Nodular thyroid disease, the presence of single or multiple nodules within the thyroid gland, is a common clinical problem. Most clinicians, particularly primary care physicians, internists, endocrinologists and general surgeons, regularly evaluated patients with thyroid nodules and consequently must make diagnostic and management decisions. Solitary thyroid nodules may be benign or malignant.1 The prevalence of clinically detected thyroid nodules in the United States population is 4–7%, with an annual incidence of 0.1%. Of an estimated 250,000 thyroid nodules that develop per year, 18,000 are newly detected thyroid cancers. Therefore, 7% of thyroid nodules are malignant.2 The challenge facing physicians in the evaluation of thyroid nodules is to identify the few patients with a thyroid malignancy among the larger majority of patients who have benign nodular disease. The former always requires surgical excision, whereas most patients with benign nodular disease can be managed without surgery. Moreover, early identification of a thyroid malignancy in patients with thyroid nodules should improve the patient’s outcome. A delay in the diagnosis allows time for tumour growth, and tumour size is correlated with tumour recurrence and mortality.³

Thyroid nodules are identified during routine physical examination, the most frequently ordered imaging studies are radionuclear scans and thyroid sonography. The incidence of thyroid cancer in cold nodules is about 10%;4 whereas the incidence of functional lesions in the thyroid is less than 2%.5 Although thyroid sonography provides detailed anatomical information, it doesn’t distinguish between benign and malignant nodules. However, thyroid sonography may show the presence of small (£ 1 cm in diameter) nodules that are not clinically relevant but result in further testing and cause a lot of investigations which augments the patients’ anxiety.6

The diagnostic and therapeutic approach to a solitary thyroid nodule at King Abdulaziz University Hospital has been reviewed in this study.

The medical records of patients referred to the radiology department because of thyroid disease during the interval of October 2003 to October 2004 were reviewed. Among 694 cases , 55 (7.9%) patients had a solitary thyroid nodule. The data collected included age, sex, nationality, description of the nodule including size and consistency, pertinent past history concerning radiation treatment, family history of thyroid disease, and compressive symptoms such as dysphagia, dyspnoea, and dysphonia.

The laboratory data included thyroid function test (FT4, FT3, TSH) using radioimmunoassay commercial kits, thyroid sonography, thyroid scans using radioactive iodine, antithyroid antibodies (anti-microsomal and anti-thyroglobulin antibodies) measured by indirect haemagglutination technique and results of FNA. The mode of therapy, which was selected according to the FNA findings, laboratory data as well as physician, surgeon or endocrinologist’s preference and choice, was also summarized (e.g. surgery, thyroxin suppression therapy, radioactive iodine treatment or follow up of patients in the clinic without intervention). We tried to estimate the number of tests, which were repeated unnecessarily, and the duration required to make a diagnosis or develop a management plan in accordance with published guidelines. The SASS (Statistical Analysis for Social Science) was utilized. The mean ± SD was determined for quantitative variables. Frequencies were adjusted and comparison tests were performed. A p-value of £ 0.05 was considered statistically significant.

All 55 patients, who were evaluated for a thyroid nodule, were included in this study. The mean age was 36.17 ± 12.3 years (range 15-67 years); 30 males and 25 females with a male:female ratio of 1.2:1. Thirty patients were non-Saudi, and 25 were Saudi with a non-Saudi to Saudi ratio of 1.2:1. The mean size of the nodule was 2.22 cm ± 0.834 (range 1-3.5 cm). The description of the thyroid was soft in 33 (60%) cases. Five (9%) were cystic; however, in 17 (31%) cases a description was not provided. There was no history of radiation exposure in any patient; however, 9 (16.3%) patients gave a history of thyroid disease in a family member.

Forty-two (76.36) patients, who have nodular disease, were referred initially from a primary physician to a surgeon, while as only 13 (23.6%) were seen by an endocrinologist in the first visit with a p-value of 0.002, which is statistically significant.

Twenty-seven (49%) patients had either a lobectomy or a subtotal thyroidectomy. Post-operative histopathology revealed a multinodular goitre in 14 patients; 9 cases were follicular tumours; 3 were cystic nodules and one case of thyroiditis was detected. Radioactive iodine treatment of the toxic adenomas was given to 4 (7%) cases. Thyroxin (L-T4) suppression therapy with follow up was selected for 3 (6%) cases only. Ten patients (18%) had follow up only with no other intervention; however, 11 (20%) cases required no treatment or follow up.

Thyroid nodules come to clinical attention when noted by the patient, as an incidental finding during routine physical examination, or during a radiological procedure. The clinical importance is primarily related to the need to exclude thyroid cancer, which accounts for 5 to 6.5% of all thyroid nodules.1,2 The early referral of patients with suspected thyroid nodules to an endocrinologist before performing expensive imaging tests results in cost saving and more efficient diagnosis.7 Evaluation of nodular thyroid disease begins with determination of the serum level of TSH. If the serum TSH is suppressed, the next test should be radioisotope scanning to rule out toxic adenoma. The serum level of TSH is usually normal and management is based on cytological results of the FNA. Many studies have addressed the questions regarding the cost effectiveness of thyroid scintigraphy in the management of thyroid nodule. Its role is mainly in evaluating patients with thyroid nodules in order to determine whether the nodule is a non-functioning cold nodule or a hot autonomously functioning nodule, which accounted for only 5-10% of all palpable thyroid nodules.8 Patients with autonomous nodules have been found to have thyroid cancer, only in a small number of cases. Only 5 patients in our study were similar to those reported in the literature.5

Almost all our patients had Tcm99 radionuclide scan, which is a very expensive tool for investigating a thyroid nodule. All FNAs were guided by ultrasonography as 76.36 % of patients were seen initially by a surgeon, who doesn’t perform FNAs in the clinic.9,10 Forty-two (76.36%) patients with a thyroid nodule were referred from a primary physician to a general surgeon; this explains that 27 (49%) patients had either lobectomy or subtotal thyroidectomy although the FNAs revealed one case of papillary carcinoma of thyroid only.11,12 It also explains the under-use of L-T4 (6%) as a suppression therapy of thyroid nodules.13-15 which does not conform with published guidelines for the diagnosis and management of thyroid nodules.16

Currently, the health care policy in Saudi Arabia is moving towards a health insurance system. Our data suggests that if primary physicians referred patients initially to an endocrinologist, who follow the guidelines for the diagnosis and management of thyroid nodules when thyroid nodule disease is suspected, that would actually result in a significant reduction in the money spent for unnecessary diagnostic tests (e.g. thyroid scintigraphy, repeated FNA because of insufficient sampling, etc.).17 It will save time for physicians and radiologists, which could be used for other activities and other patients. In addition, the length of time that patients with benign disease harbour concern about the possibility of thyroid malignancy is curtailed. Furthermore, only a few patients will be subjected to surgery particularly those with a benign thyroid disease. This will also encourage the use of L-T4 suppression therapy more.18,19