The incidentaloma of the thyroid

M. Dietlein; C. Kobe; M. Schmidt; H. Schicha

doi:10.1055/s-0038-1625208

Nuklearmedizin - NuclearMedicine, Table of Contents

Nuklearmedizin 2005; 44(05): 213-224
DOI: 10.1055/s-0038-1625208

Original Articles

Schattauer GmbH

The incidentaloma of the thyroid

Over- or underuse of diagnostic procedure for an epidemiologic finding?Das Inzidentalom der SchilddrüseÜber- oder Unterdiagnostik eines epidemiologischen Befundes?

M. Dietlein

¹Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln

,

C. Kobe

¹Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln

,

M. Schmidt

¹Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln

,

H. Schicha

¹Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln

› Author Affiliations

Abstract

Summary:

The incidentally detected thyroid nodule using sonography is described as incidentaloma; the most nodules have a diameter up to 1.5 cm. Sonography will detect thyroid nodules in more than 20% of the population in Germany. Epidemiological studies investigating the prevalence of malignancy in such incidentalomas are missing. The incidence of differentiated thyroid cancer is about 3 per 100,000 people and year. However, several monocentric studies have shown a prevalence of malignancy of up to 10% of the thyroid nodules in selected patients’ group. The histology did not found microcarcinomas only, but also small cancer with infiltration of the thyroid capsule, lymph node metastasis or multifocal spread. The studies were not designed for outcome measurement after early and incidental detection of small thyroid cancers. Hypoechogenity, ill defined borders, central hypervascularization or microcalcifications were used as combined criteria for risk stratification. The second method for risk stratification is scintigraphy and further tests are warranted for hypofunctioning nodule ≥1 cm. Additionally, the family history, patient’s age <20 years, former radiation of the neck, and measurement of calcitonin should be regarded. Without such a risk stratification selection for fine needle aspiration is impossible. Fine needle aspiration of non-palpable incidentalomas led to non-representative or unequivocal cytological findings in up to 40%. Because better outcome of incidentally detected small thyroid carcinomas is not proved and because sonography, scintigraphy and fine needle aspiration remain imprecise regarding dignity of incidentalomas, fine needle aspiration is not the standard for small, non-palpable thyroid nodules. Conclusion: For management of incidentaloma, sonographically unsuspicious, scintigraphically indifferent (nodules ≥1 cm) and without any risk factors in patients’ history, wait and see is justified when patient is informed about the problem.

Zusammenfassung:

Der sonographische Zufallsbefund eines nicht palpablen Schilddrüsenknotens (Größe meistens bis ca. 1,5 cm im Durchmesser) wird deskriptiv als „Inzidentalom“ bezeichnet. Die Sonographie entdeckt sie bei mehr als 20% der Bevölkerung in Deutschland. Epidemiologische Studien zur Malignomprävalenz in solchen Inzidentalomen fehlen. Die Inzidenz für das differenzierte Schilddrüsenkarzinom liegt bei etwa 3 auf 100 000 Einwohner und Jahr. Mehrere monozentrische Studien aus selektierten Patientenkollektiven fanden demgegenüber eine Malignomprävalenz bis 10% in den kleinen Schilddrüsenknoten. Dabei handelte es sich nicht nur um papilläre Mikrokarzinome, sondern diese kleinen Karzinome gingen unerwartet häufig mit einem Kapseldurchbruch, einer Lymphknotenmetastasierung oder mit einem multifokalen Tumorwachstum einher. Die Studien enthalten keine Daten, inwiefern die Frühdiagnose kleiner Schilddrüsenkarzinome einen Überlebensvorteil gegenüber der Diagnose im Verlauf darstellt. Echoarmut, unscharfe Knotenbegrenzung, zentrale Vaskularisation oder Mikrokalk erlaubten in Kombination eine Risikostratifikation, ebenso wie der szintigraphische Nachweis der Hypofunktionalität in Knoten >1 cm Durchmesser. Ferner sind Familienanamnese, Lebensalter <20 Jahren, frühere Halsbestrahlung und ggf. eine erhöhte Calcitoninkonzentration zu berücksichtigen. Ohne diese Risikoabschätzung wäre die Auswahl zur Feinnadelpunktion nicht realisierbar, zumal die Punktion solcher Inzidentalome bei bis zu 40% zu einer nicht repräsentativen oder uneindeutigen zytologischen Beurteilung führt. Da die Prognoseverbesserung der Früherkennung nicht belegt ist und da Sonographie, Szintigraphie und Feinnadelpunktion eine diagnostische Unschärfe bzgl. Dignität zeigen, kann die Feinnadelpunktion des kleinen, nicht tastbaren Knotens nicht zum diagnostischen Standard werden. Schlussfolgerung: Für das Inzidentalom der Schilddrüse, unverdächtig im Sonogramm, indifferent im Szintigramm (bei Knoten ≥1 cm) und ohne anamnestische Risikofaktoren wird nach Aufklärung des Patienten die langfristige Verlaufskontrolle begründbar bleiben.

Key words:

Incidentaloma - thyroid nodule - thyroid cancer - sonography - scintigraphy - fine needle aspiration - calcitonin

Schlüsselwörter:

Inzidentalom - Schilddrüsenknoten - Schilddrüsenkarzinom - Szintigraphie - Feinnadelpunktion - Calcitonin

Full Text

References

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