American Thyroid Association Management Guidelines Research Articles

7235 Papillary Thyroid Carcinoma in a Hyperfunctioning Thyroid Nodule

Abstract Disclosure: J. Yang: None. P.V. Nadkarni: None. Background: The prevalence of malignancy in a hyperfunctioning or hot thyroid nodule is considered to be low. According to the 2015 American Thyroid Association Guidelines, no cytologic evaluation is routinely recommended for hyperfunctioning nodules since they are rarely associated with malignancy (1). We present a case of a 71-year-old female with a hot nodule containing papillary thyroid cancer. Clinical Case: A 71-year-old female with Type 1 diabetes mellitus and coronary artery disease on dual antiplatelet therapy was found to have a 1.5 cm firm, non-tender right-sided thyroid nodule on a routine physical exam. Laboratory tests demonstrated low TSH <0.01 (normal 0.36 - 3.74 m[IU]/L) and FT4 level elevated at 1.62 (normal 0.76 -1.46 ng/dL). She noticed palpitations and started on low dose Methimazole. Thyroid ultrasound results showed a 2.1 x 2.0 x 2.0 cm right inferior lobe thyroid nodule. This thyroid nodule appeared mixed cystic and solid, hypoechoic, not taller than wide, with ill-defined margins and peripheral calcifications (ACR TI-RADS risk category: TR4). Nuclear medicine thyroid uptake scan demonstrated focally increased activity in the right lower pole corresponding with her right inferior thyroid nodule seen on ultrasound. Remainder of the gland appeared suppressed. She was recommended for ultrasound-guided fine needle aspiration biopsy of her right inferior thyroid nodule, given concerning characteristics on ultrasound findings despite results consistent with a hot nodule. Timing of her antiplatelet therapy was coordinated with her cardiologist, and her biopsy procedure scheduled after she stopped dual antiplatelet therapy. Her FNA results showed clusters of follicular cells with nuclear and architectural atypia, suspicious for papillary thyroid carcinoma. She underwent right thyroid lobectomy. Surgical pathology revealed 2 foci of papillary thyroid carcinoma, follicular variant (2.0 cm, 0.1 cm) and confined to the thyroid. All regional lymph nodes were negative for tumor. Methimazole was discontinued post-operatively, and she started Levothyroxine suppression therapy. Discussion: We present a rare association of papillary thyroid carcinoma presenting as a hot thyroid nodule. Though uncommon, detection of a hyperfunctioning thyroid nodule does not exclude the possibility of thyroid carcinoma and warrants careful evaluation. Clinicians should retain a high index of suspicion particularly when ultrasonography demonstrates findings suspicious for malignancy and consider additional evaluation with fine needle aspiration. Reference: (1) Haugen BR, Alexander EK, Bible KC et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. Presentation: 6/2/2024

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

Insurance-Based Disparities in Guideline-Concordant Thyroid Cancer Care in the Era of De-escalation

IntroductionPrior studies have demonstrated insurance-based disparities in the treatment of well-differentiated thyroid cancer. However, it remains unclear whether these disparities have persisted in the era of the 2015 American Thyroid Association (ATA) management guidelines. The goal of this study was to assess whether insurance type is associated with the receipt of guideline-concordant and timely thyroid cancer treatment in a modern cohort. MethodsPatients diagnosed with well-differentiated thyroid cancer between 2016 and 2019 were identified from the National Cancer Database. Appropriateness of surgical and radioactive iodine treatment (RAI) was determined based on the 2015 ATA guidelines. Multivariable logistic regression and Cox proportional hazard regression analyses, stratified at age 65, were used to evaluate the associations between insurance type and appropriateness and timeliness of the treatment. Results125,827 patients were included (private = 71%, Medicare = 19%, Medicaid = 10%). Compared to privately insured patients, patients with Medicaid more frequently presented with tumors >4 cm in size (11% versus 8%, P < 0.001) and regional metastases (29% versus 27%, P < 0.001). However, patients with Medicaid were also less likely to undergo appropriate surgical treatment (odds ratio 0.69, P < 0.001), less likely to undergo surgery within 90 d of diagnosis (hazard ratio 0.80, P < 0.001), and more likely to be undertreated with RAI (odds ratio 1.29, P < 0.001). There were no differences in the likelihood of guideline-concordant surgical or medical treatment by insurance type in patients ≥65 y old. ConclusionsIn the era of the 2015 ATA guidelines, patients with Medicaid remain less likely to receive guideline-concordant, timely surgery and more likely to be undertreated with RAI compared to privately insured patients.

To Radiate or Not to Radiate? Adjuvant External Beam Radiation Therapy for Nonanaplastic Thyroid Cancer

Nonanaplastic thyroid cancers, which include differentiated and medullary thyroid cancers, account for more than 95% of thyroid cancer cases, and the majority are often curable if diagnosed at an early stage. 1 Davies L. Welch H.G. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA. 2006; 295: 2164-2167 Crossref PubMed Scopus (2634) Google Scholar The use of adjuvant external beam radiation therapy (EBRT) following surgery in patients with nonanaplastic thyroid cancers is uncommon because of its treatment-related morbidity and a paucity of evidence from prospective clinical trials on its efficacy. The indications for its use are still controversial. The current guidelines recommend that EBRT should be considered in patients with gross residual disease postoperatively, those with evidence of aerodigestive invasion, and/or those undergoing multiple and frequent operations because of locally advanced disease. 2 Haugen B.R. Alexander E.K. Bible K.C. et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016; 26: 1-133 Crossref PubMed Scopus (7355) Google Scholar ,3 Tuttle R.M. Haddad R.I. Ball D.W. et al. Thyroid carcinoma, version 2.2014. J Natl Compr Canc Netw. 2014; 12: 1671-1680 Crossref PubMed Scopus (119) Google Scholar Trends in Adjuvant External Beam Radiation Therapy for Nonanaplastic Thyroid Cancer in California, 2003-2017Endocrine Practice Vol. 28Issue 7PreviewExternal beam radiation therapy (EBRT) is rarely used to treat patients with differentiated or medullary thyroid cancer. Although EBRT is generally administered to patients with high-risk or unresectable diseases, neither its indications for the use nor the associated outcomes are well-defined. We used a statewide cohort to assess the trends in EBRT use and postradiation outcomes in California. Full-Text PDF

Cervical lymph node metastases in papillary thyroid cancer: Preoperative staging with ultrasound and/or computed tomography.

Preoperative screening of potential risk of lymph node metastasis is necessary for thyroidectomy plus lymph node dissection. The 2015 American thyroid association management guidelines do not recommend prophylactic cervical lymph node resection without clinical evidence of metastasis. Ultrasound is recommended imaging method and routine computed tomography is not recommended by the 2015 American thyroid association management guidelines for screening of lymph node metastasis. The objective of the study was to compare the diagnostic performance of ultrasound against that of computed tomography for screening cervical lymph node metastasis of patients with papillary thyroid cancer before thyroidectomy plus lymph node dissection.Data regarding preoperative neck ultrasound, neck computed tomography, and physical examination of the head and neck and postoperative pathological results of a total of 185 patients (age > 18 years) with a diagnosis of papillary thyroid cancer who had suspicious lymph nodes on preoperative imaging and treated by thyroidectomy plus lymph node dissection for the therapeutic purpose were collected and analyzed.Sensitivity (78.09% vs 75.28%, P < .0001) and accuracy (77.29% vs 75.13%, P = .0004) of neck computed tomography scanning to detect cervical lymph node metastasis were higher than those of neck ultrasound scanning. Sensitivity, accuracy, positive clinical utility, and negative clinical utility for neck ultrasound scanning plus neck computed tomography scanning to detect cervical lymph node metastasis were higher among all index tests (P < .05 for all) and were statistically the same as those of surgical pathology (P > .05 for all). The working areas for decision-making of thyroidectomy plus lymph node dissection of the physical examination, neck ultrasound, the neck computed tomography, and the neck ultrasound scanning plus the neck computed tomography scanning were 0 to 0.691 diagnostic confidence/lesion, 0 to 0.961 diagnostic confidence/lesion, 0 to 0.944 diagnostic confidence/lesion, and 0 to 0.981 diagnostic confidence/lesion, respectively.Besides the neck ultrasound, the neck computed tomography scanning can be used as a complementary imaging method to detect cervical lymph node metastasis of patients with papillary thyroid cancer before thyroidectomy plus lymph node dissection.Level of evidence: III.Technical efficacy stage: 2.

Modified Models for Predicting Malignancy Using Ultrasound Characters Have High Accuracy in Thyroid Nodules With Small Size.

To assess the malignancy risk of thyroid nodules, ten ultrasound characteristics are suggested as key diagnostic markers. The European Thyroid Association Guidelines (EU-TIRADS) and 2015 American Thyroid Association Management Guidelines (2015ATA) are mainly used for ultrasound malignancy risk stratification, but both are less accurate and do not appropriatetly classify high risk patients in clinical examination. Previous studies focus on papillary thyroid carcinoma (PTC), but follicular thyroid carcinoma (FTC) and medullary thyroid carcinoma (MTC) remained to be characterized. Thus, this study aimed to determine the diagnostic accuracy and establish models using all ultrasound features including the nodule size for predicting the malignancy of thyroid nodules (PTC, FTC, and MTC) in China. We applied logistic regression to the data of 1,500 patients who received medical treatment in Shanghai and Fujian. Ultrasound features including taller-than-wide shape and invasion of the thyroid capsule showed high odds ratio (OR 19.329 and 4.672) for PTC in this dataset. Invasion of the thyroid also showed the highest odds ratio (OR = 8.10) for MTC. For FTC, the halo sign has the highest odds ratio (OR = 13.40). Four ultrasound features revealed distinct OR in PTC nodule groups with different sizes. In this study, we constructed a logistic model with accuracy up to 80%. In addition, this model revealed more accuracy than TIRADS in 4b and 4c category nodules. Hence, this model could well predict malignancy in small nodules and classify high-risk patients.

Cutoff Age Between Pediatric and Adult Thyroid Differentiated Cancer: Is 18 Years Old Appropriate?

Background: The characteristics of pediatric differentiated thyroid cancer (DTC) are substantially different from those of adult DTC. This study investigated whether the cutoff age of 18 years, as recommended by the American Thyroid Association (ATA) management guidelines for pediatric DTC, is appropriate based on clinical characteristics and outcomes. Methods: The medical records of 288 patients aged <21 years with DTC, who underwent initial surgery between 1979 and 2014, were retrospectively reviewed. Disease-free survival (DFS) rates and distant metastasis-free survival (DMFS) rates were calculated using the Kaplan-Meier method. As per the International Incidence of Childhood Cancer Report and the ATA management guidelines, cutoff ages of 14 and 18 years were analyzed in this study. Results: The age distributions of the subjects were as follows: 53 patients were aged <15 years (18.4%), 118 patients were aged 15-18 years (41%), and 117 patients were aged 19-20 years (40.6%). The DMFS rates were significantly different between the two cutoff ages. The DMFS was also significantly different between patients aged >15 years and patients aged 15-18 years; however, no significant difference was observed between patients aged 15-18 and 19-20 years. Multivariate analyses showed that clinically apparent lymph node metastasis (cN1) and gross extrathyroidal extension were significant factors related to DFS and DMFS. Although age as a continuous variant was not a significant factor related to either DFS or DMFS, when the cutoff age was set as 14 years rather than 18 years, differences in patient characteristics related to DMFS and DFS stood out. Conclusions: This study found that age was not significantly related to clinical outcome. However, in the younger patient group, more patients had factors that related to DFS and DMFS. Due to the indolent biological behavior of DTC, age at presentation or thyroidectomy does not always represent the age at occurrence, but patients aged <15 years had distinct clinical manifestations. Age <15 years rather than <19 years may therefore be a more suitable cutoff age in pediatric DTC.

Delicate needle with the finest gauge for a butterfly gland, the thyroid: Is it worth mentioning?

Thyroidology has yet to declare the optimal needle size for thyroid fine-needle aspiration (FNA) cytology. In this respect, the researches on this issue remain restricted in English-language literature. Currently, Saraph and colleagues (1) evaluated dissimilarity between 23- and 25-gauge needles in terms of nondiagnostic/unsatisfactory rates of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) after FNA applications. The authors had worked with a sum of 141 23- and 157 25-gauge needles and reported their nondiagnostic/unsatisfactory rates as 31.09% and 35.07%, respectively, with no statistical difference. However, Dong et al. (2) reported working with 240 consecutive nodules, had undergone US-guided FNA (US-FNA), and obtained the highest scores of sample quality with 25-gauge needles in thyroid FNA cytology, comparing with 22- and 23-gauge needles, very recently. The authors declared the nondiagnostic scores of 15.42%, 19.58%, and 14.17% for US-FNA with 22-, 23-, and 25-gauge needles, respectively (2). In addition, recently, Shumrick et al. (3) reported 148 thyroid nodules in 107 cases, had undergone US-FNA, revealing significantly less non-diagnostic cytology with 27-gauged needles, 11.3%, comparing 25-gauge needles, 24.7%. We recently have studied the possible impact of size cutoff of 10- and 15-mm for the thyroid nodules on three diagnostic tools; i) strain elastography (SE), ii) sonography-guided FNA cytology, and iii) histopathology. A sum of 425 cases with 500 thyroid nodules had undergone US-guided FNA (USFNA) with 27-gauge finest-needle by a single surgeon (I.S.), surgeon-performed US (SUS), with a local anesthetic agent (1-3 mL of 1% lidocaine with 1:100,000 epinephrine) based on American Thyroid Association (ATA) management guidelines for patients with thyroid nodules and differentiated thyroid cancer [i.e. low, intermediate, and high suspicion nodules]; 2015 ATA management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer] for three years and two months. TBSRTC 1st ed. had been used for this period, for the mentioned considerable and novel ‘SUS based’ US-FNA terminology with the specific and also ‘ well-accepted and crucial’ size cut offs of 10- and 15- mm in Thyroidology revealing the FNA cytology outcomes with27-gauge fine needles, for Category I, per se, TBSRTC, 1st ed. were revealed as 9.0% (4). Moss et al.(5) notified that regular and coordinated thyroid FNA should be performed with smaller needle gauges, 24-27-gauges, without aspiration, routinely, in a systematic review and meta-analysis. Saraph et al. (1) specified the utilization of a 25-gauge needle did not produce a lower nondiagnostic rate, comparing the 23-gauge one. In addition, they pointed out that larger nodules might increase diagnostic rates, while the older and cystic nodules are prone to inadequate samples. We agree with Saraph and colleagues’(1) opinion about the limitations of nodule location, such as a posterior, more difficult to reach nodules, and sonography of composition (mixed and solid) and echogenicity which may be crucial parameters for this issue. Nonetheless, we postulate that the so-called needle gauge concept selectively enriches with finer needles. Additionally, we currently introduced the proposal of a novel terminology, “minimally invasive FNA (MIFNA)” and “minimally invasive thyroid FNA; Thyroid MIFNA (Thy MIFNA)”, including 27-gauge fine-needle with pre-procedural topical and local anesthetic agents administration, hope to contribute in Thyroidology (6). Of note, we might recommend opting for a 27-gauge finest needle in terms of US-FNA for a butterfly gland, the thyroid, with reasonable low rates of non-diagnostic/unsatisfactory cytology, TBSRTC, 1st and 2nd ed. and low severity of pain, as a matter of course. To this end, we also recommend: “think twice with larger needles for thyroid US-FNA”. This issue merits further investigation.

Surgical Treatment of a Patient with Invasion of Multiple Organs Including the Common Carotid Artery by Papillary Thyroid Carcinoma: Surgical Management for Invasion of the Aerodigestive Tract

Background: Extrathyroidal invasion has the greatest negative prognostic impact among several adverse prognostic factors of differentiated thyroid carcinoma (DTC). Surgical treatment for locally advanced DTC is challenging. In particular, the presence of great vessel involvement makes it more challenging, with vessel rupture and infection being common occurrences, especially in patients with laryngotracheal or esophageal intraluminal invasion.1 Locoregional tumors presenting with great vessel and/or multiple organ invasion have been deemed to be unresectable. However, there has been little discussion regarding which types of locoregional tumor are unresectable. Regarding the surgical management of aerodigestive invasion, the 2015 American Thyroid Association management guidelines state that surgical decision making can be complex and must balance oncologic surgical completeness with preservation of the upper aerodigestive tract head neck function. However, surgical management of aerodigestive tract invasion remains controversial.2 Materials and Methods: A right thyroid tumor was unexpectedly detected in a 77-year-old man by computed tomography images. The man was found to have papillary thyroid carcinoma (PTC) by fine needle aspiration biopsy. He was referred for the surgical treatment of multiple organ invasion by PTC. Tumor encasement of about 180° of the right common carotid artery and aerodigestive tract invasion were suspected on pre-operative magnetic resonance imaging. We performed total thyroidectomy, including resection of multiple organ infiltration and right lateral neck dissection. Our surgical strategy for locally advanced DTC is implemented with curative surgical intent for all patients and functional preservation or reconstruction, if possible. Results: The thyroid tumor infiltrated the right common carotid artery, internal jugular vein, prevertebral fascia, pharyngoesophagus, laryngotrachea, and right recurrent laryngeal nerve (RLN). We performed subadventitial resection of the common carotid artery, partial prevertebral fascia resection, muscle layer resection of the pharyngoesophagus, framework resection of the larynx, window resection of the trachea from first to fourth ring, and resection and intralaryngeal reconstruction of the right RLN.3 After tumor resection, the right common carotid artery was covered using a deltopectoral flap and separated from the tracheacutaneous fistula. Pathology analysis confirmed well-differentiated PTC, which was classified as pT4bN1bM0. The tracheocutaneous fistula was closed 2 months after surgery. The patient underwent radioactive iodine (RAI) adjuvant therapy of 100 mCi, 6 months after surgery. RAI uptake was noticed in only the thyroid bed. Maximum phonation time was 10 seconds, 6 months after surgery. Conclusions: This video illustrates the technical details of surgical management for invasion of the aerodigestive tract. These surgical techniques are effective for improving surgical curability and functional preservation. No competing financial interests exist. Runtime of video: 9 mins 29 secs

Adiposity and the risk of thyroid nodules with a high-suspicion sonographic pattern: a large cross-sectional epidemiological study.

To our knowledge, no previous studies have evaluated the association between obesity and the risk of thyroid nodules with a high-suspicion sonographic pattern defined by the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancers. In this large cross-sectional epidemiological study, we investigated whether a positive association existed between anthropometric measurements and the risk of thyroid nodules. In total, 10,504 individuals from two towns in northern China were enrolled between May to September 2016. The height and weight were measured and the body mass index (BMI), body fat percentage (BFP), and body surface area (BSA) were calculated. A logistic regression model was used to estimate age-, sex-, and study site-adjusted odds ratios (ORs) and confidence intervals (CIs) for each of the anthropometric measurements with respect to the risk of thyroid nodules. The final analyses included 9,096 participants, among whom 3,614 (39.7%) had thyroid nodules and 365 (4.0%) had thyroid nodules with a high-suspicion sonographic pattern. An increased risk of any thyroid nodules was associated with greater height, weight, BFP, and BSA in both men and women. Compared with the lowest quartile of BFP, the ORs for the highest quartile were 1.33 (95% CI: 1.09-1.62) in women and 1.89 (95% CI: 1.35-2.65) in men. An increased risk of thyroid nodules with a high-suspicion sonographic pattern was associated with greater weight, BMI, BFP, and BSA in both men and women. Compared with the lowest quartile of BFP, the ORs for the highest quartile were 2.19 (95% CI: 1.32-3.64) in women and 3.10 (95% CI: 1.31-7.36) in men. Our results demonstrated that BFP was the most pronounced anthropometric factor associated with an increased risk of any thyroid nodules and thyroid nodules with a high-suspicion sonographic pattern.

Variations in radioiodine ablation: decision-making after total thyroidectomy.

The role of radioiodine treatment following total thyroidectomy for differentiated thyroid cancer is changing. The last major revision of the American Thyroid Association (ATA) Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer in 2015 changed treatment recommendations dramatically in comparison with the European Association of Nuclear Medicine (EANM) 2008 guidelines. We hypothesised that there is marked variability between the different treatment regimens used today. We analysed decision-making in all Swiss hospitals offering radioiodine treatment to map current practice within the community and identify consensus and discrepancies. RESULTSAND CONCLUSION: We demonstrated that for low-risk DTC patients after thyroidectomy, some institutions offered only follow-up, while RIT with significant activities is recommended in others. For intermediate- and high-risk patients, radioiodine treatment is generally recommended. Dosing and treatment preparation (recombinant human thyroid stimulation hormone (rhTSH) vs. thyroid hormone withdrawal (THW)) vary significantly among centres.

Active Surveillance for Small Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis.

Background: The rapid increase in the incidence of small papillary thyroid carcinoma (PTC) appears to be caused by the detection of small thyroid cancers. Active surveillance (AS) was therefore suggested to overcome this problem. As the results were favorable with low rates of size enlargement and lymph metastasis, the 2015 American Thyroid Association Management Guidelines endorsed AS as an alternative to immediate surgery. As the clinical value of AS is a subject of ongoing active discussions and surveys, we considered a systematic review and meta-analysis to be timely and necessary. Methods: Ovid-MEDLINE and EMBASE databases were searched up to January 5, 2019, for studies reporting patients who were followed up with AS for PTC. Data extraction and methodological quality assessment were performed independently by two radiologists. The primary outcomes were to identify the annual pooled proportions of size enlargement of 3 mm or more and the detection of lymph node metastases at a 5-year follow-up period. These were calculated using an inverse-variance weighting model. An additional outcome was evaluation of the reasons for surgery during AS. Results: The pooled proportion of size enlargement occurring at 5 years was 5.3% [95% confidence interval (CI), 4.4-6.4%], and the pooled proportion of 5-year lymph node metastasis was 1.6% [CI, 1.1-2.4%]. In many subjects undergoing delayed operations, the reasons for operation were often other than those of size enlargement or lymph node metastasis. Conclusions: AS is effective for the management of small PTC, with a low proportion of size enlargement or lymph node metastasis occurring at 5 years. However, a substantial proportion of the causes of delayed surgery were other than size enlargement or lymph node metastasis, and these situations need to be optimally managed.

Can Clinical Presentation and Ultrasonography Predict the Risk of Malignancy in Thyroid Nodules

Background: Thyroid nodules are frequent occurrences. This study aims to evaluate the risk of malignancy based on the 2015 American Thyroid Association Management: Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Methods: In this cross-sectional study, ultrasonography and clinical manifestations were compared with pathology findings to predict the risk of malignancy in thyroid nodules. Assessment of the ultrasound findings was based on the criteria recommended by The 2015 American Thyroid Association Management Guidelines for Thyroid Nodules. For the evaluation of the association between clinical and ultrasound findings with histopathology results, we used the chi-square and Fisher’s exact tests. The relative risk and prediction of malignancy was assessed by multiple logistic regression analysis. Data analysis was performed by the SPSS19. The significance level was set at P<0.05. Results: From 130 patients with thyroid nodules, 110 (84.6%) were female. The mean age of participants was 46.1±11.5 years. Histopathology findings showed malignancy in 17.7% of the nodules, all of were papillary thyroid carcinoma. Multivariate logistic regression showed some of the ultrasonography parameters, absence of halo (P<0.001, OR=28), taller than wide shape (P=0.001, OR=18.3), nodule size more than 4 cm (P=0.04, OR=12.1), irregular margin (P=0.001, OR=10.06), solid or mixed composition (P=0.002, OR=8.1), hypoechoic (P=0.001, OR=4.5), lymph node positive (P=0.002, OR=4.3), positive calcification (P=0.03, OR=2.08), positive internal vascularity (P<0.001, OR=1.05), and intermediate/high level of suspicion (P=0.001, OR=12) could predict malignancy in patients with thyroid nodules. Conclusion: Based on increasing rate of thyroid cancer, in this study, the new and accurate ultrasound technique is recommended as alternative diagnostic method due non-invasive nature and lower cost used.

Disparity in the use of adjuvant radioactive iodine ablation among high-risk papillary thyroid cancer patients

BackgroundWe sought to identify treatment disparities existing prior to publication of the 2015 American Thyroid Association Management Guidelines in order to identify patients with papillary thyroid cancer (PTC) at risk for receiving inadequate treatment. MethodsPatients diagnosed with PTC from 2011 to 2013 were identified using Surveillance, Epidemiology and End Results database. High-risk disease was defined as T4, N1, or M1. Chi-square tests compared characteristics of patients with and without high-risk disease and characteristics of high-risk patients who did and did not receive radioactive iodine ablation (RAI). Likelihoods of having high-risk disease, of receiving RAI, and of cause-specific death were calculated using regression analyses. ResultsSample included 32,229 individuals; 7894 (24.5%) had high-risk disease. Mean age was 50.0 years, 24,815 (77.0%) were female, and 21,318 (66.2%) were white. Odds of high-risk disease were greater among males (OR:2.04; 95% CI:1.92–2.16), Hispanics (OR:1.67; 95% CI:1.56–1.79) and Asians (OR:1.49; 95% CI:1.37–1.62), and uninsured (OR:1.24; 95% CI:1.07–1.43), and lower among patients ages 45–64 (OR:0.57; 95% CI:0.53–0.60), and ≥65 years (OR:0.54; 95% CI:0.50–0.59), and Blacks (OR:0.46; 95% CI:0.40–0.53). Most (69.3%) high-risk patients received RAI. Odds of receiving RAI were lower among patients age ≥65 years (OR:0.67; 95% CI:0.58–0.77), uninsured (OR:0.52; 95% CI:0.41–0.67), or with Medicaid (OR:0.58; 95% CI:0.50–0.69). RAI use reduced the risk of cause-specific mortality (HR:0.29; 95% CI:0.18–0.47). ConclusionKnowledge of these treatment disparities will allow recognition of groups at risk for high-risk disease and receiving inadequate treatment.

The overuse of radioactive iodine in low-risk papillary thyroid cancer patients

BackgroundThe aim of this study was to use current American Thyroid Association (ATA) management guidelines to identify groups who might be at risk of overtreatment with radioactive iodine (RAI) ablation after surgery for low-risk papillary thyroid cancer (PTC). MethodsPTC patients were identified using the Surveillance, Epidemiology and End Results database. Characteristics of low-risk patients (defined as T1 without metastasis) were compared to those not low-risk. Predictors of receiving RAI for low-risk disease were determined using logistic regression. ResultsOf 32,229 cases, 17,286 (53.6%) were low-risk. Low-risk patients, compared to others, were older (mean age 51.3 versus 48.5 years), and more often female (81.6% versus 71.7%), white (69.7% versus 62.0%), and insured (87.6% versus 85.6%)(all p-values < 0.001). Nearly 25% of low-risk patients received RAI. Predictors of overtreatment with RAI included age <45 years (OR: 1.393; 95% CI: 1.250–1.552), age 45–64 years (OR: 1.275; 95% CI: 1.152–1.412), male sex (OR: 1.191; 95% CI: 1.086–1.305), Hispanic (OR: 1.236; 95% CI: 1.110–1.376) and Asian (OR: 1.306; 95% CI: 1.159–1.473) race, and extensive lymphadenectomy (OR: 1.243; 95% CI: 1.119–1.381). ConclusionLow-risk PTC patients were more likely to receive post-surgical RAI when not indicated under ATA guidelines if they were younger, male, Hispanic or Asian, or underwent extensive lymph node surgery. Identification of groups at risk for overtreatment can help impact practice patterns and improve the effective utilization of healthcare resources.

Management and dynamic risk stratification of differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is the most frequently diagnosed thyroid cancer. With the development of the imaging technology and fine needle aspiration, early diagnosis rate of DTC is increasing. Most patients have favorable prognosis for DTC's low-invasion. TNM staging is more widely used for predicting mortality than predicting recurrence. In 2008, it was suggested that recurrence risks for DTC should be assessed based on the results of dynamic monitoring treatment response. The validity of dynamic risk stratification (DRS) has been supported by different researches in various countries and DRS is recommended in 2015 American Thyroid Association Management Guidelines. Long-term DRS in patients with DTC make individual management possible.

European Perspective on 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: Proceedings of an Interactive International Symposium.

The American Thyroid Association (ATA) management guidelines for patients with thyroid nodules and differentiated thyroid cancer (DTC) are highly influential practice recommendations. The latest revision appeared in 2015 ("ATA 2015"). These guidelines were developed predominantly by North American experts. European experts frequently have different perspectives, given epidemiological, technological/methodological, practice organization, and medicolegal differences between the respective regions. Divergent viewpoints were the focus of an invited symposium organized by the European Association of Nuclear Medicine involving 17 European thyroidologists, four ATA Guidelines Taskforce members, and an audience of 200 international experts. The group discussed the preoperative assessment of thyroid nodules, surgery and the role of pathology, radioiodine (RAI) therapy (RAIT), the assessment of initial therapy and dynamic risk stratification, and the treatment of persistent disease, recurrences, and advanced thyroid cancer. The dialogue resulted in this position paper contrasting European and ATA 2015 perspectives on key issues. One difference pertains to the permissiveness of ATA 2015 regarding lobectomy for primary tumors ≤4 cm. European panelists cited preclusion of RAIT, potential need for completion thyroidectomy, frequent inability to avoid chronic thyroid hormone replacement, and limitations of supportive evidence as arguments against widely applying lobectomy. Significant divergence involved ATA 2015's guidance regarding RAIT. European panelists favored wider use of postoperative RAIT than does ATA 2015. Rationales included the modality's association with favorable patient outcomes and generally limited toxicity, and lack of high-quality evidence supporting withholding RAIT. Additionally, European panelists favored recombinant human thyrotropin (rhTSH) in more settings than does ATA 2015, citing avoidance of hypothyroid morbidity and quality-of-life impairment, without apparent sacrifice in oncologic outcomes. Based on clinical evidence plus theoretical advantages, European experts advocated dosimetric versus fixed-activity RAIT approaches for advanced DTC. European panelists noted that the ATA 2015 risk-stratification system requires information sometimes unavailable in everyday practice. ATA 2015 recommendations regarding RAI-refractory DTC should consider potential palliative benefits of RAIT in patients who also have RAI-susceptible lesions. European panelists suggested modifications to approximately one-third of ATA 2015 recommendations. Varying European and ATA 2015 perspectives can stimulate analysis and discussion of the literature and performance of primary research to resolve discrepant recommendations and potentially improve patient outcomes.

Verification and comparisons of different ultrasound risk-stratification systems in the evaluation of thyroid nodules

Objective To verify and compare the TI-RADS developed by Kwak et al.(Kwak TI-RADS), 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (ATA Guideline Classification), 2017 TI-RADS released by the American College of Radiology (ACR TI-RADS) and TI-RADS developed by Zhou et al.(Zhou TI-RADS) in the evaluation of thyroid nodules. Methods The ultrasound images of 339 thyroid nodules in 273 patients were analyzed by retrospective study. The thyroid nodules were categorized into aforementioned four stratified systems. Based on the pathological findings considered the gold standard , the receiver operating characteristic(ROC) curve was created to compare the clinical application value of aforementioned four stratified systems. Results The percentage of nodules that could not be categorized were 1.2%, 17.5%, 0 and 1.2% for the Kwak TI-RADS, ATA guidelines, ACR TI-RADS, and Zhou TI-RADS, respectively and the area under the ROC curve (AUC) was 0.899, 0.879, 0.876, and 0.918, respectively. The sensitivity of Kwak TI-RADS, ATA guidelines classification, and ACR TI-RADS were higher than that of Zhou TI-RADS (all P 0.05). Conclusions Four thyroid risk stratification systems provide effective risk assessment for thyroid nodules, Zhou TI-RADS has relatively lower sensitivity, but its specificity and AUC value are the highest among the four evaluated systems. In addition, ACR TI-RADS can classify the most nodules, while the number of nodules that can′t be categorized by ATA guideline is maximum. Key words: Ultrasonography; Thyroid nodules; Ultrasound risk-stratification system; Receiver operating characteristic curve

American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence-based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules.

Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality. Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. A consensus-based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty-one panelists achieved consensus on 16 statements about workflow-embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care. A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.

Ultrasound risk evaluation of thyroid nodules that are "unspecified" in the 2015 American Thyroid Association management guidelines: A retrospective study.

This study sought to assess the malignant risks of “unspecified” thyroid nodules; that is, nodules that were not of a type described in the 2015 American Thyroid Association (ATA) guidelines.We retrospectively reviewed medical records and ultrasound (US) data for 1808 consecutive patients with 2614 thyroid nodules who underwent thyroidectomy between January 2015 and December 2015. Nodules with US features that did not satisfy the criteria for any risk category in the 2015 ATA guidelines were defined as “unspecified” nodules. These thyroid nodules were retrospectively assessed using the Thyroid Imaging, Reporting and Data System proposed by Kwak (Kwak-TIRADS) and the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR-TIRADS).There were 70 “unspecified” nodules (2.7%, 70/2614), and 18.6% (13/70) of these nodules were malignant. The percentages of nodules with Kwak-TIRADS grades 4a, 4b and 4c were 53.3%, 40.0%, and 6.7%, respectively. The percentages of nodules with ACR-TIRADS grades TR2, TR3, TR4, and TR5 were 5.7%, 2.9%, 70.0%, and 21.4%, respectively. Among the “unspecified” nodules, there were significantly more nodules in Kwak-TIRADS categories 4b and 4c in the malignant pathology group than in the benign pathology group (P <.01).Our results imply that “unspecified” thyroid nodules based on the ATA guidelines could partly be evaluated using the Kwak-TIRADS and that the ATA guidelines could incorporate more accurate malignant risk stratification.