent problem in the everyday practice is Hashimoto's thyroiditis: discrete hypoechogenic and/or hyperechogenic lesions are present in more than 80% of cases. >>>

Who has to perform thyroid ultrasound?

I have no doubt that thyroid ultrasound has to be performed by the thyroidologist who manages the patient. First, for organizational reasons. If the clinician him- or herself performs thyroid ultrasound then the evaluation of the patient is more simple and fast. Naturally, the thyroidologist has to perform the ultrasound-guided aspiration, too. If the thyroidologist performs ultrasound, it is more simple to achieve that the first and subsequent ultrasound examination will be performed by the same investigator.
Moreover, significant additional professional advances come from this practice.

Waiting for the wonder tool

In the last three decades uncountable methods were tested and published in the literature resolving the issues of preoperative diagnostic: the sensitivity of FNAC is around 90-95%, while the specificity is around 80%. It means that significant proportion of nodular goiter patients are unnecessarily operated on.
To test new methods is the way of get new knowledge but it may lead to serious and very dangerous consequences which is demonstrated on one example.

After the paradigm shift in the thyroid

After a continuous debate in the literature that has lasted for two decades, the American Thyroid Association and the European Thyroid Association have published new guidelines of evaluation of nodular goiter in 2006. While there are some differences between the two protocols, they are quite identical regarding their principles. They provide the key role of ultrasonography in the evaluation of thyroid disease and the key role of fine needle aspiration cytology in the evaluation of nodular thyroid goiter. >>>



The influence of iodine intake

An iodine deficiency is well known to increase the prevalence of benign nodular goiter. Hence, there is a low risk of malignancy in an iodine-deficient (ID) thyroid nodule as compared to a nodule from an iodine-sufficient (IS) region. Iodine intake exerts a significant impact on the proportions of the various cancer types too. Follicular and anaplastic carcinomas are more prevalent in ID areas, while papillary carcinomas predominate in IS areas. 85-95% of papillary carcinomas are correctly diagnosed by FNAC, whereas the most important limitation of FNAC is its inability to differentiate benign from malignant follicular lesions. >>>

The fundamental of our everyday practice

How to measure quality of life? If the start point of the measure is the entrance door of our consulting room then the task is relatively simple. We met a patient who previously underwent on an ultrasound screening which described a non-palpable lesion or visited the family physician who palpated a nodule. She surfed on the net and found the word "carcinoma", "tumor", "cancer" etc. 20 times on the first page of the search engine. We do our duty, perform blood test, a repeat ultrasound, cytology. And finally the results are reassuring and a week later we can set the patient at ease. We did what we could and surely improved the quality of life of our patient, decreased or even resolved her anxiety caused by the recognition of her thyroid lesion - this is nowadays the most common success story in thyroidology.

Nevertheless, be aware that the start point of the measure is far away from the entrance door of our workplace for the patient - both in time and in space. >>>