Molecular Profiling of Thyroid Nodules: A Conversation with Dr. Steven Hodak

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In a recent podcast episode of Doctor Thyroid and RFAMD, host Philip James was joined by Dr. Steven Hodak, a Professor of Medicine and Endocrinology at NYU Langone Health, New York. Dr. Hodak, who is also the President of the North American Society for Interventional Fibrinology, was present at the TNT conference in Italy when the podcast was recorded. The pair dived into the intriguing topic of molecular profiling of thyroid nodules and how it could relate to either ablation or thyroidectomy.
The Significance of Molecular Diagnostic Testing
Dr. Hodak began by explaining the relevance of molecular diagnostic testing to thyroid nodule ablation. He recounted that, ten to fifteen years ago, before molecular diagnostic testing was widely available, patients with an indeterminate nodule biopsy would almost always undergo surgery for a definitive diagnosis. This was due to the nodule not appearing normal, yet not definitively looking like cancer either. As a result, the only solution at the time was to remove the nodule, examine it under the microscope, and then provide a definite diagnosis.
The shocking part of this approach was that in 80% of cases, patients did not have cancer, and would never have developed it. That meant these patients underwent a surgery that could have been avoided had the molecular diagnostic testing been available. Today, however, this testing has been revolutionary, enabling preoperative risk stratification of nodules, potentially avoiding unnecessary surgical interventions.
Concerns Over Previous Practice
Host Philip James highlighted the alarming nature of the previous practice where 80% of patients with an indeterminate thyroid nodule would undergo surgery as a diagnostic step. The patients would have their thyroid removed, only to discover that they did not have cancer.
Dr. Hodak acknowledged the concern, explaining that while it may sound like an uncaring and unnecessary approach, the limitations of diagnostic methods available at the time left no other choice. Leaving the nodule there to 'see what happens' could have led to worse consequences if it was indeed cancerous.
The Present Scenario and Global Adoption
Currently, Dr. Hodak confirmed that molecular diagnostics is widely used by most doctors in the United States, thanks to the availability of good commercially available tests. However, he admitted that outside the U.S., it is still a struggle, primarily due to the lack of willingness among socialized medical programs to cover the cost.
Dr. Hodak emphasized that the adoption of molecular diagnostics testing worldwide is crucial. He acknowledged that the U.S. had its struggles too before it was widely accepted, often due to inertia and resistance to change. However, the cost-saving potential of molecular diagnostics, along with the ability to reassure patients of a low risk in 60 to 70% of cases, underlines its potential.
Molecular Testing and Ablation
Dr. Hodak also discussed the connection between molecular testing and ablation. He noted that some of the questions regarding molecular testing and ablation remain open. For tumors with a negative genetic profile, which essentially equates to having a benign microscopic diagnosis, ablation can be used as a treatment method. For those with a positive genetic finding, however, the decision to offer ablation instead of surgery is still under active study.
Dr. Hodak affirmed the growing personalization of care, thanks to technology advancements such as molecular testing, AI imaging, and ablation.
Concluding Remarks
In conclusion, Dr. Hodak stressed the importance of incorporating molecular profiling in decision-making regarding thyroid nodule treatment. For countries where this technology is readily available, it should be part of the treatment planning. For those where it is not, it remains an unfortunate reality and a sore point