title: GAUGING THE EXTENT OF THYROIDECTOMY FOR INDETERMINATE THYROID NODULES: AN ONCOLOGIC PERSPECTIVE.
abstract: OBJECTIVE
  Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN.
  
  
  METHODS
  We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation.
  
  
  RESULTS
  There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%).
  
  
  CONCLUSIONS
  In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN.
  
  
  BACKGROUND
  ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.
authors.forename: David F
authors.initials: DF
authors.lastname: Schneider
authors.forename: Linda M
authors.initials: LM
authors.lastname: Cherney Stafford
authors.forename: Nicole
authors.initials: N
authors.lastname: Brys
authors.forename: Caprice C
authors.initials: CC
authors.lastname: Greenberg
authors.forename: Courtney J
authors.initials: CJ
authors.lastname: Balentine
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Elfenbein
authors.forename: Susan C
authors.initials: SC
authors.lastname: Pitt
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D020249:Hormone Replacement Therapy / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D018447:Medical Futility; D000069342:Medical Overuse / Q000706:statistics & numerical data; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D000067490:Prescription Drug Overuse; D012189:Retrospective Studies; D013964:Thyroid Neoplasms / Q000188:drug therapy / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D016606:Thyroid Nodule / Q000188:drug therapy / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D013965:Thyroidectomy / Q000592:standards / Q000706:statistics & numerical data*; D013974:Thyroxine / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D013974:Thyroxine