Is consensus a good thing in the management of thyroid nodules?
Is consensus a good thing in the management of thyroid nodules?
复制标题
在甲状腺结节的治疗中达成共识是一件好事吗？
DOI：
10.1089/thy.2006.16.205
复制
发表时间：
2006
期刊：
影响因子：
6.6
通讯作者：
T. Davies
中科院分区：
文献类型：
--
作者：
T. Davies
IAM ALWAYS SUSPICIOUS of the word “consensus.” To me this word means that not everyone agrees. Furthermore, in medical practice every “Consensus Conference” that I have known has resulted in considerable controversy. Look at the sparks flying over when to treat or not to treat mild thyroid failure (1, 2). The reason is obvious. Trying to make definitive decisions on inadequate evidence is impossible. Such a conference or statement is, by necessity, a compromise. As I often state—what you see depends upon where you stand. So... no surprise that a paper in the journal Radiology last month has caused much discussion (3). The paper is entitled “Management of thyroid nodules detected at sonography: Society of Radiologists in Ultrasound consensus conference statement” and I have invited two colleagues to comment on this for our journal. One is an experienced clinical thyroidologist and the other is an experienced radiologist with an interest in thyroid ultrasound (p. 5–7; this issue). Now, from where I stand, all thyroid ultrasonography should be performed by a thyroidologist him/herself in real time where the clinical history, examination, and ultrasound can be combined into a sensible management plan. Unfortunately I also recognize that this is the ideal and not the real world and so we should welcome efforts by our radiology colleagues to plot a course of action. In my scenario, it would be the referring endocrinologist who would make the decision to biopsy, based on the management plan, rather than the radiologist who may or may not be simply observing images obtained by an ultrasound technician in isolation. Suppose the patient has a suppressed TSH, suggesting no need for biopsy? Or the patient has a history of radiation exposure suggesting that any nodule should be biopsied? One thing to be sure of is that the days of planting one’s hands on the neck and pronouncing the lack of thyroid nodules to the patient have gone. The number of significant nodules revealed by ultrasound is astounding and has changed the face of clinical practice for all of us since the incidence of thyroid cancer is the same in nonpalpable nodules as it is in palpable ones (4). Most disturbing is the fact that thyroid cancer appears to be just as common in multinodular glands as with single nodules (10%) and even worse, it is not always the dominant nodule which is malignant. So what to do? We certainly can’t biopsy every nodule, but to rely on arbitrary sizing—more than 1 cm or more than 2 cm—defies all scientific logic. Every thyroid cancer starts out small and the sooner we have molecular tools to distinguish them from benign nodules, the better. Until then, we have to rely on the art of practical medicine, not arbitrary guidelines which can lead to problems for the individual patient.
