New guidelines for the management of thyroid nodules and differentiated thyroid cancer

Z Milas, J Shin, M Milas
Minerva Endocrinologica 2011, 36 (1): 53-70
The last 5 years witnessed publication of several multidisciplinary guidelines that address management of benign and malignant thyroid diseases. The primary goal of this review was to excerpt highlights from the most recent 2009 guidelines of the American Thyroid Association that provided recommendations for treating thyroid nodules and differentiated thyroid cancer. There is a systematic algorithm for the evaluation of thyroid nodules based on clinical history, physical examination, measurement of thyroid stimulating hormone (TSH), and neck ultrasound, which has become the preferred radiologic modality for imaging thyroid disease. Radionuclide thyroid scanning is reserved for the evaluation of patients with suppressed TSH levels. Ultrasound-guided fine needle aspiration biopsy (FNAB) is indicated for cytologic assessment of most thyroid nodules >1 cm; additional criteria are specified for FNAB of nodules <1 cm. There is an expanded classification system for reporting thyroid cytologic finding, based on risk of malignancy. Treatment guidelines for thyroid cancer have rapidly evolved. Total thyroidectomy is advocated for initial surgical treatment of differentiated thyroid cancers >1 cm in size. Concurrent therapeutic central and lateral neck dissections remain essential to treat known cervical metastases, but prophylactic central neck dissection is controversial and should be cautiously chosen based on individual patient risk factors. Updates have been made for the use of radioactive iodine ablation and long-term surveillance for thyroid cancer recurrence, where ultrasound imaging is also important. A risk stratification paradigm is proposed to define the chance of recurrence and death from thyroid cancer, and modify treatment plans at various stages of management to the level of risk. Recommendations addressing both benign and malignant thyroid disease topics were graded according to the strength of available and published clinical evidence. Awareness of multidisciplinary recommendations for the treatment of benign and malignant thyroid diseases can enhance the practice of evidence-based medicine and provide practical tools for decision-making relevant to daily clinical encounters.

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