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Submitted on March 29, 2006
Accepted on June 29, 2006
From: Dept. of Radiology (MCF, CBB, PMD, MC); Thyroid Section, Division of Endocrinology, Hypertension and Diabetes, Dept. of Medicine (EK, JO, PRL, EM, EKA), Dept of Pathology (ESC); and Dept. of Surgery (FDM); Brigham & Women's Hospital and Harvard Medical School, Boston, MA
* To whom correspondence should be addressed. E-mail: ekalexander{at}partners.org.
Context: Controversy remains as to the optimal management of patients with thyroid nodules.
Objective: To determine the prevalence, distribution, and sonographic features of thyroid cancer in patients with solitary and multiple thyroid nodules.
Design: Retrospective, Observational Cohort Study, 1995 to 2003
Setting: Tertiary care hospital.
Patients: Patients with one or more thyroid nodules >10 mm in diameter who had ultrasound-guided fine needle aspiration (FNA).
Main Outcome Measure: Prevalence and distribution of thyroid cancer, based on patient characteristics, number of nodules and sonographic features.
Results: 1,985 patients underwent FNA of 3,483 nodules. The prevalence of thyroid cancer was similar between patients with a solitary nodule (175 of 1181 patients, 14.8%) and patients with multiple nodules (120 of 804, 14.9%) (P = 0.95, chi-square). A solitary nodule had a higher likelihood of malignancy than a non-solitary nodule (P < 0.01). In patients with multiple nodules >10 mm, cancer was multifocal in 54%, and 72% of cancers occurred in the largest nodule. Multiple logistic regression analysis of statistically significant features demonstrates that the combination of patient gender (P < 0.02), whether a nodule is solitary vs. one of multiple (P < 0.002), nodule composition (P < 0.01) and presence of calcifications (P < 0.001) can be used to assign risk of cancer to each individual nodule. Risk ranges from a 48% likelihood of malignancy in a solitary, solid nodule with punctate calcifications in a man to less than 3% in a noncalcified predominantly cystic nodule in a woman.
Conclusions: In a patient with one or more thyroid nodules >10 mm in diameter, the likelihood of thyroid cancer per patient is independent of the number of nodules, while the likelihood per nodule decreases as the number of nodules increases. For exclusion of cancer in a thyroid with multiple nodules >10 mm, up to 4 nodules should be considered for FNA. Sonographic characteristics can be used to prioritize nodules for FNA based on their individual risk of cancer.
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