2015 ATA Management Guidelines for Adult Patients With Thyroid Nodules and Differentiated Thyroid Cancer

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    Thyroid   ©2015 American Thyroid Association DOI: 10.1089/thy.2015.0020

    2015 American Thyroid Association Management Guidelines for Adult Patients

    with Thyroid Nodules and Differentiated Thyroid Cancer

    The American Thyroid Association (ATA) Guidelines Taskforce

    on Thyroid Nodules and Differentiated Thyroid Cancer Bryan R. Haugen, M.D.1 (Chair)*,

    Erik K. Alexander, M.D. 2 , Keith C. Bible, M.D., Ph.D.

    3 , Gerard M. Doherty, M.D.

    4 , Susan J. Mandel,

    M.D., M.P.H.5, Yuri E. Nikiforov, M.D., Ph.D.6,

    Furio Pacini, M.D.7, Gregory W. Randolph, M.D.8, Anna M. Sawka, M.D., Ph.D.9,

    Martin Schlumberger, M.D.10, Kathryn Schuff, M.D.11, Steven I. Sherman, M.D.12,

    Julie Ann Sosa, M.D.13, David L. Steward, M.D.14, R. Michael Tuttle, M.D.15,

    and Leonard Wartofsky, M.D.16 

    *Authors are listed in alphabetical order and were appointed by ATA to independently formulate the

    content of this manuscript. None of the scientific or medical content of the manuscript was dictated by the ATA.

    1 University of Colorado School of Medicine, Aurora, Colorado.

    2 Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusettes.

    3The Mayo Clinic, Rochester, Minnesota.

    4Boston Medical Center, Boston, Massachusettes.

    5 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

    6

    University of Pittsburgh Medical Center, Pittsburgh, Pennsylvannia. 7 The University of Siena, Siena, Italy.

    8Massachusettes Eye and Ear Infirmary, Massachusettes General Hospital, Harvard Medical

    School, Boston, Massachusettes.

    9University Health Network, University of Toronto , Toronto, Canada.

    10Institute Gustave Roussy and University Paris Sud, Villejuif, France.

    11Oregon Health and Science University, Portland, Oregon.

    12University of Texas M.D. Anderson Cancer Center, Houston, Texas.

    13

    Duke University School of Medicine, Durham, North Carolina. 14University of Cincinnati Medical Center, Cincinnati, Ohio.

    15Memorial Sloan-Kettering Cancer Center, New York, New York.

    16 MedStar Washington Hospital Center, Washington, DC.

    Running title: ATA Thyroid Nodule/DTC Guidelines

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    ABSTRACT

    Background:  Thyroid nodules are a common clinical problem, and differentiated thyroid

    cancer is becoming increasingly prevalent. Since the American Thyroid Association’s guidelines

    for the management of these disorders were revised in 2009, significant scientific advances have

    occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers,

    and health policy makers on published evidence relating to the diagnosis and management of

    thyroid nodules and differentiated thyroid cancer.

    Methods:  The specific clinical questions addressed in these guidelines were based on

     prior versions of the guidelines, stakeholder input, and input of task force members. Task force

     panel members were educated on knowledge synthesis methods, including: electronic database

    searching, review and selection of relevant citations, and critical appraisal of selected studies.

    Published English language articles on adults were eligible for inclusion. The American College

    of Physicians (ACP) Guideline Grading System was used for critical appraisal of evidence and

    grading strength of recommendations for therapeutic interventions. We developed a similarly

    formatted system to appraise the quality of such studies and resultant recommendations. The

    guideline panel had complete editorial independence from the ATA. Competing interests of

    guideline task force members were regularly updated, managed and communicated to the ATA

    and task force members.

    Results:  The revised guidelines for the management of thyroid nodules include

    recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle

    aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular

    markers and management of benign thyroid nodules. Recommendations regarding the initial

    management of thyroid cancer include those relating to screening for thyroid cancer, staging and

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     o  r r  e c  t i  o  n  .  T  h  e  f i  n  a  l  p  u  b  l i  s h  e  d  v  e  r s  i o n

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    risk assessment, surgical management, radioiodine remnant ablation and therapy, and TSH

    suppression therapy using levothyroxine. Recommendations related to long-term management of

    differentiated thyroid cancer include those related to surveillance for recurrent disease using

    imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and

    metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for

    future research.

    Conclusions:  We have developed evidence-based recommendations to inform clinical

    decision-making in the management of thyroid nodules and differentiated thyroid cancer. They

    represent, in our opinion, contemporary optimal care for patients with these disorders.

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     o  r r  e c  t i  o  n  .  T  h  e  f i  n  a  l  p  u  b  l i  s h  e  d  v  e  r s  i o n

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    INTRODUCTION

    THYROID NODULES are a common clinical problem. Epidemiologic studies have shown

    the prevalence of palpable thyroid nodules to be approximately 5% in women and 1% in men

    living in iodine-sufficient parts of the world (1;2). In contrast, high-resolution ultrasound (US)

    can detect thyroid nodules in 19 – 68% of randomly selected individuals with higher frequencies

    in women and the elderly (3;4). The clinical importance of thyroid nodules rests with the need to

    exclude thyroid cancer, which occurs in 7 – 15% depending on age, sex, radiation exposure

    history, family history, and other factors (5;6). Differentiated thyroid cancer (DTC), which

    includes papillary and follicular cancer, comprises the vast majority (>90%) of all thyroid

    cancers (7). In the United States, approximately 63,000 new cases of thyroid cancer were

     predicted to be diagnosed in 2014 (8) compared with 37,200 in 2009 when the last ATA

    guidelines were published. The yearly incidence has nearly tripled from 4.9 per 100,000 in 1975

    to 14.3 per 100,000 in 2009 (9). Almost the entire change has been attributed to an increase in

    the incidence of papillary thyroid cancer (PTC). Moreover, 25% of the new thyroid cancers

    diagnosed in 1988-89 were < 1cm compared with 39% of the new thyroid cancer diagnoses in

    2008-9 (9). This tumor shift may be due to the increasing use of neck ultrasonography or other

    imaging and early diagnosis and treatment (10), trends that are changing the initial treatment and

    follow-up for many patients with thyroid cancer. A recent population based study from Olmsted

    County reported the doubling of thyroid cancer incidence from 2000-2012 compared to the prior

    decade as entirely attributable to clinically occult cancers detected incidentally on imaging or

     pathology (11). By 2019, one study predicts that papillary thyroid cancer will become the third

    most common cancer in women at a cost of 19-21 billion dollars in the U.S. (12). Furt