European Thyroid Association Guidelines Research Articles

Approach to management of hypo and hyperthyroidism in Bangladesh: a nationwide physicians' perspective survey.

Thyroid disorders are common clinical conditions globally. The objective of the present study was to evaluate the physicians' approach to the diagnosis and treatment of thyroid disorders in Bangladesh. The present nationally representative cross-sectional study was conducted among 662 physicians of different levels (general practitioners as well as specialists) from different hospitals in Bangladesh from January to June 2023. A self-administered semi-structured questionnaire including information about demographics and practice patterns for the diagnosis and management of thyroid disorders was used for data collection. Descriptive statistics were used to analyze the data. The American Thyroid Association (ATA) guidelines were the most commonly followed guidelines for the diagnosis and management of thyroid disorders (60%), followed by the American Association of Clinical Endocrinologists (AACE) guidelines (18%) and the European Thyroid Association (ETA) guidelines (9%). Serum TSH, free T3 and free T4 levels were the most frequently used diagnostic tests for the evaluation and follow-ups of both hypothyroid and hyperthyroid states in adults, pregnant women and children, followed by total T3 and total T4 levels. Other tests, such as anti-TPO antibody, anti-TG antibody, anti-TPO, ultrasound scan of the thyroid gland, etc., were rarely used by the participating physicians. Levothyroxine at a dose of 25 to 50 mcg and carbimazole at a dose of 30 to 45 mg were the most frequently used drugs for hypothyroid and hyperthyroid patients, respectively. Almost 65% of the physicians suggested routine thyroid function tests before surgery. In addition, more than 90% of the physicians agreed that thyroid screening for pregnancy, neonates, school children and adults would be mandatory. The majority of the physicians participating in our study followed relevant guidelines for the diagnosis and management of thyroid disorders in Bangladesh. However, there are still some gaps to be improved, as a good number of physicians did not follow specific guidelines for these disorders.

2022 European Thyroid Association Guidelines for the management of pediatric thyroid nodules and differentiated thyroid carcinoma

2022 European Thyroid Association Guidelines for the management of pediatric thyroid nodules and differentiated thyroid carcinoma

Effects of levothyroxine substitution therapy on hunger and food intake in individuals with hypothyroidism.

In individuals with hypothyroidism and overweight, levothyroxine substitution therapy is often expected to cause weight loss due to its effect on resting energy expenditure. However, despite levothyroxine-induced enhancement of resting energy expenditure, fat mass loss is rarely seen after levothyroxine substitution therapy. The mechanism behind this conundrum is unknown. The aim of the study was to assess the effect of levothyroxine therapy on hunger sensations and ad libitum food intake in individuals with hypothyroidism. Prospective cohort study of 18 newly diagnosed hypothyroid women (thyroid-stimulating hormone (TSH) >10 mU/L). Participants were investigated at diagnosis, after normalization of TSH (<4.0 mU/L), and after 6 months of successful treatment. Eighteen age and body mass index-matched healthy controls were also included. Hypothyroid individuals were treated with levothyroxine according to European Thyroid Association guidelines. Changes in hunger sensation were assessed using visual analog scales (cm) before and during a standardized mixed meal test, and food intake was measured during a subsequent ad libitum meal (g). After 6 months of levothyroxine therapy, mean resting energy expenditure was increased by 144 kcal/day (10%) (P < 0.001). Weight loss was comprised of 0.8 kg fat-free mass while fat mass remained unchanged. Fasting hunger sensation increased from a mean of 4.5 (s.d. 2.2) cm to 5.5 (s.d. 2.2) cm (P = 0.047). The numerical increase in ad libitum meal intake did not reach statistical significance. Our data suggest that levothyroxine-induced hunger may be a culprit in the lack of fat mass loss from levothyroxine therapy.

Improvement in neck ultrasound report quality following the implementation of European Thyroid Association guidelines for postoperative cervical ultrasound for thyroid cancer follow-up, a prospective population study.

The aim of this study was to prospectively evaluate the quality of postoperative neck ultrasound (POU) for thyroid cancer patients after implementing European Thyroid Association (ETA) guideline-based POU assessment. Our analysis involved 672 differentiated thyroid cancer patients. POU report quality was compared between the implementation radiology group (IRG), which implemented ETA guideline-based assessment in 2018, and all non-implementation radiology groups (NIRG). Differences in POU quality were evaluated before and after the implementation of guideline-based assessment. Additionally, we evaluated the ability of serum thyroglobulin (Tg) level <0.2 ng/mL or between 0.21 and 0.99 ng/mL and normal POU lesion status at 1-year follow-up to predict the absence of persistent disease or relapse at 3-year follow-up. IRG had significantly higher mean utility scores for POU reports of abnormal thyroid bed nodules compared to NIRG (P < 0.001). IRG's POU reports for suspicious nodules and lymph nodes were considered sufficient in 94% and 85% of cases, respectively, compared to 45% and 68% for NIRG. For patients with normal US lesion status and Tg <0.2 ng/mL or Tg 0.21-0.99 ng/mL at 1-year follow-up, the negative predictive values were 96% for both. Implementation of 2013 ETA POU-reporting guidelines allowed for the provision of high-quality POU reports, which may lead to increased accuracy in assessing the response to treatment and in estimating the risk of recurrence of thyroid cancer and likely reduce unnecessary repeat POU or FNA.

Part II: Interactive case: Drug‐induced endocrine disorders

Part <scp>II</scp>: Interactive case: <scp>Drug‐induced</scp> endocrine disorders

Critical Approach to Hypothyroid Patients With Persistent Symptoms.

Hypothyroidism is a common condition, and numerous studies have been published over the last decade to assess the potential risks associated with this disorder when inappropriately treated. The standard of care for treatment of hypothyroidism remains levothyroxine (LT4) at doses to achieve biochemical and clinical euthyroidism. However, about 15% of hypothyroid patients experience residual hypothyroid symptoms. Some population-based studies and international population-based surveys have confirmed dissatisfaction with LT4 treatment in some hypothyroid patients. It is well established that hypothyroid patients treated with LT4 exhibit higher serum thyroxine:triiodothyronine ratios and can have a persistent increase in cardiovascular risk factors. Moreover, variants in deiodinases and thyroid hormone transporter genes have been associated with subnormal T3 concentrations, persistent symptoms in LT4-treated patients, and improvement in response to the addition of liothyronine to LT4 therapy. The American (ATA) and European Thyroid Association (ETA) guidelines have recently evolved in their recognition of the potential limitations of LT4. This shift is reflected in prescribing patterns: Physicians' use of combination therapy is prevalent and possibly increasing. Randomized clinical trials have recently been published and, while they have found no improvement in treating hypothyroid patients, a number of important limitations did not allow generalizability. Meta-analyses have reported a preference rate for combination therapy in 46.2% hypothyroid patients treated with LT4. To promote discussions about an optimal study design, the ATA, ETA, and British Thyroid Association have recently published a consensus document. Our study provides a useful counterpoint on the controversial benefits of treating hypothyroid patients with combination therapy.

Comments to the Section on Radioiodine Therapy for Differentiated Thyroid Cancer in Children of the European Thyroid Association Guidelines 2022

Children are not “miniature” adults! Most experts around the world recognize the differences between adult and pediatric thyroid cancer and emphasize the need for specific guidelines for the pediatric population. The American Thyroid Association (ATA) first developed separate Guidelines for the Treatment of Pediatric Thyroid Nodules and Carcinoma (hereafter, ATA Guidelines) in 2015 [1], which has not been revised to date. In September 2022, the European Thyroid Association (ETA) published its Guideline on the Management of Pediatric Thyroid Nodules and Differentiated Thyroid Carcinoma (hereafter, ETA Guidelines) [2]. The aim of our article, in anticipation of the revision of Russian clinical guidelines for the treatment of pediatric thyroid cancer, is to inform specialists in the field of radioiodine therapy (RIT) with the key recommendations of the ETA.

The Impact of Subclinical Hypothyroidism on the Quality of Life During Pregnancy: Mapping 5-Level Version of EQ-5D and ThyPRO-39

ObjectivesTo describe how subclinical hypothyroidism (SubHypo) influences the quality of life (QoL) during pregnancy. MethodsIn primary data collection (NCT04167423), thyroid stimulating hormone (TSH), free thyroxine (FT4), thyroid peroxidase antibodies, generic quality of life (QoL; 5-level version of EQ-5D [EQ-5D-5L]), and disease-specific QoL (ThyPRO-39) were measured among pregnant women. SubHypo during each trimester was defined according to the 2014 European Thyroid Association guidelines (TSH > 2.5, 3.0, and 3.5 IU/L, respectively; with normal FT4). Path analysis described relationships and tested mediation. Linear ordinary least squares, beta, tobit, and two-part regressions were used to map ThyPRO-39 and EQ-5D-5L. Alternative SubHypo definition was tested in sensitivity analysis. ResultsA total of 253 women at 14 sites (31 ± 5 years old, 15 ± 6 weeks pregnant) completed the questionnaires. Sixty-one (26%) had SubHypo and differed from 174 (74%) euthyroid women in smoking history (61% vs 41%), primiparity (62% vs 43%) and TSH level (4.1 ± 1.4 vs 1.5 ± 0.7 mIU/L, P < .001). EQ-5D-5L utility in SubHypo (0.89 ± 0.12) was lower than that in euthyroid (0.92 ± 0.11; P = .028) even after adjustment (difference −0.04, P = .033), whereas ocular (P = .001, ThyPRO-39), cognitive symptoms (P = .043), anxiety (P < .0001), and the composite score were higher. The impact of SubHypo on utility was mediated by anxiety. Results were confirmed by sensitivity analysis. Final mapping equation (ordinary least squares) includes goiter symptoms, anxiety, upset stomach, composite score (ThyPRO-39), FT4 levels, and week of pregnancy (determination coefficient 0.36). ConclusionThis is the first QoL mapping of SubHypo during pregnancy and the first evidence that SubHypo is associated with a negative impact on QoL. The effect is mediated by anxiety. EQ-5D-5L utilities can be generated based on ThyPRO-39 scores collected in pregnant euthyroid and patients with SubHypo.

Pediatric thyroid cancer guidelines: challenges in stratifying care based on limited data.

The European Thyroid Association (ETA) Guidelines for the management of pediatric thyroid nodules and thyroid carcinoma were developed by a task force comprising well-respected, expert clinicians with good representation of the European community, including several previously involved in authorship of country-specific guidelines from Poland, the United Kingdom, the Netherlands, and the United States. Van Santen and the guidelines committee are to be commended for their thoughtful and stringent review of the literature in an effort to optimize the care of pediatric patients diagnosed with thyroid nodules and thyroid cancer.

The 2022 European Thyroid Association guideline for the management of pediatric Graves’ disease

The 2022 European Thyroid Association guideline for the management of pediatric Graves’ disease

European thyroid association guideline on the management of pediatric thyroid nodules and thyroid carcinoma

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Review of the Korean Society of Interventional Radiology and European Thyroid Association Guidelines Regarding the Role of Radiofrequency Ablation for Benign and Malignant Thyroid Tumors

While radiofrequency ablation (RFA) for the treatment of symptomatic thyroid nodules has been gaining more widespread adoption in the United States, there is limited societal guidance for its role, and safe adoption. As many of the first adopters of thyroid nodule RFA developed their practices, they looked to the Korean Society of Interventional Radiology (KSIR), and European Thyroid Association (ETA) guidelines as a framework. Currently, efforts are underway from the American Thyroid Association to create updated guidelines for US providers. International consensus guidelines are also underway. Until these guidelines are available, a thorough understanding of the current available guidelines is key for interventionalists building a thyroid nodule RFA program.

Sonographic Diagnosis of Cervical Lymph Node Metastasis in Patients with Thyroid Cancer and Comparison of European and Korean Guidelines for Stratifying the Risk of Malignant Lymph Node.

To evaluate the ultrasonography (US) features for diagnosing metastasis in cervical lymph nodes (LNs) in patients with thyroid cancer and compare the US classification of risk of LN metastasis between European and Korean guidelines. From January 2014 to December 2018, US-guided fine-needle aspiration was performed on 836 LNs from 714 patients for the preoperative nodal staging of thyroid cancer. The US features of LNs were retrospectively reviewed for the following features: size, presence of hilum, margin, orientation, cystic change, punctate echogenic foci (PEF), large echogenic foci, eccentric cortical thickening, abnormal vascularity, and cortical hyperechogenicity. A multiple logistic regression analysis was performed to identify the independent US features for the diagnosis of metastatic LNs. The diagnostic performance of independent US features was subsequently evaluated. LNs were categorized according to the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and European Thyroid Association (ETA) guidelines, and the correlation between the two sets of classifications was assessed. Absence of the hilum, presence of cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features of metastatic LNs. Cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity showed high specificity (86.8%-99.6%). The absence of the hilum had the highest sensitivity yet low specificity (66.4%). When LNs were classified according to the ETA guidelines and K-TIRADS, they yielded similar categorizations of malignancy risks and were strongly correlated (Spearman coefficient, 0.9766 [95% confidence interval, 0.973-0.979]). According to the ETA guidelines, 9.8% (82/836) of LNs were classified as "not specified." Absence of hilum, cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features suggestive of metastatic LNs in thyroid cancer. Both K-TIRADS and the ETA guidelines provided similar risk stratification for metastatic LNs with a high correlation; however, the ETA guidelines failed to classify 9.8% of LNs into a specific risk stratum. These results may provide a basis for revising LN classification in future guidelines.

2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Part 1

2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Part 1

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.

Субклінічний гіпертиреоз: діагностичні критерії і принципи лікування. Огляд вибраних глав керівництва Європейської тиреоїдної асоціації 2015 року «Diagnosis and treatment of endogenous subclinical hyperthyroidism»

Подано вибрані глави керівництва Європейської тиреоїдної асоціації 2015 року з діагностики і лікування ендогенного субклінічного гіпертиреозу. Оригінальний текст керівництва знаходиться у відкритому доступі на сайті https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4637513/

What Is the Role of Radiofrequency Ablation for Benign Thyroid Nodules?

What Is the Role of Radiofrequency Ablation for Benign Thyroid Nodules?

Outcomes of active surveillance of EU-TIRADS 5 thyroid nodules.

Active surveillance of cytologically proven microcarcinomas has been shown as a safe procedure. However, fine needle aspiration biopsy (FNAB) is not recommended by European Thyroid Association (ETA) and American Thyroid Association (ATA) guidelines for highly suspicious nodules ≤ 10 mm. The aim of the study was to assess the outcomes of active surveillance of EU-TIRADS 5 nodules ≤ 10 mm not initially submitted to FNAB. 80 patients with at least one EU-TIRADS 5 nodule ≤ 10 mm and no suspicious lymph nodes, accepting active surveillance, were included. Mean baseline diameter and volume were 5.4 mm (±2.0) and 64.4 mm3 (±33.5), respectively. After a median follow-up of 36.1 months, a volumetric increase ≥ 50% occurred in 28 patients (35.0%) and a suspicious lymph node in 3 patients (3.8%). Twenty-four patients underwent an FNAB (30.0%) after at least a 1 year follow-up of which 45.8% were malignant, 8.3% benign, 33.3% undetermined and 8.3% nondiagnostic. Sixteen patients (20.0%) underwent conversion surgery after a median follow-up of 57.2 months, confirming the diagnosis of papillary carcinoma in 15/16 cases (not described in 1 histology report), all in remission at 6-12 months postoperative follow-up. Applying ETA and ATA guidelines to avoid FNA of EU-TIRADS 5 sub-centimeter nodules and proceeding to active surveillance of such nodules in selected patients is a safe procedure. Thus, US-FNAB could be postponed until the nodule shows signs of progression or a suspicious lymph node appears, with no added risk for the patient.

Review of European Thyroid Association Guideline (2018) for the Manage-ment of Graves’ Hyperthyroidism

Graves’ disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T-cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves’ hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves’ hyperthyroidism are usually medically treated for 12–18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12–18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves’ patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves’ patients with mild/active orbitopathy receiving RAI.

Ultrasound Surveillance of Abnormal Cervical Lymph Nodes in Patients With Papillary Thyroid Carcinoma After Surgery.

To document the changing trends of abnormal cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC) who had serial follow-up ultrasound (US) scans after surgery and to determine how these node abnormalities progress in real time. Ultrasound findings from 568 consecutive patients with PTC who were monitored postoperatively were reviewed. Abnormal LNs were classified as either suspicious or indeterminate according to the European Thyroid Association guidelines. Outcomes from US monitoring of the LNs were recorded and analyzed. Seventy-six (13.4%) of 568 patients were identified with abnormal LNs. Among them, 55 (72.4%) were initially found to have suspicious LNs, and the other 21 (27.6%) had indeterminate lesions. Of the 55 suspicious LNs, final scans showed that 38 (69.1%) lesions were still suspicious, whereas the remaining 17 (30.9%) nodes were shown to have resolved after a median follow-up of 36 months. Of the 21 indeterminate node abnormalities, final scans showed that 16 (76.2%) LNs remained indeterminate, whereas the other 5 (23.8%) nodes had developed into suspicious LNs after a median follow-up of 44 months. Loss of the fatty hilum and peripheral or diffusedly increased vascularity were more likely to be linked to persistent suspicious LNs (P = .02 and .04, respectively). Suspicious LNs with echogenic foci but a lack of other abnormal features were more frequently found to have resolved thereafter (P = .03). Abnormal LNs detected after PTC surgery can often remain indolent during US surveillance, and a small portion of the nodes would have resolved over time.