In most cases of asymptomatic thyroid nodules, fine needle aspiration (FNA) biopsy should be deferred to a later time when the risk for exposure to coronavirus disease 2019 (COVID-19) is lower, according to a consensus by the Endocrinology Division at Phoenix VA Healthcare System published in Clinical Thyroidology.
The COVID-19 pandemic has affected countries across the world, and in order to reduce the exposure of patients and healthcare workers to COVID-19 and preserve limited resources, the US Center for Disease Control and Prevention (CDC) and the US Surgeon General ordered a cancellation of all elective medical procedures, such as thyroid FNAs.
Most thyroid cancers are differentiated thyroid malignancies, which have excellent outcomes with low overall mortality. Furthermore, there is no solid evidence that early detection and treatment of these tumors significantly improve the outcomes. For these reasons, the attendees of a multidisciplinary meeting convened by the Phoenix VA Healthcare System concluded that FNA biopsy of most asymptomatic thyroid nodules should be deferred to a later date, taking into consideration the sonographic characteristics and clinical picture.
The group believes that the decision to complete immediate thyroid FNA biopsy or surgery should not be based solely on the ultrasound features.
Conversely, as delays in diagnosis and treatment for medullary thyroid cancer can adversely affect the prognosis, it is recommended to assess calcitonin levels in cases of thyroid nodules appropriate for FNAs, especially if the patient has a family history of these tumors or has nodules located in the posterior upper third of the lateral lobes. FNA should be completed as soon as possible in the presence of a calcitonin level >10 pg/mL and surgery without FNA should be considered with a calcitonin level >100 pg/mL.
Urgent thyroid surgery is indicated for anaplastic thyroid cancers and although FNA is part of the routine workup for these malignancies, it is often nondiagnostic. As such, the panel suggested that during the COVID-19 pandemic, surgery may be appropriate with or without prior FNA based on the clinical care team’s judgment.
FNA can also assist in determining the extent of surgical interventions for thyroid masses associated with compressive symptoms, but in cases for which the decision for surgery has already been determined, FNA may be less important in the current COVID-19 pandemic. The consensus authors suggested most FNAs should be considered optional in these cases and that the extent of surgery can be determined by pathological analysis of frozen sections intraoperatively.
Safety measures should be implemented in all cases that require urgent thyroid FNA, including testing such patients for COVID-19 and using personal protective equipment.
“It is crucial to carefully weigh the risks of COVID-19 exposure, availability of resources, and urgency of these procedures for each patient in our individual practice settings,” concluded the experts.