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Decision Analysis of Discordant Thyroid Nodule Biopsy Guideline Criteria

Division of Endocrinology and Metabolism (C.R.M.), Department of Medicine; and Department of Public Health Sciences (G.J.S.), University of Virginia Health System, Charlottesville, Virginia 22908

Address all correspondence and requests for reprints to: Christopher R. McCartney, M.D., Division of Endocrinology and Metabolism, Department of Medicine, Box 800391, University of Virginia Health System, Charlottesville, Virginia 22908. E-mail: cm2hq{at}virginia.edu.

Context: Recently published guidelines are discordant regarding diagnostic approaches to small (10–14 mm) thyroid nodules.

Objective: The objective of the study was to explore the relative desirability of alternative diagnostic approaches to small thyroid nodules using decision analysis.

Design: Four diagnostic approaches to a 10- to 14-mm thyroid nodule are modeled: 1) observation only, consistent with American Thyroid Association guidelines; 2) routine fine-needle aspiration biopsy (FNAB), an approach traditionally chosen by many endocrinologists and consistent with American Thyroid Association guidelines; 3) FNAB only when microcalcifications are present, as recommended by Society of Radiologists in Ultrasound guidelines; and 4) FNAB only when the nodule is hypoechoic and has at least one other ultrasonographic risk factor, as endorsed by American Association of Clinical Endocrinologists guidelines.

Main Outcome Measures: Measures included expected values; a priori likelihoods of prespecified outcomes; and two-way sensitivity analyses based on the utility of observation only in the setting of thyroid cancer and thyroid surgery for benign, asymptomatic thyroid disease.

Results: Expected values (EVs) were similar among decision alternatives modeling Society of Radiologists in Ultrasound guidelines, American Association of Clinical Endocrinologists guidelines, and routine observation (EVs from 0.912 to 0.927). Routine FNAB had the lowest EV (0.757–0.861), primarily related to a high a priori likelihood of having surgery for a benign nodule.

Conclusions: As a general approach to 10- to 14-mm thyroid nodules, routine FNAB appears to be the least desirable. This analysis offers additional data that physicians can use when choosing diagnostic approaches to small thyroid nodules based on perceived risks of delayed cancer diagnosis and unnecessary thyroid surgery.