American Thyroid Association Recommendations Research Articles

Comparative evaluation of low and high radioiodine doses in differentiated thyroid carcinoma management: A multicenter study

Iodine-131 (131I) therapy plays a crucial role in the ablation of thyroid remnants in differentiated thyroid cancer (DTC), although there remains ongoing debate concerning the appropriate dosage. This study aims to compare the effects of low and high doses of radioiodine (RAI) in the management of DTC. For this purpose, 100 adult patients with verified DTC histology who had either total or nearly total thyroidectomy were injected with either 1.1 GBq (30 mCi) or 3.7 GBq (100 mCi) of radioiodine (131I). Those patients were categorized as low or intermediate risk following the American Thyroid Association (ATA) recommendations. Retrospective data was manipulated from multiple center units nuclear medicine in Saudi Arabia on equal numbers of selected male and female patients, with ages in the range from 20 to 66 years with an average of 40.72 ± 11.49. According to the tumour-node-metastasis (TNM) classification, the most tumours (T) stages in both groups were T1 or T2, with 80% in the high-dose group and 86% in the low-dose group. After the radioiodine therapy (RIT), the thyroglobulin (Tg) levels were below 10 ng/ml across both groups (72 % in the high-dose group and 66 % in the low-dose group). There was no discernible therapeutic distinction between patients with low and moderate risks in terms of treatment efficacy. The results revealed that the RIT with a low-dose ablation success rate (78%) is almost the same as the high-dose ablation success rate (82%). Therefore, this indicates that both the low and high-dose ablation effectively reduce Tg levels and achieve successful ablation.

Papillary thyroid microcarcinoma: Does management differ based on facility variables?

PurposePapillary thyroid carcinoma detection has increased dramatically in the United States. However, the indolent nature of papillary thyroid microcarcinoma (mPTC) has led the American Thyroid Association (ATA) to advocate for more conservative management. The 2015 ATA recommendations advocated for observation or lobectomy for mPTC. However, the majority of mPTCs continue to be treated with more aggressive surgical management. In this study, we aim to understand the management of mPTC based on facility variables. Materials and methodsA retrospective observational study of patients diagnosed with mPTC between 2004 and 2018 was performed using the National Cancer Database incidence data. We collected data on patient sex, age, tumor size, race, ethnicity, geographic location, thyroid surgical volume at the facility, and treatment modality for mPTC were collected. Conservative and non-conservative treatment modalities based on patient and facility characteristics were compared both longitudinally and cross-sectionally between pre- and post-2015 ATA recommendations. ResultsTotal thyroidectomy with or without radioactive iodine ablation (RAI) remains the treatment of choice regardless of patient and facility characteristics. Patients treated at low-volume facilities were actually more likely to be treated conservatively. ConclusionsDespite 2015 ATA recommendations advocating for observation or lobectomy for mPTC, patients with mPTC are still more likely to be treated with total thyroidectomy with or without RAI, especially at high-volume facilities.

Value of follow-up diagnostic radioiodine scans in differentiated thyroid cancer.

The most important part of the follow-up of differentiated thyroid carcinoma (DTC) is the measurement of serum thyroglobulin (Tg). An increase of Tg levels indicates likely tumor recurrence. According to the guidelines of the European Society of Medical Oncology (ESMO), the follow-up should consist of serum Tg assays and a neck ultrasound, while the American Thyroid Association (ATA) recommends serum Tg assays, neck ultrasounds, and a diagnostic radioiodine whole-body scan (WBS) if non-stimulated Tg is greater than 10 ng/mL or if Tg is rising. This study questions the necessity of a diagnostic WBS in patients with low stimulated Tg levels during the initial follow-up. This study is a retrospective data analysis. The data of 185 patients, who were in regular treatment and aftercare between 2015 and 2018 at the Department of Nuclear Medicine in Vienna, as well as the data of 185 patients who were treated in Tbilisi between 2015 and 2019, were analyzed. There was a highly significant relationship between low stimulated Tg levels (<0.5 ng/mL) and the outcome of the diagnostic WBS at the first follow-up (χ 2 = 14.7, P < 0.001). In total, 31 out of 370 patients (8.4%) had positive findings in the diagnostic WBS. Seventy-five of 370 patients (19.74%) had stimulated Tg levels >0.5 ng/mL. Our data suggest that the first follow-up, 4-12 months after the initial therapy of DTC, including the measurement of basal and stimulated Tg levels and Tg antibody levels, does not mandate a diagnostic WBS on all patients. In this study, we examined the still commonly used routine diagnostic radioiodine whole-body scan in the first follow-up of patients with differentiated thyroid carcinoma. We questioned the necessity of the scan in patients with low stimulated thyroglobulin levels. Therefore, we combined retrospective data from the University Hospital in Vienna and in Tbilisi to analyze 370 patients. We were able to demostrate a highly significant relationship between low stimulated thyroglobulin levels (<0.5 ng/mL) and the outcome of the diagnostic scan at the first follow-up (χ = 14.7, P < 0.001).

Evaluation of YouTube As A Source For Graves' Disease Information: Is High-Quality Guideline-Based Information Available?

To understand the quality of informational Graves' disease (GD) videos on YouTube for treatment decision-making quality and inclusion of American Thyroid Association (ATA) treatment guidelines. Cross-sectional cohort. Informational YouTube videos with subject matter "Graves' Disease treatment." The top 50 videos based on our query were assessed using the DISCERN instrument. This validated algorithm discretely rates treatment-related information from excellent (≥4.5) to very poor (<1.9). Videos were also screened for ATA guideline inclusion. Descriptive statistics were used for cohort characterization. Univariate and multivariate linear regressions characterized factors associated with DISCERN scores. Significance was set at P < .05. The videos featured 57,513.43 views (SD = 162,579.25), 1054.70 likes (SD = 2329.77), and 168.80 comments (SD = 292.97). Most were patient education (52%) or patient experience (24%). A minority (40%) were made by thyroid specialists (endocrinologists, endocrine surgeons, or otolaryngologists). Under half did not mention all 3 treatment modalities (44%), and 54% did not mention any ATA recommendations. Overall, videos displayed poor reliability (mean = 2.26, SD = 0.67), treatment information quality (mean = 2.29, SD = 0.75), and overall video quality (mean = 2.47, SD = 1.07). Physician videos were associated with lower likes, views, and comments (P < .001) but higher DISCERN reliability (P = .015) and overall score (P = .019). Longer videos (P = .015), patient accounts (P = .013), and patient experience (P = .002) were associated with lower scores. The most available GD treatment content on YouTube varies significantly in the quality of medical information. This may contribute to suboptimal disease understanding, especially for patients highly engaged with online health information sources.

Case Report: Pneumonia Provocate Thyroid Storm in Graves Disease

&lt;p&gt;&lt;strong&gt;Introduction:&lt;/strong&gt; A thyroid crisis is an endocrine emergency involving many organ systems and can be fatal to the patient's survival. Although cases of thyroid crisis are rare, the mortality rate is significant which reaches 20–50%. The presence of comorbidities such as pneumonia infection increases the risk of death dramatically. Infection is a factor that can trigger thyroid crisis and exacerbate thyrotoxicosis. This condition of thyroid crisis most often occurs in people with hyperthyroidism caused by Graves' disease. We present the case of a patient with Graves' disease, aged 22 years, who developed a thyroid crisis due to community-acquired pneumonia infection. This study aims to provide a case report regarding the thyroid crisis due to pneumonia.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; We carried out a physical and some appropriate supporting examinations to confirm the diagnosis. Wayne's index was 26, indicating hyperthyroidism. Assessment with Burch-Wartofsky obtained a score of 45, indicating suspicion of a thyroid storm. Then supportive care was provided to the patient. The community-acquired pneumonia as a triggering factor was treated with antibiotics. Thyrotoxicosis conditions were treated with antithyroid, beta-blocker, and glucocorticoid drugs. The patient's condition improved after treatment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;It is crucial to detect and treat thyroid storm as quickly as possible since it has a high mortality rate. Wayne's score is useful for identifying hyperthyroidism based on clinical symptoms. The Burch-Wartofsky Point Scale scores are used to diagnose thyroid storms. Thyroid storm should be managed according to PERKENI (Perkumpulan Endokrinologi Indonesia) and ATA (American Thyroid Association) recommendations. This case serves as an example of how to make a proper diagnosis and treatment to prevent morbidity and death due to thyroid crisis.&lt;/p&gt;

The Relationship between Oxidative Status and Radioiodine Treatment Qualification among Papillary Thyroid Cancer Patients.

Total oxidative status (TOS), total antioxidant capacity (TAC), tumor protein 53 (p53), nuclear factor kappa B (NF-κB), forkhead box protein O1 (FOXO), and sirtuin 1 (SIRT1) play crucial roles in oxidative homeostasis and the progression of papillary thyroid cancer (PTC), as previously demonstrated in the literature. Therefore, profiling these markers among PTC patients may be useful in determining their eligibility for radioiodine (RAI) treatment. Since treatment indications are based on multiple and dynamic recommendations, additional criteria for adjuvant RAI therapy are still needed. In our study, we evaluated the TOS, TAC, and serum concentrations of p53, NF-κB, FOXO, and SIRT1 to analyze the relationship between oxidative status and qualification for RAI treatment. For the purpose of this study, we enrolled 60 patients with PTC allocated for RAI treatment as the study group and 25 very low-risk PTC patients not allocated for RAI treatment as a reference group. The serum TOS and SIRT1 concentrations were significantly higher in the study group compared to the reference group (both p < 0.001), whereas the TAC and p53, NK-κB, and FOXO concentrations were significantly lower (all p < 0.05). We also demonstrated the diagnostic utility of TAC (AUC = 0.987), FOXO (AUC = 0.648), TOS (AUC = 0.664), SIRT1 (AUC = 0.709), p53 (AUC = 0.664), and NF-κB (AUC = 0.651) measurements as indications for RAI treatment based on American Thyroid Association recommendations. Our study revealed that oxidative status-related markers may become additional criteria for RAI treatment in PTC patients.

Hemithyroidectomy in Papillary Thyroid Cancers: A Prospective, Single Institutional Surgical Audit and Contemplating on the Clinical Implications of 2015 American Thyroid Association Guidelines.

Papillary thyroid carcinoma (PTC) contributes to 88% of thyroid malignancies and its extent of surgical management has been a topic of debate in the past 2 decades. American thyroid association (ATA) recommendations have been periodically updated for its robust and evidence-based management. We present our experience in implementing 2015 ATA guidelines, assessment of surgical outcomes of hemithyroidectomy in PTC ≤ 4cm and contemplating on the potential clinical implications of 2015 ATA guidelines. A prospective study in a cohort of Bethesda class V and VI PTC with nodule ≤ 4cm who underwent Hemithyroidectomy between 2012 and 2020. Data on thyroid nodule evaluation, management, histopathology and follow up were used for risk stratification. Of 37 patients, 27 (72.9%) were low risk and 10 (37%) were intermediate risk ATA group. 4 (40%) intermediate risk patients had structural incomplete response and underwent completion thyroidectomy. 1 (2.7%) out of 4 completion surgery patients required adjuvant radio-ablation iodine (RAI) and 3 patients were under surveillance. Overall, 2 (5.4%) of 37 patients, 1 each from low and intermediate groups were given remnant RAI in view of aggressive histology, old age and unwillingness for a completion surgery. During follow up of 4.94 ± 2.4 years, 35 (94.5%) showed excellent response and 2 (5.4%) showed biochemical incomplete response. The difference in RFS between two groups was statistically significant with p < 0.001. Thyroid preserving surgery combined with real time risk stratification seems appropriate for low and intermediate risk PTC ≤ 4cm.

Improved Adherence to ATA Medullary Thyroid Cancer Treatment Guidelines.

The 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) were created to unify national practice patterns. Our aims were to (1) evaluate national adherence to ATA guidelines before and after 2009, (2) identify factors that are associated with concordance with guidelines, and (3) evaluate whether there is an association between survival and concordant treatment. Patients with MTC were identified from the 2009 to 2015 National Cancer Database. Adherence to ATA recommendations regarding extent of surgery (R61-R66) was analyzed. Logistic regression was used to determine predictors of discordance and propensity score matching was used to compare concordant treatment rates between time periods. Kaplan-Meier survival analysis was used to determine association between survival and concordant treatment. There were 3421 patients with MTC, and of these 3087 had M0 disease and 334 had M1 disease. We found that 72% of M0 cases adhered to R61-66, and 68% of M0 cases without advanced local disease were adherent to R61-63. Following propensity score matching, the adherence rate was 67% before 2009 and 74% after. Patient factors associated with discordant treatment were female gender, older age, treatment at a nonacademic facility, and living within 50 miles of the treatment facility. Adherence to guidelines was associated with improved overall survival (OS) (p < 0.01). Treatment of MTC was discordant from guidelines in 26% of cases from 2009 to 2015 compared with 33% prior to 2009 in a propensity matched analysis, and was most often in cases with localized, noninvasive disease. Improved adherence to guidelines may improve overall survival.

ODP463 Assess the Usefulness of Pre–Ablation Diagnostic I-123 Iodine Scans in Patients with Differentiated Thyroid Cancer

Abstract Context: Over the last decade, there have been significant changes in the post-operative management of Differentiated Thyroid cancer. The use of Diagnostic 123-Iodine scans has become controversial as many endocrinology practices now give empiric doses of RAI (Radioactive Iodine) when needed based on risk stratification. Allegheny Health Network (AHN) routinely uses I-123 Pre RAI scans prior to ablative or adjuvant therapy. As per the 2015 ATA (American Thyroid Association) guidelines – Pre therapy scans and/or measurement of thyroid bed uptake may be useful when the extent of the thyroid remnant cannot be accurately ascertained from the surgical report or neck ultrasonography, or when the results would alter either the decision to treat or alter the activity of RAI dose that is administered. ATA recommendation is vague and further studies are needed to identify these patients who need pretreatment scan. Objective The objective of our study is to evaluate the utility of pre-therapy diagnostic 131-I scan for the risk stratification and Radioactive Iodine administration decisions in patients with Differential Thyroid cancer after thyroidectomy. Design: The study is a retrospective blinded chart review of cases at AHN. Setting: The study was conducted at an academic tertiary care center of a large Health Network in Western Pennsylvania. Method: Retrospective chart review of patients at AHN who underwent RAI treatment from 2016-2021 has been completed. 195 patients with Differentiated Thyroid cancer have been included in this study. These patients had a pre-therapy WBI (Whole Body Iodine) scan as per AHN's current clinical practice. Data collection includes demographic information, surgical details including lymph neck dissection performed or not, tumor histopathology, TNM classification, post thyroidectomy labs including TSH (Thyroid Stimulating Hormone), TG (Thyroglobulin) and TGA (Thyroglobulin antibody), pre and post-operative ultrasound, RAI dose, Pre-therapy scan findings and Post therapy RAI scan findings. Intervention: Using clinical and histopathology information a group of blinded endocrinologist are performing risk stratification to determine postoperative management with respect to radioiodine therapy (RAI) planning. The decision to withhold or to administer RAI, and the recommended low, medium or high 123-I activity will be decided by them without having information from the Diagnostic 123-Iodine scans. Main Outcome Measure: Main outcome measures will be difference in risk stratification and management with and without Diagnostic 123-Iodine scans. We plan to compare this empiric management strategy to the actual management strategy that took place based on the Pre-therapy scan. Results This will include percentage of patients where decision to treat or dose of radioactive iodine was different, when information from Diagnostic 123-Iodine scan was not available. This will help streamline Endocrinologist practice for patients with Differentiated Thyroid cancer. Presentation: No date and time listed

ODP476 Does Levothyroxine Intake at Breakfast Matter for Patients With Hypothyroidism? A Meta- Analysis of Randomized Control Trials

Abstract The American Thyroid Association recommends taking levothyroxine consistently, "either 60 minutes before breakfast or at bedtime." However, clinicians typically opt to recommend taking levothyroxine on an empty stomach, rather than offering the option of bedtime or with breakfast. Many patients find it cumbersome to take levothyroxine in the morning without food. A meta-analysis was performed to evaluate the effects of taking levothyroxine (LT4) before breakfast (BB) vs. with breakfast (AB) on thyroid function tests in our included four clinical trials. Four randomized controlled trials involving 243 patients were retrieved from PubMed, according to established inclusion criteria. The Standard Mean Difference (SMD) of thyroid-stimulating hormone (TSH), free T4 (FT4), and free or total T3 (F/TT3) with their 95% confidence intervals between AB vs. BB were calculated. Random effect or fixed-effect model was used based on heterogeneity significance. Then a subgroup analysis of liquid levothyroxine and tablet levothyroxine was performed. Sensitivity analysis and publication bias detection were performed. All statistical analysis was performed using RevMan software (v5.4; Cochrane library) and R Core Team (2016, Vienna, Austria), and all p-values were two-tailed, and the significance level was 0. 05. No statistically significant differences of TSH (Mean 1.45-3.74 vs. 1.26-3. 00, SMD 0.25; 95% CI: -0. 06, 0.56; p=0.11, I2=65%), FT4 (Mean 1. 03-1.35 vs. 1. 02-1.24, SMD 0.14; 95% CI: -0.33,0.62; p=0.55, I2=78%), and F/TT3 (SMD -0. 06; 95% CI: -0.28,0.15; p=0.57, I2=0%) between AB vs. BB were found. The subgroup analysis showed that no statistically significant difference of TSH between AB vs. BB when patient took liquid form of levothyroxine (1.45-2.59 vs. 1.26–3. 00; SMD=0. 03; 95% CI: -0.21, 0.27; p=0.81, I2=0%). Although TSH was significantly higher with AB vs. BB when patient took tablet form of levothyroxine (2.89-3.74 vs. 1.54 -1.9; SMD=0.64; 95% CI: 0.24, 0.103; p=0. 001, I2=49%), TSH was within normal limits in both groups. This meta-analysis demonstrates that TSH of patients taking levothyroxine with breakfast is non-inferior to those taking it before breakfast. Although AB group taking levothyroxine by tablet has a significantly higher TSH level than the BB group, both groups have well-controlled levels. Limitations of this study include limited sample size and number of studies. It also was unable to differentiate patients with hypothyroidism from benign or malignant diseases. We also were not able to assess adherence to the prescribed regimen. Patient satisfaction and adherence with treatment may be improved by letting patients know to take LT4 consistently at a time of their choice. Presentation: No date and time listed

Free the T3: Implementation of Best Practice Advisory to Reduce Unnecessary Orders

Thyroid function tests (TFTs) are commonly overused and amount to 1.6 billion dollars annually in health care spending in the United States.1,2 Although national guidelines recommend a thyroid-stimulating hormone (TSH)-centered approach, clinicians often inappropriately order triiodothyronine (T3) and thyroxine (T4).2 This may be due to lack of knowledge or ease of ordering all 3 tests at once in premature anticipation of an abnormal TSH.3 Additionally, clinicians order free T3 rather than total T3, despite the American Thyroid Association's recommendations to avoid free T3 due to its high rate of variability.

Posthemithyroidectomy Pregnancy Thyroid Function Surveillance: Frequency, Adherence, and Guideline Impact

ObjectivePosthemithyroidectomy women are at an increased risk for gestational subclinical hypothyroidism. Therefore, the American Thyroid Association (ATA) recommends increased thyroid function surveillance for this subgroup of pregnant women. The purpose of this study was to evaluate the frequency of thyroid function surveillance during pregnancy in posthemithyroidectomy women and to evaluate the adherence to the 2017 ATA guidelines and its possible impact since being published on thyroid function surveillance rates. MethodsA retrospective study of pregnant posthemithyroidectomy women operated at our institution between 1997 and 2020 was performed. The study cohort was subdivided by pregnancy dates before 2018 and 2018 onward to evaluate the impact of the 2017 ATA guidelines. Adherence to the guidelines was defined as at least 1 thyroid-stimulating hormone test in each trimester. ResultsAfter exclusions, a total of 120 pregnancies conceived by 66 women who underwent hemithyroidectomy surgeries were included in this study. Overall, serum thyroid-stimulating hormone examinations were performed during the first, second, and third pregnancy trimesters in 86.6%, 40%, and 16.6% of pregnancies, respectively (P <.005). The examination rate since 2018 was 88%, 40%, and 8% for the first, second, and third trimesters, respectively (P <.005). ConclusionAdherence to the latest ATA guidelines is low, and its publication in 2017 did not increase the thyroid function surveillance rate in posthemithyroidectomy women. Better patient education regarding the risks of gestational hypothyroidism following hemithyroidectomy and improved communications among treating surgeons, obstetricians, and endocrinologists may improve these rates.

Thyroid lobectomy for low-risk thyroid cancers.

The 2016 American Thyroid Association (ATA) guidelines proposed thyroid lobectomy for low-risk differentiated thyroid cancer (DTC); however, this approach is yet to be widely adopted. The aim of the study was to review our practice over three years following the publication of these guidelines identifying patients who underwent lobectomy-only for low-risk DTC in two regional units in the same multidisciplinary team (MDT). A retrospective review of patients who were operated between January 2016 and December 2018 was carried out. In total, 288 patients undergoing thyroid surgery were included. The preoperative distribution of cytology was: Thy 1 or 2 in 46, THY3a in 57, THY3f in 154, THY4 in 18 and THY5 in 13 patients. Median size of nodules was 26mm (range 1-70mm). DTC was diagnosed in 95 patients (33%). Overall, 39% (n = 37) of patients underwent completion thyroidectomy according to ATA recommendations on size or adverse histological features. The only variable associated with likelihood of completion was tumour size (p < 0.05, OR 1.14). Ten patients were discharged following surgery with no further follow-up as they had T1a/b well-differentiated DTC with no high-risk histological features. Lobectomy-only appears to be the current surgical practice in two-thirds of patients presenting to our regional units with differentiated thyroid carcinoma. In the context of the current drive to reduce the extent of treatment for low-risk thyroid cancer, there is a need for a more homogeneous approach to these patients and for protocols for long-term follow-up after lobectomy-only.

Thyroid lobectomy for low-risk thyroid cancers.

The 2016 American Thyroid Association (ATA) guidelines proposed thyroid lobectomy for low-risk differentiated thyroid cancer (DTC); however, this approach is yet to be widely adopted. The aim of the study was to review our practice over three years following the publication of these guidelines identifying patients who underwent lobectomy-only for low-risk DTC in two regional units in the same multidisciplinary team (MDT). A retrospective review of patients who were operated between January 2016 and December 2018 was carried out. In total, 288 patients undergoing thyroid surgery were included. The preoperative distribution of cytology was: Thy 1 or 2 in 46, THY3a in 57, THY3f in 154, THY4 in 18 and THY5 in 13 patients. Median size of nodules was 26mm (range 1-70mm). DTC was diagnosed in 95 patients (33%). Overall, 39% (n = 37) of patients underwent completion thyroidectomy according to ATA recommendations on size or adverse histological features. The only variable associated with likelihood of completion was tumour size (p < 0.05, OR 1.14). Ten patients were discharged following surgery with no further follow-up as they had T1a/b well-differentiated DTC with no high-risk histological features. Lobectomy-only appears to be the current surgical practice in two-thirds of patients presenting to our regional units with differentiated thyroid carcinoma. In the context of the current drive to reduce the extent of treatment for low-risk thyroid cancer, there is a need for a more homogeneous approach to these patients and for protocols for long-term follow-up after lobectomy-only.

Performance of repeat cytology with reflex ThyroSeq genomic classifier for indeterminant thyroid cytology.

The American Thyroid Association recommends either repeat fine-needle aspiration biopsy (FNAB) or molecular testing (eg, ThyroSeq) of Bethesda category III (atypia of undetermined significance/follicular lesion of undetermined significance [AUS/FLUS]) nodules to provide further risk stratification. How a testing algorithm that uses ancillary molecular tests performs as a reflex test for repeat sampling of indeterminant nodules remains unclear. Thyroid FNABs performed over a 24-month period that received a diagnosis of AUS/FLUS and underwent subsequent FNAB were analyzed. In total, 187 patients were identified who received an FNAB diagnosis of AUS/FLUS and had repeat sampling. Of these patients, 64% received a subsequent indeterminant diagnosis on repeat biopsy: 7 (3.7%) repeat biopsies were diagnosed as nondiagnostic/unsatisfactory, 104 (55.6%) were diagnosed as AUS/FLUS, and 8 (4.3%) were diagnosed as follicular neoplasm/suspicious for follicular neoplasm. Of the repeat biopsied nodules, 63% underwent subsequent testing with ThyroSeq version 3. The diagnostic performance was calculated using only surgically confirmed nodules (sensitivity, 100%; specificity, 30%; positive predictive value, 41%; negative predictive value, 100%) and by assigning nonresected nodules with negative ThyroSeq or benign cytology results as benign (sensitivity, 100%; specificity, 88%; positive predictive value, 41%; negative predictive value, 100%). In the majority of patients, repeat FNAB for AUS/FLUS did not preclude subsequent molecular ancillary testing because of the high rate of indeterminant results on repeat biopsy. The diagnostic performance of the testing algorithm reported here was very similar to other reports using either repeat biopsy or molecular testing alone. Ultimately, the algorithm of performing molecular testing on repeat indeterminant nodules increased the number of biopsies performed and lengthened the time to definitive risk stratification without a disproportionate decrease in the use of molecular testing or an appreciable improvement in diagnostic performance.

Outcomes in Pregnant Patients with Subclinical Hypothyroidism and Thyroid Autoimmunity: A Critical Appraisal of Recent Randomized Controlled Trials

The management of subclinical hypothyroidism (SCH) and thyroid autoimmunity (TAI) in pregnancy is still uncertain. Over the years, several scientific societies published guidelines on the management of thyroid dysfunction before, during, and after pregnancy, the most recent ones being published by the American Thyroid Association (ATA) in 2017. This study aimed to review the published literature in the field from 2017 onward to investigate whether new findings can change ATA recommendations. A literature search was conducted in PubMed between March 2017 (date of the publication of the ATA guidelines) and March 2020. The research was restricted to randomized controlled trials (RCTs), having pregnancy-related complications in patients with SCH and TAI as the main focus. A total of 5 RCTs were retrieved, 2 of which investigated pregnant women with SCH and 3 with TAI. Selected studies displayed proofs against treating maternal SCH and hypothyroxinemia because no benefit from LT4 was demonstrated in offspring intelligence quotient and in pregnancy outcomes; moreover, they reported proofs against treating TAI patients because no benefit from LT4 was demonstrated in improving pregnancy rate or live birth rate or reducing miscarriage rate.RCTs published from 2017 to 2020 might have a significant impact on current ATA guidelines. In particular, they suggested that isolated hypothyroxinemia and SCH should not be treated and that considering treatment in antibodypositive women, especially those with TSH of 2.5-4.0 mIU/L, would not be justified; they suggested that infertility and miscarriage rates are not decreased by LT4 treatment in euthyroid antibody-positive women seeking pregnancy.

Діагностика й лікування тиреотоксикозу під час вагітності й у післяпологовому періоді. Фрагмент матеріалів Клінічних рекомендацій Американської тиреоїдної асоціації щодо діагностики й лікування захворювань щитоподібної залози під час вагітності й у післяп

У 2017 році були опубліковані настанови Американської тиреоїдної асоціації (АТА) щодо діагностики й лікування захворювань щитоподібної залози під час вагітності й у післяпологовому періоді [1]. Це перший перегляд аналогічних рекомендацій АТА, які вперше були опубліковані в 2011 році. У зв’язку зі швидким збільшенням кількості друкованих праць на цю тему на початку проекту були заплановані перегляди рекомендацій кожні 4–5 років. Президентом АТА за згодою правління було створено робочі групи за участю компетентних фахівців у галузі дорослої й дитячої ендокринології, акушерства, перинатології (материнської й фетальної медицини), ендокринної хірургії, йодного споживання й епідеміології. Задля широкої спеціалізації й географічного представництва, а також забезпечення свіжих поглядів близько третини робочої групи замінювалось для кожної версії/етапу настанов згідно з політикою АТА.

Papillary thyroid carcinoma micro-deposits in cervical lymph nodes without intra-thyroid malignancy: A comment in consideration of the latest American Thyroid Association guidelines.

Differentiated thyroid cancer (DTC) represents the vast majority of all thyroid cancers, with the papillary variant being the most common. According to the previous 2009 American Thyroid Association (ATA) guidelines, papillary thyroid microcarcinoma (PTMC; ≤1 cm in diameter) exhibiting cervical lymph node metastasis corresponded to an intermediate-risk group for recurrence or metastasis. However, the latest 2015 ATA guidelines advocate that a patient with PTMC is low-risk if there are ≤5 regional node micrometastases. This means that therapeutic radioactive iodine (RAI) is not required. The current study reports a rare case of a patient who underwent total thyroidectomy due to multi-nodular goiter where the pathologic specimen exhibited two PTMC foci in regional lymph nodes, but no primary cancer was identified in the thyroid despite thorough examination of the thyroid parenchyma. The etiology of such results is unknown and it was hypothesized that it may be the consequence of insufficient pathologic examination or due to the regression of a primary PTMC in the thyroid. Moreover, the risk-stratification of cases with intra-lymph node PTMC without any evidence of primary cancer in the thyroid is not considered in the ATA recommendations. The aim of the current report was to elucidate the risk-stratification of this rare occurrence and to reconsider the possible etiologies. By extrapolating the latest ATA recommendations concerning a patient with a known primary PTMC and ≤5 metastatic micro-foci (thus the only difference between cases being the absence of a primary tumor), it was concluded that the patient should be considered low-risk. As a consequence, RAI therapy should be deemed as unnecessary despite the presence of lymph node microfoci. Moreover, it was proposed that cervical lymph node PTMC with no evidence of a primary tumor in the thyroid could be the consequence of normal thyroid tissue micro-deposit progression to cancer within the lymph node, which is a rare benign entity.

A practical individualized radiation precaution based on the dose rate at release time after inpatient 131I ablation therapy.

IntroductionRetained radioactivity of 131I after ablation therapy largely differs in each patient according to factors including the amount of remnant thyroid tissue, renal function, and use of recombinant human thyroid-stimulating hormone. To reduce unnecessary restriction of patient’s daily life after inpatient 131I ablation therapy, we propose a practical individualized method for radiation precaution based on dose rate at release time.MethodsWe evaluated 215 patients with differentiated thyroid cancer who underwent inpatient 131I ablation therapy following total thyroidectomy. Effective dose equivalent rates at 1-m distance were measured upon release (EDRR) on day 2 and during delayed whole-body scan (EDRD) visits on day 6‒8 after 131I administration. The biexponential model was designed to estimate total effective dose equivalent to others. To assess conservativeness of our model, EDRD estimated by our model was compared with measured EDRD. EDRR-based periods of precaution not to receiving 1 mSv of radiation exposure were estimated and compared with those based on administered radioactivities on American Thyroid Association (ATA) recommendations.ResultsThe EDRR ranged from 1.0–48.9 μSv/hr. The measured EDRD were equal to or lower than estimated EDRD in all patients, except for one, indicating that our model is sufficiently conservative. According to our model, no subjects needed additional daytime restriction after release. The maximum permissible times for public transportation use were longer in all patients compared with those based on administered radioactivities. Nighttime restriction periods were significantly shorter than those based on administered radioactivity; median periods requiring sleeping apart were 0 (range, 0‒5), 4 (range, 1‒14), and 3 (range, 2‒13) days after release in patients treated with radioactivity doses of 2.96, 5.50, and 7.40 GBq, respectively, needing 8, 16, and 19 additional days, respectively, based on administered radioactivity.ConclusionsRadiation safety instructions using proposed method based on EDRR of individual patient could safely reduce the burden of radiation precaution.

Assessing potential impact of 2015 American Thyroid Association guidelines on community standard practice for I-131 treatment of low-risk differentiated thyroid cancer: case study of Jordan

The 2015 American Thyroid Association (ATA) guidelines called for significantly more selective 131I therapy in patients with low-risk differentiated thyroid cancer (DTC). We hypothesized that application of these guidelines would significantly reduce the 131I activity utilized by an academic tertiary hospital in Jordan. All DTC patients managed at Jordan University Hospital (JUH) between 1/2009 and 6/2019 were classified according to the 2015 ATA risk category and 131I activity was assigned accordingly. The actual 131I activity administered was compared with that recommended by the 2015 ATA guidelines. In total, 135/182 DTC patients (74.2%) managed at JUH underwent 131I therapy. Of those, 58 (43%) had ATA low-, 58 (43%) intermediate-, and 19 (14%) high-risk disease. The low-, intermediate-, and high-risk DTC patients received an average (±SD) initial 131I activity of 3.53 ± 0.95, 4.40 ± 1.49, and 5.06 ± 2.52 GBq, respectively. Withholding 131I therapy altogether in the 2015 ATA low-risk patients would result in decreasing the 131I activity in the overall patient population by 37%. Withholding 131I therapy only in low-risk papillary thyroid microcarcinomas while administering 1.11 GBq of 131I to other low-risk patients would result in 28% reduction of 131I. This study demonstrates a significant reduction in 131I therapeutic activity that would be given to DTC patients in an academic tertiary setting in Jordan, following acceptance of the 2015 ATA recommendations. Institutions that adopted the 2015 ATA guidance should measure outcomes in comparison to their historical controls and report those findings, while long-term results of randomized controlled trials are forthcoming.