Differentiation of benign and malignant cervical lymph nodes with color Doppler sonography

OBJECTIVE: This study proposed to evaluate the efficacy of color Doppler sonography in detecting possible differences in blood flow patterns between malignant and benign cervical lymph nodes. SUBJECTS AND METHODS: During a period of 12 months, the palpable cervical lymph nodes of 48 untreated patients were prospectively evaluated with color Doppler sonography and Doppler flow wave analysis. Histopathologic diagnoses were obtained by sonographically guided fine-needle aspiration biopsy and/or excisional biopsy. RESULTS: We found 16 benign lymph nodes (four were tuberculous lymphadenitis, four were reactive hyperplasia, and eight were unspecified) and 32 malignant lymph nodes (13 were squamous cell carcinomas, nine were adenocarcinomas, four were small-cell carcinomas, three were lymphomas, and three were miscellaneous). Color Doppler flow patterns were seen in six (38%) of the 16 benign lymph nodes and in 29 (91%) of the 32 malignant lymph nodes. Twenty-six (81%) of the 32 malignant lymph nodes had abnormal flow patterns, with resistance indexes less than 0.6. However, three (19%) of the 16 benign lymph nodes also had abnormal flow patterns, and only seven (54%) of 13 squamous cell carcinomas had abnormal flow patterns. CONCLUSION: Color Doppler sonography has limited clinical value in differentiating malignant from benign cervical lymph nodes and in obviating biopsy.     

Small lymph nodes of the abdomen, pelvis, and retroperitoneum: usefulness of sonographically guided biopsy

PURPOSE: To evaluate the usefulness of sonographically guided percutaneous biopsy of small lymph nodes in the abdomen, retroperitoneum, and pelvis. MATERIALS AND METHODS: From May 1995 through January 1997, 35 sonographically guided lymph node biopsies were performed in 34 patients. All biopsies were performed with a 20- (n = 18) or 22-gauge (n = 10) self-aspirating needle alone or in combination (n = 7). To determine the amount of compression achieved with the transducer, the skin-to-lesion distance on reference computed tomographic (CT) scans was compared with that on sonograms. A biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist. RESULTS: Of 35 sonographically guided biopsies, 30 (86%) were successful. Diagnoses included 26 (74%) cases of carcinoma, three (9%) cases of benign reactive lymphocytosis confirmed at open biopsy, and one (3%) case of a lymph node with a positive acid-fast bacilli stain. The average lymph node diameter was 2.1 cm (range, 0.9-4.3 cm). With sonography, a mean of 2.5 needle passes (range, 1-5) were made per biopsy. Transducer compression reduced the skin-to-lesion distance from an average of 8.8 cm (at CT) to 4.5 cm. CONCLUSION: Sonographic guidance seems to provide a reasonable alternative to CT in biopsy of small abdominal, pelvic and retroperitoneal lymph nodes.     

Reliability of needle biopsy of solitary thyroid nodules in view of surgical indications

To evaluate the accuracy of fine-needle biopsy in the management of the solitary thyroid nodules, 320 biopsies without aspiration were performed in 212 patients, iteratively in 91 cases. Among the 212 initial biopsies, 93 smears were found presumably benign (43.9%), 6 malignant (2.8%), 49 benign implying cytologic control (23.1%), 24 suspicious with decision to operate (11.3%), 40 inadequate (18.9%). On 67 surgical indications (malignant or suspicious cytology, or clinical data), 59 operations were performed. The 11 diagnosed cancers (5.2% of the patients; 18.6% of the operations) correspond to six malignant and five suspicious cytologies at the first or second biopsy. On 145 cases without decision to operate, 125 were clinically surveyed, with sometimes another biopsy (mean survey: 27.6 months; range: 6-80 months), and it was never necessary to modify the initial expectancy attitude. Our results, rather similar to those related by most of the previous publications, confirm that the fine-needle biopsy is a reliable and effective means for the etiologic diagnosis of thyroid nodules and the indications for operative intervention. It spares many patients from a useless operation and is worthy to take a leading place in exploring these nodules.     

Utility of fine-needle aspiration cytology and frozen-section examination in the operative management of thyroid nodules

Fine-needle aspiration cytology has a high sensitivity for the diagnosis of solitary thyroid nodules. Certain diagnoses involving follicular histologies often cannot be made with needle biopsy alone. The utility of frozen-section examination of thyroid nodules, with particular regard to those lesions with follicular histologies, is also limited. We examined the correlation of fine-needle aspiration cytology and frozen-section examination in solitary thyroid nodules to determine the contribution of frozen-section examination to the operation. We reviewed the fine-needle aspiration cytology, frozen-section examination, and final pathology of 100 consecutive patients undergoing thyroidectomy for a solitary solid thyroid nodule in an 4-year period. The diagnoses were classified as indeterminant, benign, or malignant. The utility and impact of the diagnosis from fine-needle aspiration or frozen section on the operative procedure performed was analyzed. Fine-needle aspiration cytology as a diagnostic test for thyroid nodules demonstrated an indeterminant rate of 23 per cent, with a diagnostic accuracy of 77 and 92 per cent for benign and malignant disease, respectively. In all patients with inaccurate benign diagnosis on fine-needle aspiration cytology, follicular neoplasm was misinterpreted for follicular adenoma or multinodular goiter. In comparing frozen-section results, the indeterminant, benign, and malignant rates were 7, 96, and 64 per cent, respectively. Of the 23 patients with indeterminant results on fine-needle aspiration cytology, the intraoperative frozen-section diagnosis on 4 patients was deferred to permanent section; 18 received accurate cytological diagnosis; and in 1 patient, carcinoma was missed. Overall, the decision about the extent of surgical thyroid resection was changed in only 2 patients based on the frozen-section results. Preoperative evaluation with fine-needle aspiration cytology can accurately and appropriately define the extent of thyroid surgery in most patients with a diagnosis of malignant neoplasm or benign disease. Intraoperative frozen-section examination may be helpful if fine-needle aspiration cytology results are inderminant and in cases of follicular histology as an adjunct for evaluation of the thyroid nodule, but overall, frozen section does not contribute to the management of the thyroid lesion at the time of surgery.     

Use of fine needle aspiration for solid breast lesions is accurate and cost-effective

BACKGROUND: Palpable breast tumors have traditionally been diagnosed with open biopsy or core biopsy. We propose fine needle aspiration biopsy (FNA) as a reliable, cost-saving initial procedure in these patients. METHODS: Eighty-five palpable solid breast masses of the breast in 85 patients were classified by a combination of physical examination, mammography, and/or ultrasound as probably benign, indeterminate, or highly suspicious for cancer. All tumors had FNA biopsies. All patients had either a confirmatory open biopsy (55) or close clinical follow-up (30) with a mean follow-up of 29 months (range 6 to 36). RESULTS: Thirty-four patients classified as clinically benign had a benign FNA biopsy. No cancers were detected in this group by either open surgical biopsy or clinical follow-up. Twenty patients were classified clinically as indeterminate. All had FNA biopsies, and 6 were either positive for cancer or suspicious for cancer. Fourteen patients had negative FNA biopsies. Five of the 6 abnormal biopsies had cancer on open biopsies. The 1 false-positive result occurred in a lactating patient. Thirty-one patients were classified clinically as highly suspicious for cancer. Twenty-three were confirmed as cancer with FNA biopsy. Eight needed open surgical biopsy to confirm cancer. All 31 patients clinically suspicious for cancer had cancer. In patients classified clinically as highly suspicious or probably benign, FNA was a reliable first diagnostic step (100% positive predictive value, 100% specificity, 87% sensitivity, and 89% negative predictive value). CONCLUSIONS: Fine needle aspiration biopsy of solid palpable breast lesions should be the diagnostic procedure of choice for those patients classified clinically as probably benign or clinically as highly suspicious for cancer. Cost analysis revealed elimination of an open biopsy in such cases would save $1,100 per patient. For highly suspicious cases, a negative fine needle aspiration should not deter an open surgical biopsy. For patients classified as indeterminate, fine needle aspiration biopsy results are not reliable enough to determine treatment.     

Percutaneous needle aspiration of hilar and mediastinal masses

Needle aspiration biopsy of hilar and mediastinal masses was attempted in 100 patients and completed in 91. There were no major complications. In the group with completed biopsies, there were 83 patients with malignant neoplasms; a positive diagnosis of malignancy was established in 80 (96%). Two of the three false-negative results occurred in patients with Hodgkin disease. In all 8 patients with benign masses, the biopsy results were correct. Five of the nine incomplete biopsies occurred in patients with aortic aneurysms that simulated lung or mediastinal masses. In the other 4 patients, the needle biopsy was not completed for technical reasons. Needle biopsy can be performed in practically all areas of the mediastinum, does not require general anesthesia or hospitalization, and is well tolerated by the patient. In this series, the use of mediastinal needle biopsy made it possible to avoid surgery and mediastinoscopy in 72 patients with unresectable malignant neoplasms and 5 patients with innocuous benign mediastinal masses. Needle biopsy may be the preferred initial procedure to obtain a tissue diagnosis in patients with mediastinal masses.     

Fine-needle aspiration cytology of lymphoid lesions of the salivary gland: a review of 35 cases

OBJECTIVE: The aim of this study was to evaluate the effectiveness of fine-needle aspiration (FNA) in the diagnosis of primary lymphoid processes of the salivary gland. DESIGN: A retrospective study. METHOD: Between 1987 and 1994, 35 patients who underwent fine-needle aspiration (FNA) of the salivary gland had a diagnosis of a primary lymphoid process. Most presented with palpable parotid (28 patients) or submandibular (4 patients) gland masses which prompted a clinical diagnosis of pleomorphic adenoma. FNA was performed with immediate on-site evaluation. Flow cytometric cell-surface-marker analysis was performed in 28 of the 35 cases to determine the clonality of the B-cell proliferations. RESULTS: Sixteen cases of reactive hyperplasia and nine cases of malignant lymphoma diagnosed by FNA were confirmed by subsequent histopathologic examination. Lymphoma was confirmed in six of eight cases diagnosed as suspicious for lymphoma by FNA. Hodgkin's disease was suspected but not confirmed in one case and was diagnosed as a probable Warthin's tumour in another case. In all cases, the FNA diagnosis of either a reactive or malignant lymphoid process was unexpected and influenced the patient's further management. For patients diagnosed with an intraparotid lymph node, surgery could be deferred for a short period with the hope that the lymphadenopathy would spontaneously regress. For patients with a preoperative FNA diagnosis of lymphoma, a more limited biopsy could be performed, thereby reducing the operative risk to the patient and plans to process the tissue according to the institution's lymphoma protocol could be made. CONCLUSION: Clinically, reactive intraparotid lymph nodes and lymphomas present as parotid enlargements that are indistinguishable from pleomorphic adenomas. FNA is the only method of accurately establishing a preoperative diagnosis in these patients.     

Ultrasonographically guided percutaneous biopsy of gastric, small bowel, and colonic abnormalities: efficacy and safety

The purposes of this study were to evaluate the efficacy of sonographically guided percutaneous biopsy of gastric and bowel lesions and to document any associated complications. A retrospective review of all patients undergoing ultrasonographically guided biopsy of gastric, small bowel, or colonic lesions was performed. Cases were evaluated for size of lesion, location, efficacy in obtaining a diagnostic specimen, and any procedure-related complications. A total of 46 biopsies were performed in 44 patients over a 6 year period. Fifteen gastric, four duodenal, seven small bowel, 16 right colonic, and two left colonic lesions were identified. Histologic diagnosis included 20 adenocarcinomas, seven lymphomas, 10 mesenchymal tumors, and two cases of candidal enteritis. In 18 (41%) patients the initial fine-needle aspirate was negative, although 10 of these patients subsequently underwent ultrasonographically guided core biopsy with a diagnosis of neoplasm established in all 10. Two patients with an initial negative result on fine-needle aspiration underwent repeat aspiration, demonstrating malignancy. Two additional false-negative aspirates were obtained; these patients did not undergo repeat biopsy but were subsequently found to have lymphoma. Two of the patients with aspirates that were negative for malignancy were believed to have inflammatory changes secondary to pancreatitis. One patient was lost to follow-up evaluation. No complications were recorded. Percutaneous fine-needle aspiration of gastric and bowel lesions is a simple and safe procedure and may be particularly useful with poor candidates for endoscopy or for lesions that are difficult or impossible to reach endoscopically. Diagnostic yield is high, particularly in documenting malignancy, although in suspected stromal tumors a core biopsy often is required.     

Significance of nondiagnostic fine-needle aspiration of the thyroid

BACKGROUND: Fine-needle aspiration biopsy (FNAB) has been shown to be rapid and cost effective in the evaluation of thyroid nodules. The significance of nondiagnostic (unsatisfactory) FNAB is uncertain, however. METHODS: We reviewed 345 consecutive thyroid FNABs and identified 59 patients with initially unsatisfactory specimens. These patients had follow-up to determine whether their thyroid nodules proved to be malignant. RESULTS: Three patients (5.1%) were found to have organ-confined papillary carcinoma of the thyroid, the largest tumor mass measuring 1.2 cm. Six patients (10.2%) had benign adenomas. CONCLUSIONS: In most cases of initially nondiagnostic FNAB of a thyroid nodule, neoplasia is not found subsequently. A minority of cases may still harbor malignancy. None of our patients in whom repeated FNA was either nondiagnostic or suggestive of benign disease were ultimately found to have a malignancy.     

The value of aspiration cytology within the scope of triple diagnosis of palpable breast changes

The diagnostic value of aspiration cytology and the overall diagnostic quality of the so-called triple test (aspiration cytology, mammography and physical examination) in the evaluation of palpable breast masses were investigated in a retrospective study. 608 histologically evaluated cancers and 224 benign lesions were investigated. A main purpose of the study was to find out whether the triple diagnostic test can replace surgical biopsy and thereby reduce the number of unnecessary biopsies. All lesions triple-diagnosed as malignant were histologically proved to be malignant, i.e. there were no false positive results. The rate of false negative results was found to be within the range reported for false negative results in fresh frozen sections. Based on these results we state that the dogmatic statement "every palpable mass in the breast must be excised" should be replaced by the recommendation "every palpable mass must be assessed and clarified". A great number of retrospectively unnecessary biopsies can be avoided by a systematic use of the triple diagnosis. The diagnostic safety of this method is close to that of open biopsy. In all cases where positive or negative concordant triplets are found, histological confirmation by biopsy can be avoided. Patients with benign lesions can be thoroughly followed up by repeated physical and radiological examinations. Patients with triple diagnostic malignant results can be adequately treated. Lesions for which triple diagnosis yields neither benign nor malignant, must be biopsied: This is also necessary in all cases with suspicious findings in mammography without a palpable mass, if the equipment for stereotactic or ultrasound- guided biopsies is not available.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of thyroid nodules

Clinically apparent thyroid nodules occur in about 5 percent of the population. Because most patients with thyroid nodules present initially to their primary care physician, family physicians should have a thorough understanding of the diagnosis and treatment of thyroid nodules. The history and physical examination may be helpful in detecting thyroid nodules but are not useful in predicting malignancy. Furthermore, laboratory studies, ultrasonography and nuclear medicine scans do not reliably differentiate between benign and malignant thyroid nodules. In most cases, fine-needle aspiration biopsy can accurately identify malignant thyroid nodules. Fine-needle aspiration biopsy is safe and can be performed in an office setting.     

Clinical value of endoscopic ultrasound-guided transesophageal fine needle puncture of mediastinal lesions

BACKGROUND AND OBJECTIVE: As the mediastinum has been a region difficult to access for biopsy, mediastinoscopy has been required in most cases. In a prospective study the value of transoesophageal endoscopic ultrasound (TEUS) guided aspiration biopsy was assessed as an alternative. PATIENTS AND METHODS: TEUS-guided fine-needle aspirations were performed between May 1995 and March 1998 in 35 patients with mediastinal space-occupying lesions. In all cases the conventional endoscopic method or percutaneous puncture-sonography had been impossible or had failed. In one patient it had been performed after a negative mediastinoscopy. RESULTS: In 34 patients (97%) the aspirated tissue cylinder could be evaluated histologically. There were no complications. Malignancy was demonstrated in 24 patients, and there were one case each of sarcoidosis, silicoanthracosis and two cases of retrosternal goitre. In four of seven patients the negative preoperative diagnosis was confirmed at operation or by follow-up. There were two false-negative results and in one patient there has been no definitive diagnosis. The accuracy of the method was thus 91.4%, the positive predictive value for malignancy 88.9% and the negative predictive value for malignancy 72.7%. Ultrasound alone was a poor predictor of malignancy in lymph node enlargement. CONCLUSION: TEUS-guided fine-needle aspiration of space-occupying mediastinal lesions is an effective and low-risk method that can in selected cases shorten the diagnostic process and avoid methods that are expensive or lead to complications such as transpulmonary biopsy guided by computed tomography or mediastinoscopy.     

Superficial soft-tissue masses suggestive of recurrent malignancy: sonographic localization and biopsy

OBJECTIVE: We investigated the usefulness of high-resolution sonography to localize superficial soft-tissue masses and to guide needle sampling for recurrent malignancy. MATERIALS AND METHODS: High-resolution sonography (10-MHz) was used to locate and guide needle sampling of 16 palpable and eight impalpable superficial masses suggestive of recurrent malignancy in 23 patient (12 men, 11 women; 34-85 years old). After detection, 22 (92%) of the masses were immediately sampled by fine-needle aspiration with 18- to 25-gauge needles and two (8%) were sampled by a 20-gauge core gun. RESULTS: Diagnostic material was obtained without complication from all 24 masses and proved positive for recurrent disease in 13 (54%). Ten (63%) of 16 palpable and three (38%) of eight impalpable masses proved positive for recurrent malignancies. One third of superficial soft-tissue masses were detected by imaging only, and of the masses not revealed on imaging, three (23%) of 13 were the site of first recurrence. Most nonnodal superficial masses (8/13) were benign, unlike the lymph nodes, of which three (27%) of 11 were benign. CONCLUSION: Not all early recurrent malignancies within the skin and subcutaneous tissues are detected by clinical examination. High-resolution sonography provided us with a rapid, safe, and accurate means of localizing and then guiding needle biopsies of superficial soft-tissue masses suggestive of recurrent malignancy.     

Telomerase activity in lesions of the thyroid: application to diagnosis of clinical samples including fine-needle aspirates

The telomerase enzyme is capable of replacing telomeric DNA sequences that are lost at each cell division. It has been suggested that the function of this enzyme is necessary for cells to become immortal, and in concordance with this hypothesis, telomerase activity has been detected in malignant tumor cells, whereas the enzyme is inactive in normal somatic cells. The measurement of this activity in human tissue samples may have diagnostic value, and in this study, we examined whether such a measurement may be useful for the detection of malignant cells within the thyroid. Telomerase activity was assayed using the telomeric repeat amplification protocol and related to the histological diagnosis of thyroid biopsy tissue samples and of cells obtained from the thyroid by fine-needle aspiration (FNA). Extracts from 9 of 11 (82%) carcinoma biopsy tissue samples contained telomerase activity, whereas enzyme activity was detected in only 2 of 14 (14%) benign tissue sample extracts. These two positive cases were subsequently diagnosed as Graves' disease with severe lymphocytic infiltration. Five of six (83.3%) histologically confirmed carcinoma FNA samples were identified by using the telomeric repeat amplification protocol assay, and two samples considered to be suspicious by FNA cytology were also positive. Conversely, only 4 of 48 (8.3%) benign FNA samples had telomerase. These promising data indicate that this sensitive assay could become a useful adjunct to microscopic cytopathology in the detection of cancer cells in small tissue biopsies and in fine-needle aspirates of the thyroid.     

Predictive value of specimen radiography for core needle biopsy of noncalcified breast masses

OBJECTIVE: Our objective was to determine the predictive value of specimen radiography for large core (14-gauge) needle biopsy of noncalcified breast masses. SUBJECTS AND METHODS: Eighty-four biopsies of 83 breast masses yielded 403 specimens. Specimens showing dense material on specimen radiography were predicted to be diagnostic; specimens showing intermediate- or low-density material were predicted to be nondiagnostic. Specimen radiographic and histopathologic findings were correlated for each specimen using vital dyes to mark individual specimens. RESULTS: Of the 403 specimens, 307 (76%) contained diagnostic material representative of the lesion, with a specific diagnosis achieved for 82 (99%) of 83 lesions (62 benign, 20 malignant). Of the 293 passes containing dense material, 268 (91%) proved to be diagnostic; 11 (18%) of 62 specimens containing only low-density material proved to be diagnostic. Of the 25 (9%) of 293 specimens containing radiographically dense but nondiagnostic material, 18 (72%) showed focal fibrosis and had missed the lesion; 15 (83%) of 18 such specimens were obtained in dense parenchyma. The positive predictive value of specimen radiography was 13 (100%) of 13 in fatty breasts; 77 (96%) of 80 in breasts with minimal scattered fibroglandular elements; 91 (94%) of 97 in heterogeneously dense breasts; and 35 (70%) of 50 in breasts with extremely dense parenchyma. Of the 16 lesions sampled stereotactically, specimen radiography helped assess the inadequacy of initial sampling in three (19%). In six (9%) of 68 sonographically guided biopsies, only one or two specimens could be obtained; specimen radiography helped us predict whether material was adequate for diagnosis. CONCLUSION: Radiography of core specimens obtained from noncalcified breast masses accurately reveals the adequacy of sampling unless the breast parenchyma is extremely dense. Such immediate assessment can help ensure adequate material from lesions that are difficult to biopsy and can thereby improve the diagnostic yield of large core needle breast biopsy.     

Primary cryptococcal infection of the larynx in a patient with AIDS: a case report

From January of 1990 to December of 1992, 6,954 consecutive cytologic breast fine-needle aspiration biopsies (FNAB) were performed at the Laboratory of Pathology of Sant'Anna Hospital in Turin. Of these cases 62% were solid nodes, 35% were cystic nodes, and 2.7% were nonpalpable breast lesions (stereotaxic or ultrasound guided FNAB). We verified 4,110 cases: 913 cases underwent surgery and 3,197 were evaluated clinically, and/or cytologically, and/or with mammography at least 1 yr after the first diagnosis, or checked with the database of the Tumor Registry of Turin. In our series the FNAB sensitivity was 94.6%, specificity was 99.9%, accuracy was 98.8%, inadequate samples were 6.4%, false-negative rate was 1.4%, and false-positive rate was 0.3%. Our results indicate that the use of cell block improves sensitivity (from 85.2 to 94.6%) and strongly reduces false-negative results (from 3.9 to 1.4%). We conclude that FNAB is a discriminant procedure to the surgical biopsy in cases with clinical, ultrasound, or mammographic low or intermediate suspect, contributing to allow a high malignant/benign surgical biopsy rate and to reduce the need for frozen section diagnosis and medical costs.     

Cystic thyroid lesions in children

BACKGROUND/PURPOSE: Cystic lesions of the thyroid encompass a wide and heterogeneous group of disease states in children, ranging from benign purely cystic entities to malignant tumors. The purpose of this study was to study both the presentation and management of cystic thyroid lesions in the pediatric population. METHODS: A retrospective review of all thyroid masses presenting between 1978 and 1996 and found to be purely or partially cystic on ultrasound examination was conducted, looking at presentation, family history, laboratory values, ultrasound scan and radionuclide imaging, and pathological and cytological evaluation. RESULTS: Twenty-four patients (19 girls, 5 boys) aged 6 to 18 years received the diagnosis of cystic lesions of the thyroid. Of these, 23 presented with painless neck masses, 21 were clinically euthyroid, only one had a single abnormal thyroid function test, only two had mildly positive antithyroid antibody test results, and nearly 30% had a positive family history of thyroid disease. Ultrasonography showed pure cysts in five patients and mixed solid cystic lesions in 19 patients. On scintiscan, six lesions were hot, 13 were cold, three showed normal uptake, and two were mixed. Treatment included either observation, aspiration, cyst sclerosis, surgery, or combinations thereof. Pathological and cytological results included follicular adenoma (n = 9), cystic degeneration (n = 6), multinodular goiter (n = 4), carcinoma (n = 2), branchial cleft cyst (n = 1), and undetermined (n = 2). CONCLUSIONS: Thyroid cysts are often thought to represent benign degenerative disease. Our study, which is the first in the literature to specifically address thyroid cysts in children, shows that ultrasound scan is useful in evaluating thyroid masses, whereas laboratory and radionuclide are of less value, and that single lesions of mixed echogeneity are likely to represent neoplasms, a significant percentage of which are malignant.     

Thyroxine suppressive therapy in patients with nodular thyroid disease

PURPOSE: To review evidence about thyroxine suppressive therapy in patients with thyroid nodules, including the clinical importance and natural history of nodules and the effects and potential side effects of thyroxine therapy. DATA SOURCES: English-language articles published from 1986 to December 1996 were identified through searches of the MEDLINE database, selected bibliographies, and personal files. DATA EXTRACTION: Randomized, controlled trials and nonrandomized trials of thyroxine suppressive therapy for solitary and predominantly solid thyroid nodules were reviewed. In most studies, nodule cytology was evaluated by fine-needle aspiration biopsy. Therapy was considered suppressive if suppression was documented by thyroid-stimulating hormone-releasing hormone tests or sensitive thyroid-stimulating hormone assays. Response was defined as a decrease of 50% or more in nodule size or volume; most recent studies measured nodule size by ultrasonography. DATA SYNTHESIS: The evidence suggests that thyroxine suppressive therapy fails to shrink most nodules: Only 10% to 20% of nodules responded to this treatment. Fine-needle aspiration biopsy is more reliable in distinguishing benign from malignant nodules. Recent studies suggest that spontaneous decrease in size with complete disappearance of thyroid nodules is not uncommon. No data show that thyroxine therapy arrests further growth in most existing nodules or prevents the emergence of new nodules. Postoperative thyroxine therapy does not seem to prevent recurrence of thyroid nodules except in patients with a history of radiation therapy. Potential adverse effects of long-term suppressive therapy include osteoporosis and heart disease. CONCLUSIONS: Patients with cytologically benign nodules are best followed without thyroxine treatment. Most benign nodules remain stable in size and remain benign when monitored for a long time. For nodules that increase in size, biopsy should be done again or surgery should be performed.     

Solitary thyroid nodules. Separating benign from malignant conditions

Although features found on history taking, physical examination, thyroid function tests, and imaging studies help categorize solitary thyroid nodules as benign or malignant, fine-needle aspiration biopsy is the diagnostic test of choice. Nodules found to be malignant on cytologic examination should be treated with surgery. Benign nodules may be followed clinically or treated with levothyroxine to suppress their growth. Intermediate nodules should be excised if there is clinical suspicion of malignancy. In suspect nodules, levothyroxine therapy with follow-up ultrasound assessment for size is appropriate. Nodules that do not shrink significantly within 6 months should be excised.