I wish to add three comments regarding the initiation of prospective studies.
Scintigraphy: the AACE/AME guidelines only ascribe evidence level IV C to this procedure (1). Instead of recommending “baseline scintigraphy” (the radiation exposure is that of some 45 thoracic x-ray films) (2), the gain in diagnostic-therapeutic insights should be questioned (1, 3), so the procedure is not, as a German saying goes, as “unnecessary as a goiter.” Routine clinical practice has shown that scintigraphy does not show the majority of sonographically and surgically exposed nodules/cancers and focal autonomies with a size of less than 1–1.5 cm. Without blinded studies of its meaningfulness, the widespread use of scintigraphy should not be promoted.
Measuring calcitonin: the extent to which this should be done in every case of nodular goiter (2) or, in a targeted manner, in sonomorphologically suspect thyroid nodules, in order to detect sporadic medullary thyroid cancer, is—in the absence of prospective studies— the subject of controversy (1, 3, 4). Generalized measurements entail risks and unsettle patients because of technical problems in the laboratory and the many false-positive/false-negative results. Measuring calcitonin in specialized thyroid outpatient clinics with valid laboratory testing facilities and expertise in assessing the result seems a viable alternative (4).
Ultrasound-guided Percutaneous Ethanol Injection/PEI was not mentioned as the definitive treatment of focal autonomies (1–3). The procedure has been conducted successfully in several thousand patients worldwide and is a routine procedure in intervention centers. Its advantages are a rapid therapeutic effect even after exposure to iodine, cost-effectiveness in the outpatient setting, high acceptability for patients. In unifocal or bifocal autonomies, percutaneous sonography-guided PEI should be discussed with each patient in the interdisciplinary case conference as a low-risk alternative to surgery/radio-iodine treatment. Because of its potential side effects, the procedure should be undertaken in specialized centers with the appropriate expertise (3).
Footnotes
Conflict of interest statement
Professor Braun has received honoraria from the German publishing house Thieme for a book chapter on interventional ultrasonography.
References
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