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Effect of the COVID-19 pandemic on surger
for indeterminate thyroid nodules
(THYCOVID)

Background
• Since its outbreak in early 2020, the COVID-19 pandemic has
diverted resources from non-urgent and elective procedures,
leading to diagnosis and treatment delays, with an increased
number of neoplasms at advanced stages worldwide.
• The aims of this study were to quantify the reduction in surgical
activity for indeterminate thyroid nodules during the COVID-19
pandemic; and to evaluate whether delays in surgery led to an
increased occurrence of aggressive tumors.

Introduction
• The COVID-19 pandemic has threatened the sustainability of health-care systems
worldwide, diverting substantial resources from non-urgent and elective
procedures to the diagnosis and treatment of COVID-19.
• The management of oncology patients has been challenging, with surgical
procedures for diagnosed cancers postponed, and screening programmes and
follow-up visits slowed down or even stopped for long periods.
• Several studies have reported that the COVID- 19-induced delays in diagnosis and
treatment led to an increased number of patients with malignancies at advanced
stages worldwide, particularly for rapid-growth tumors, including oral, head and
neck, breast, gastric, pancreatic, and colorectal cancers.

Introduction
• This study aimed for Indeterminant nodules.
• In October, 2020, a survey involving 64 experienced surgeons and
endocrinologists suggested that patients with Bethesda class III thyroid
nodules on fine-needle aspiration cytology (FNAC) should have been followed-
up with surveillance principles until the end of the pandemic, and that surgery
for patients with Bethesda class IV nodules should have been postponed for
3–6 months.

Research Question
•Whether the delay in surgery
was associated with an increased
occurrence of aggressive
thyroid tumors or not

Methods
• In this retrospective, international, cross-sectional study, centres were invited
to participate in June 22, 2022; each centre joining the study was asked to
provide data from medical records on all surgical thyroidectomies
consecutively performed from Jan 1, 2019, to Dec 31, 2021.
• Patients with indeterminate thyroid nodules were divided into three groups
according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020
(global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic
escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase).

Methods
• The main outcomes were, for each phase, the number of surgeries for
indeterminate thyroid nodules, and in patients with a postoperative
diagnosis of thyroid cancers, the occurrence of tumours larger than 10
mm, extrathyroidal extension, lymph node metastases, vascular invasion,
distant metastases, and tumours at high risk of structural disease
recurrence.
• Univariate analysis was used to compare the probability of aggressive
thyroid features between the first and third study phases.

Methods
• Data Collection:
• Searched the database through Scopus: from Jan 1, 2014, to May 31, 2022,
containing the words “thyroidectomy” or “indeterminate thyroid nodule” in the title, abstract, or keywords.
1544 centers from 115 countries contributed in study, providing data of all patients
within time frame.
• Excluded centres not providing fundamental data, including sex, cytological classification,
the full pathological examination report, and ATA classification of risk of structural disease
reccurence.
• No other inclusion or exclusion criteria were used.

ATA classification of risk of structural disease
reccurence

Methods
• For the purpose of the study, patients were divided into three groups based on when
they underwent thyroidectomy (figure):
• the first group included patients who had undergone thyroidectomy before the COVID-
19 pandemic (from Jan 1, 2019, to Feb 29, 2020; phase 1)
• the second group included patients who had undergone surgery during the first global
escalation of the COVID-19 pandemic (from March 1, 2020, to May 31, 2021; phase 2)
• the third group included patients who underwent surgery during the pandemic
decrease period (from June 1 to Dec 31, 2021; phase 3),

Methods
• For this study, cytologic reporting system Bethesda was used.
• The nodules classified as Bethesda class III or Bethesda class IV on
FNAC were defined as indeterminate thyroid nodules.

Findings
• Data from 157 centres (n=49 countries) on 87,467 patients who underwent
surgery for benign and malignant thyroid disease were collected
• 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male
patients) received surgery for indeterminate thyroid nodules.
• We observed a significant reduction in surgery for indeterminate thyroid
nodules during the pandemic escalation phase (median monthly surgeries
per centre, 1·4, compared with the prepandemic phase (2·0) and pandemic
decrease phase (2·3).

Findings
• Compared with the prepandemic phase, in the pandemic decrease phase we observed an
increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515
[71·5%] of 2119;
• lymph node metastases (343 [9·3%] vs 264 [12·5%];
• Tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006.

Discussion
• This study indicates that surgical activity for thyroid diseases, particularly for indeterminate thyroid
nodules, was overall reduced during the COVID-19 pandemic.
• Study further showed that tumours in the decreasing phase of the pandemic were more aggressive
than those in the prepandemic phase.
• We found a significant increase in the occurrence of lymph node metastasis (which increased from
9·3% to 12·5%), tumours at high risk of structural recurrence (from 5·7% to 7·7%), and tumours
larger than 10 mm (from 69·0% to 71·5%).
• These results are in accordance with the work of Grani and colleagues, who found that the delayed
treatment of thyroid cancers led to an increased incidence of lymph node metastasis (14/55 [26%] vs
17/36 [47%]) and to an increase in the rate of tumours at high risk of recurrence (3/55 [6%] vs 7/36
[19%]) compared between March, 2019, to February, 2020, and March, 2020, to February, 2021.

Discussion
• Surgeons might have prioritised patients with more suspicious thyroid nodule features in
the pandemic decrease phase. This hypothesis is supported by the increase in the rate of
central compartment lymph node dissections in the third phase in our study.
• A delay in the treatment of indeterminate thyroid nodules has led to an increased
occurrence of aggressive thyroid neoplasms, is that thyroid tumours are characterised by
slow growth in most cases. Thus, the delay in surgery caused by the pandemic, even if
reaching 6–12 months in the worst-case scenario, would have had a limited effect on
tumour progression and most tumours would have remained indolent throughout the
pandemic.

Discussion
• Even if thyroid cancer is usually a slow growing cancer, an early aggressive
cancer that is not resected might subsequently be detected as an advanced
tumour.
• We should also consider that SARS-CoV-2 infection could have had a role in
tumour progression. SARS-CoV-2 infection appears to alter thyroid function
through an intense inflammatory response (a cytokine storm), that might
damage the thyroid gland, inducing subacute or acute thyroiditis and
thyrotoxicosis. Considering the global spread of SARS-CoV-2 infection, this
mechanism could have had a role in patients with a thyroid malignancy,
promoting tumor growth and progression.

Interpretation
• In conclusion, in our study we observed an increase in the
postoperative diagnosis of aggressive thyroid tumors among
surgeries for indeterminate thyroid nodules in the last 7 months of
2021, compared with the prepandemic period.

Interpretation
• The reduction in surgical activity for indeterminate thyroid nodules during the
COVID-19 pandemic period could have led to an increased occurrence of
aggressive thyroid tumors.
• It was proposed that surgery for indeterminate thyroid nodules should no
longer be postponed even in future instances of pandemic escalation.

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Effect of covid 19 on thyroid surgery.pptx

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