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New guidelines for the management of patients with thyroid nodules and well-differentiated thyroid cancer: Part 2
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An update to the American Thyroid Association guidelines for the management of patients with thyroid nodules and well-differentiated thyroid cancer was recently released.
In patients with confirmed or suspected thyroid cancer, preoperative ultrasound is advised to assist with staging and in determining which patients may benefit from more extensive lymph node dissection at the time of initial thyroidectomy. However, one problem with ultrasound is that it is operator dependent. Other preoperative imaging studies such as MRI, CT and/or PET are not routinely recommended.
Near total or total thyroidectomy is recommended if the thyroid cancer is >1 cm or there are additional high-risk factors. Central lymph node neck dissection should be performed at time of initial thyroidectomy in patients with central and/or lateral lymph node involvement. Therapeutic lateral neck lymph node dissection should be performed in those with biopsy proven metastatic disease.
In low-risk patients with papillary cancer <1 cm, unilateral thyroid lobectomy may be an option. However, thyroid lobectomy prevents the use of radioactive iodine ablative therapy, also known as I-131, and serum thyroglobulin monitoring to detect recurrence. That should not be an issue in a low-risk disease but must be discussed with the patient in detail.
Over the years, there has been a trend towards less use and lower doses of postoperative I-131 ablative therapy. This is reflected in the guidelines which discuss the merits and risks associated with I-131 ablation and provide an algorithm to assist clinicians. The task force advises the use of staging systems to assist in predicting prognosis and determining long term monitoring. Recombinant human thyroid-stimulating hormone may be used to prepare for I-131 ablation instead of thyroid hormone withdrawal, especially in those patients intolerant of hypothyroidism and/or who are unable to achieve a sufficiently elevated TSH >30 mU/L.
The recommendations also provide an algorithm for management of differentiated thyroid cancer 6 to 12 months after I-131 remnant ablation. The guidelines for thyroid hormone suppressive therapy are similar to those advised previously. In addition to stimulated and non-stimulated thyroglobulin, an increased role is suggested for cervical ultrasound in the surveillance of patients with history of thyroid cancer. 18FDG-PET imaging may be considered in those patients who are thyroglobulin positive and negative on I-131 imaging, and/or those with more aggressive or invasive poorly differentiated cancers.
The updated recommendations cover many issues beyond those I can cover here in detail. I strongly encourage colleagues involved in the management of patients with thyroid nodules and cancer to read these guidelines for themselves.
There is one final point I would like to make. Every guideline should serve as only a "guide" to assist clinicians in their decision making process. There will be times when it may be appropriate for a clinician to not follow recommendations exactly. However, whenever I deviate from expert guidelines, I always explain why to the patient and make my rationale for doing so clear in my notes. Guidelines should never be considered a substitute for good clinical judgment and individualized care.