What are the Benefits and Risks of Thyroid Nodule Evaluation in Patients ≥70 Years Old.
Comments by Dr.G.
1.1200 > 70 year old patients with 2600 nodules.
2. 67 % of nodules were benign.
3. FNA lead to surgery in 210 patients and 93/210 were benign.
4. Significant risk thyroid cancer was reviewed anaplastic, medullary,and poorly diff thyroid cancers was only 1.5 % of the cases.All 10 cancer deaths 0.9% were from this group.
4. 160 14% died over 4 year followup from other causes.
5.1112 patients demonstrated that a separate non-thyroidal malignancy or coronary artery disease at the time of nodule evaluation was associated with increased mortality.
6.These are important variables to identify prior to thyroid nodule evaluation.
7.For patients ≥70 years old, US and FNA are safe and prove helpful in identifying significant risk cancers and benign cytology.
8.However, the surgical management of patients ≥70 years old presenting without high-risk findings should be tempered, especially when comorbid illness is identified.
9. The use of non -surgical alternatives such as ethanol and radiofrequency ablation can treat the majority of thyroid lesions in the older populations.
RFA for nodules and cancer in elderly instead of surgery.
Ethanol ablation of thyroid and parathyroid cysts in elderly saves a surgery with it’s possible complications.
Call 1-310-393-8860 or email to [email protected] for an evaluation for these alternatives if you are over 70 before you go under the surgical knife.
Quantitative Analysis of the Benefits and Risk of Thyroid Nodule Evaluation in Patients ≥70 Years Old
Background: In older patients, thyroid nodules are frequently detected and referred for evaluation, though usually prove to be benign disease or low-risk cancer. Therefore, management should be guided not solely by malignancy risk, but also by the relative risks of any intervention. Unfortunately, few such data are available for patients ≥70 years old.
Methods: All consecutive patients ≥70 years old assessed by ultrasound (US) and fine-needle aspiration (FNA) between 1995 and 2015 were analyzed. Clinical, US, and histologic data, including patient comorbidities and outcomes, were obtained. Imaging and cytology results from initial evaluation were reviewed to detect significant-risk thyroid cancer (SRTC), which was defined as anaplastic, medullary, or poorly differentiated carcinoma, or the presence of distant metastases. Overall survival analyses were then performed to assist with risk-to-benefit assessment.
Results: A total of 1129 patients ≥70 years old with 2527 nodules ≥1 cm were evaluated. FNA was safe in all, and cytology proved benign in 67.3% of patients. However, FNA led to surgery in 208 patients, of whom 93 (44.7%) had benign histopathology. Among all patients who underwent FNA, only 17 (1.5%) SRTC were identified, all of which were preoperatively identifiable by imaging and/or cytology. These SRTC were responsible for all (n = 10; 0.9%) thyroid cancer deaths. Among all other patients (n = 1112), 160 deaths (14.4%) were confirmed during a median follow-up of four years. None of these were thyroid cancer related. Survival analysis for these 1112 patients demonstrated that a separate non-thyroidal malignancy or coronary artery disease at the time of nodule evaluation was associated with increased mortality compared to those without these diagnoses (hazard ratio = 2.32 [confidence interval 1.66–3.26]; p < 0.01), confirming these are important variables to identify prior to thyroid nodule evaluation.
Conclusions: For patients ≥70 years old, US and FNA are safe and prove helpful in identifying SRTC and benign cytology. However, the surgical management of patients ≥70 years old presenting without high-risk findings should be tempered, especially when comorbid illness is identified.
However, most thyroid cancer is low risk and progresses at a slow rate. Consequently, delay in treatment appears to impart minimal harm to many such patients (6).
. Furthermore, surgical interventions are often a source of morbidity that must be balanced with their potential benefits.
Advancing patient age is an important consideration in the evaluation and management of nodular disease.However, older patients have fewer life-years ahead of them, and frequently have co-morbid diseases that increase surgical risks. Current guidelines broadly suggest a more conservative approach to thyroid nodule evaluation and thyroid cancer treatment in older patients
Complications of thyroidectomy were defined as re-operation for hematoma, bilateral recurrent laryngeal nerve (RLN) injury, persistent (>6 months) unilateral RLN injury, postoperative hypocalcemia requiring reevaluation, or persistent (>6 months) hypoparathyroidism.
These data confirm the utility of sonographic neck evaluation, and UG-FNA, in patients ≥70 years old when thyroid nodules ≥1 cm are identified. Using this strategy, benign cytology will be identified in approximately two-thirds of patients, which is a highly accurate finding and allows conservative management, alleviating concern among patients and providers.
In summary, these data depict the risks and benefits of thyroid nodule evaluation in patients aged ≥70 years. While one cannot exclude a modest possible benefit to treating all biopsy-confirmed thyroid cancer, the data are consistent with the known indolent course demonstrated by most well-differentiated thyroid cancers. In support, the American Thyroid Association guidelines note that a conservative strategy may be reasonable in such older individuals (2) because the majority of older patients with nodular disease will have benign or relatively indolent thyroid cancer (14,20), and prior studies support a conservative approach in low-risk papillary microcarcinomas (21,22). Though the surgical complications were low in this cohort, as the patients were treated by high-volume thyroid surgeons, the risks of intervention are likely greater in lower-volume settings. Together, these findings support the application of an individualized approach to surgical intervention in older patients without clear evidence of aggressive thyroid cancer.
In conclusion, these data confirm that US and UG-FNA assist with the initial risk assessment of thyroid nodules in patients aged ≥70 years by identifying those with benign cytology or by identification of sonographic/cytologic findings suggesting highly aggressive malignant disease. However, the surgical management of patients ≥70 years old presenting with lower-risk thyroid nodules (based on US and/or cytology), including those with indeterminate and non-diagnostic cytology, should be individualized, and a conservative approach favored given the significant potential for morbidity in comparison to more limited therapeutic benefit. This is particularly true for those with significant medical conditions such as CAD or other non-thyroidal malignancies at the time of initial evaluation.