436 chapter 10 Dear Editor, With interest we have read the SFA-AFCE-SFMN 2022 consensus on the management of thyroid nodules “section 5: what is the role of functional imaging and isotopic treatment?” by Thuillier et al. published ahead of print in Annales d'Endocrinologie [666]. What specifically drew our attention was the paragraph on the use of [18F]FDG-PET/CT in the analysis of thyroid nodules with indeterminate fineneedle aspiration cytology (FNAC) including atypia of undetermined significance or follicular lesion of undetermined significance (Bethesda III, AUS/FLUS) and (suspicious for a) follicular neoplasm (Bethesda IV, FN/SFN) or Hürthle cell neoplasm (Bethesda IV, HCN/SHCN) [18, 667]. The follicular lesions of which this group largely consists require histopathological assessment of capsular and vascular invasion to obtain a conclusive benign or malignant diagnosis [18]. Current international guidelines recommend repeat FNAC in Bethesda III nodules and consideration of clinical and ultrasound characteristics and patient preference in both Bethesda III and IV nodules, before deciding to proceed with either active surveillance or diagnostic surgery [17, 18]. Alternative diagnostic approaches to prevent unnecessary diagnostic hemithyroidectomy are vast, with molecular diagnostics, assessing the genetic changes in these lesions, and molecular imaging using [99mTc]Tcsestamibi scintigraphy or [18F]FDG-PET/CT, as most promising techniques [651]. The authors of this French consensus document discuss the value of molecular imaging [666] including our meta-analysis [304] and modelled cost-effectiveness [53] of the diagnostic value of [18F]FDG-PET/ CT. Because the “excellent diagnostic performance” specifically in larger nodules are contradicted by more recent studies and meta-analyses, they come to the conclusion that both visual and quantitative “ [18F]FDG-PET/CT is not recommended for FNAC-indeterminate thyroid nodules (Bethesda 3-4), due to suboptimal NPV in recent studies and the lack of added value over and above combined ultrasound/ cytology. Grade A ++” (Recommendation 5.7) [666]. The same observations have led the American Thyroid Association 2015-guideline on thyroid nodules “not to routinely recommend for the evaluation of thyroid nodules with indeterminate cytology” (Recommendation 18: Weak recommendation, Moderate-quality evidence) [17]. It seems therefore the authors have taken over this conclusion without re-assessing recent literature as we fully disagree with their conclusion. Based on this lack of high-quality evidence, we have undertaken a nationwide randomised-controlled trial in 15 academic and non-academic centres (“Efficacy of [18F]FDG-PET in Evaluation of Cytological indeterminate Thyroid nodules prior to Surgery (EfFECTS)”, NCT02208544), the main results of which were published earlier this year [661-665]. We’ve randomised (2:1) 132 patients with centrally revised indeterminate cytology to either an arm driven by the result of centrally blindly read [18F]FDG-PET/CT and an arm in which all patients underwent diagnostic hemithyroidectomy regardless the result of the [18F]FDG-PET/CT. Patients managed without surgery (i.e. with negative [18F]FDG-PET/CT) were followedup by their endocrinologists according to the risk of a benign nodule, including an ultrasonography
RkJQdWJsaXNoZXIy MTk4NDMw