Indeterminate Thyroid Nodule Surgical Activity Reduced During COVID-19 Pandemic

Surgery for indeterminate thyroid nodules decreased, which resulted in an increase in the occurrence of aggressive thyroid tumors, during the COVID-19 pandemic, according to study results published in Lancet Diabetes Endocrinology. 

Researchers conducted a retrospective, international, multicenter, cross-sectional study of 1544 centers in 115 different countries. Medical records of all surgical thyroidectomies performed from January 2014 to May 2022 were collected from each center.

Patients were divided into 3 cohorts based on when their surgical thyroidectomy was performed. The first group included patients who underwent thyroidectomies pre-COVID-19 (January 2019 to February 2020); the second group included patients who had surgery during the first COVID-19 escalation (March 2020 to May 2021); and the third group included those who underwent surgery during COVID-19 de-escalation (June 1 to December 2021).

The primary outcomes collected from medical record data included the number of surgeries performed for indeterminate thyroid nodules, the occurrence of tumors greater than 10 mm in size in patients with thyroid cancer, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastasis, and tumors with a high risk for structural disease recurrence, according to the American Thyroid Association (ATA) guidelines.

A total of 87,467 patients underwent surgeries across all centers, of which 22,974 (26.3%) were indeterminate thyroid nodules. A total of 18,052 patients (78.6%) who underwent indeterminate thyroid nodule surgery were women.

The median monthly number of surgeries for indeterminate thyroid nodules were significantly decreased during the COVID-19 escalation phase compared with the other 2 phases. In the first group, the median monthly indeterminate thyroid nodules surgeries per center was 2.0, 1.4, and 2.3 in pre-pandemic, escalation, and de-escalation phases, respectively. 

Among patients diagnosed with postoperative thyroid cancer, more patients had a tumor size greater than 10 mm in the pandemic de-escalation phase compared with the pre-pandemic phase (OR 1.1; 95% CI 1.0-1.3; P =.042). A total of 69% of patients had a tumor size greater than 10 mm in the pre-pandemic phase vs 71.5% in the de-escalation phase. 

Lymph node metastasis prevalence was significantly higher among patients in the second phase (11.7%; 95% CI, 10.7%-12.9%; P =.0008) and third phase (12.5%; 11.1%-13.9%; P <.0001) compared with the first phase (9.3%; 95% CI, 8.4%-10.2%) of the COVID-19 pandemic. The calculated OR was 1.4 (1.2-1.7; P =.0001) for lymph node metastases in the third phase. Significant differences regarding thyroid cancer recurrence risk were also observed. The researchers found that patients in the third vs first phase also had an increased risk for structural disease recurrence (OR, 1.4; 1.1-1.7; P =.0039). 

Because this was an international study, COVID-19 restrictions, health policies, and pandemic peaks could have occurred at different times, leading to inaccurate classifications and results.

The study authors concluded, “[S]urgical activity for indeterminate thyroid nodules with a high suspicion of malignancy should not be postponed, even in future instances of restrictions due to new pandemic escalations or other causes.”