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base insertions/de- letions (indels), and gene rearrangements has been reported tohave a sensitivity of 90% for FN/SFN FNA cytology speci- mens from a single-center study (170). A limitation was that the pathologists evaluating the gold standard surgical pathol-ogy specimens were aware of the results of earlier generat... |
testing as a means to inform decision-making on extent of primary thyroid surgery (i.e., lobectomy ortotal thyroidectomy) (162) were developed at a time when the ATA guidelines favored tota l thyroidectomy for most PTCs >1 cm in diameter (25). However, this does not reflect recom- mendations in these guidelines (see Rec... |
five insti-tutions, Alexander et al. (171) reported that the prevalence of 167 GEC benign readings by institution varied up to 29%, which was not statistically significant. The distribu-tion of recruitment from each of the five study sites was highly variable (total n=339 nodules), with two sites contributing only 30 and ... |
months (me-dian 8 months, range 1–24 months); ultimately, 6% of patients in this group (11/174) had surgery, with one histopatho- logically confirmed malignancy (171). The reproducibilityof 167 GEC NPV measures in different populations of pa- tients with indeterminate cytology thyroid nodules has re- cently been questio... |
util ity studies are needed to in- form potential future clinical practice implications of the 167 GEC. Immunohistochemical stains such as galectin-3 and HBME-1 have been examined in multiple studies of histo-logically confirmed thyroid FNA samples with indeterminate cytology, with reports of relatively high rates of sp... |
109 patients with AUS/ FLUS or FN cytology, showed 89% sensitivity, 85% speci-ficity, with a 73% PPV and 94% NPV on this group with a 32% prevalence of malignancy (186). Finally, peripheral blood TSH receptor mRNA assay has been reported to have a 90% PPVand 39% NPV in FNA-based assessment of thyroid noduleswith atypica... |
because reported quality assurance practices may be superior compared to other settings. (Strong recommendation, Low-quality evidence) Many molecular marker tests are available in hospital-based molecular pathology laboratories and in reference laboratories. Importantly, all molecular marker tests intended for clinical... |
ofproceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasi- bility should be considered in clinical decision-making. (Weak recommendation, Moderate-quality evidence)(B) If repeat FNA cytology, molecular testing, or both are not performed or inconclusive, ei... |
thyroid FNA samples (105,191). In studies that utilized the criteria established by the Bethesda System, the risk of cancer for patients with AUS/FLUS nodules who underwentsurgery was 6%–48%, with a mean risk of 16% (191). A second opinion review of the cytopathology slides by a high-volume cytopathologist may be consi... |
cytologic interpretation following the initial AUS/FLUSdiagnosis (2/7, 29%) (196). Use of thyroid core-needle bi-opsy was reported by some to be more informative than re- peated FNA for sampling nodules that were AUS/FLUS on initial FNA (119), and it is reasonably well-tolerated (197). The refinement of risk stratificati... |
of nodules with AUS/FLUS cytol-ogy (653 consecutive nodules, of which 247 had surgical follow-up) from a single institution, detection of any of these mutations using RT-PCR with fluorescent melting curveanalysis was reported to convey an 88% risk of cancer among nodules with surgical follow-up; 63% of cancers on final h... |
apositive test (167). There were also 11 AUS/FLUS cytologynodules, which were benign on histopathologic evaluation; 9 of 11 had a negative molecular test result and 2 of 11 had a positive result. Interpretation of results from the AUS/FLUSsubgroup is limited by the small reported sample size (167). Molecular testing us... |
clinical extrapolation suggesting that nodules that have a negative167 GEC test results may be followed without surgery (163). In a recent single-center retrospective study including 68 cases of AUS/FLUS nodules, 16 AUS/FLUS cases were re-ported to have a 167 GEC suspicious result, and the PPV was 61% (11 of 18) for th... |
(200). In three other recent studies, there were insufficient data for analysis in the AUS/FLUS subgroup to draw any mean- ingful conclusion on 167 GEC test performance in that sub-group (172–174). In addition, published follow-up for the 167GEC is currently limited to a mean of 8.5 months in a subgroup of 71 patients (... |
confirmation of malignancy andlong-term follow-up data were generally lacking. The preva- lence of suspicious sonographic features among studies of AUS/ FLUS cytology nodules ranged from 18% to 50%, assumingthat one or more suspicious features were deemed to be suffi- cient to be categorized as a sonographically suspicio... |
study from Brazil (205)], the high suspicion sonographic pattern still raises the risk of malignancy, but the PPV is lower at 70%. None-theless, the incidence of cancer in AUS/FLUS nodules witheither the high suspicion pattern US or just one suspicious US feature is significantly higher than that generally accepted for ... |
considering clinical and sonographic features on the potential utility and interpreta- tion of molecular testing of FNA specimens. [A18] Follicular neoplasm/suspicious for follicular neo- plasm cytology &RECOMMENDATION 16 (A) Diagnostic surgical excision is the long-established standard of care for the management of FN... |
(ii) comprised almost ex- clusively of oncocytic (Hu ¨rthle) cells (99,206,207). This is an intermediate risk category in the Bethesda System, with a15%–30% estimated risk of malignancy. Studies that applied the Bethesda System reported the use of this diagnostic cat- egory in 1%–25% (mean, 10%) of all thyroid FNA samp... |
un- certain malignant potential (208). Nodules lacking all of these mutations still have a substantial cancer risk, which is due to thepresence of a subset of tumors that lack any of the mutationstested by this seven-gene panel (162). Expansion of the current panels to include additional mutations and gene rearrangemen... |
markers detected in earlier and later generation assays, there is a potential for bias (170), and the results need to be replicated in other studies. Molecular testing using the GEC was reported to have a 94% NPV [95% CI 79%–99%], and a 37% PPV [95% CI 23%–52%] in the FN/SFN/Hu ¨rthle cell neoplasm Bethesda subgroup (1... |
15% (4 of 27), and NPV 75% (three of four) (173). In a single- center retrospective study including 64 nodules subjected to 167 GEC testing and a cytology read as FN/FN with oncocyticfeatures, the PPV for a suspicious GEC result was 37% (11 of30), although the PPV was significantly higher in the FN group (53%) compared ... |
should be simi- lar to that of malignant cytology, depending on clinical risk factors, sonographic features, patient preference, andpossibly results of mutational testing (if performed). (Strong recommendation, Low-quality evidence)(B) After consideration of clinical and sonographic features, mutational testing for BRA... |
surgery in 53%–87% (mean, 75%) of these nodules (191). Due to the high risk of cancer, the diagnosis of suspicious forpapillary carcinoma is an indication for surgery. Mutational testing has been proposed to refine risk prior to surgery, assuming that surgical management would changebased on a positive test result. BRAF... |
c) in nodules with cytology suspicious for ma- lignancy is associated with a sensitivity of 50%–68%, speci-ficity of 86%–96%, PPV of 80%–95%, and NPV of 72%–75%in respective single-center studies (162,165,168). Molecular testing using the 167 GEC has a PPV that is similar to cytol- ogy alone (76%) and a NPV of 85% (163)... |
diameter (221). A recent meta-analysis included seven studies, of which five were prospective (222). The cancerprevalence was 26% inclusive of all combined data, con- firming a typical study cohort. Sensitivity and specificity of 18FDG-PET were 89% and 55%, respectively, resulting in a 41% PPV and 93% NPV, which is simila... |
in patients with cytolog- ically indeterminate thyroid nodules. [A21] What is the appropriate operation for cytologically indeterminate thyroid nodules? &RECOMMENDATION 19 When surgery is considered for patients with a solitary, cytologically indeterminate nodule, thyroid lobectomy isthe recommended initial surgical ap... |
recommended based on the indeterminate nodule being malignant following lobectomy. (Strong recommendation, Moderate-quality evidence) (B) Patients with indeterminate nodules who have bilateral nodular disease, those with significant medical co- morbidities, or those who prefer to undergo bilateral thy-roidectomy to avoi... |
[<1 g] of tissue adjacent to the recurrent laryngeal nerve near the ligament of Berry), or total thyroidectomy (removal of allgrossly visible thyroid tissue). Removal of the nodule alone,partial lobectomy, and subtotal thyroidectomy, leaving >1g of tissue with the posterior capsule on the uninvolved side, are inappropr... |
as AUS/FLUS or FN and benign using the 167 GEC, or AUS/FLUS and neg- ative using the seven-gene mutation panel have an estimated 5%–6% risk of malignancy (162,163). Nodules that are cyto-logically classified as FN and negative using the seven-gene mutation panel have an estimated 14% risk of malignancy, which is slightl... |
with thyroid carcinoma have an estimated84% risk of malignancy and should be considered in a similar risk category to cytologically suspicious for malignancy (Table 8) (103,230). Nodules that are cytologically classifiedas AUS/FLUS or FN or SUSP and that are positive for knownBRAF V600E,RET/PTC ,o rPAX8/PPAR cmutations ... |
for malignancy (202). The risks of total thyroidectomy are significantly greater than that for thyroid lobectomy, with a recent meta-analysis suggesting a pooled relative risk (RR) significantly greater for all complications, including recurrent laryngeal nerve in-jury (transient RR =1.7, permanent RR =1.9), hypocalcemia... |
Hypothyroidism is not an indication for thyroidectomy, andits use as justification for total thyroidectomy over lobectomy should be weighed against the higher risks associated with total thyroidectomy. In contrast, coexistent hyperthyroidismmay be an indication for total thyroidectomy depending upon the etiology. Thyroi... |
follicular variant of PTC and FTC. The individual patient must weigh the relative advantages and disadvantages of thyroid lobectomy with possible total thyroidectomy or24 HAUGEN ET AL. |
subsequent completion thyroidectomy versus initial total thyroidectomy. [A22] How should multinodular thyroid glands (i.e., two or more clinically relevant nodules) be evaluated for malignancy? &RECOMMENDATION 21 (A) Patients with multiple thyroid nodules ‡1 cm should be evaluated in the same fashion as patients with a... |
( ‡2 cm) or continue surveillance without FNA. (Weak recommendation, Low-quality evidence) &RECOMMENDATION 22 A low or low-normal serum TSH concentration in patients with multiple nodules may suggest that some nodule(s) may be autonomous. In such cases, a radionuclide (pref- erably123I) thyroid scan should be considere... |
same and independentof the number of nodules (77). A recent systematic reviewand meta-analysis confirmed the slightly higher risk of ma- lignancy in a solitary nodule compared with an individual nodule in a MNG. However, this appeared to hold true mostlyoutside of the United States and in iodine-deficient popula- tions (... |
each nodulecan assist in identifying those nodules with the highest like- lihood of cancer (see section [A10]). [A23] What are the best methods for long-term follow-up of patients with thyroid nodules? [A24] Recommendations for initial follow-up of nodules with benign FNA cytology &RECOMMENDATION 23 Given the low false... |
of new suspicious so-nographic features, the FNA could be repeated or obser- vation continued with repeat US, with repeat FNA in case of continued growth. (Weak recommendation, Low-quality evidence)(C) Nodules with very low suspicion US pattern (including spongiform nodules): the utility of surveillance US andassessmen... |
Although therisk of malignancy after two benign cytology results is vir- tually zero (129–133,236), routine rebiopsy is not a viable or cost-effective option because of the low false-negative rate ofan US-guided FNA benign cytology result. Prior guidelines have recommended repeat FNA for nodules that grow during serial... |
nodule size, which is equivalent to a 20% increase in two of the three nodule dimensions. If a 50% volume increase cutoff is applied, only 4%–10% of nodules were reportedto be larger at a mean of 18 months (133,238). However,using cutoffs of a 15% volume increase based upon inter- nally assessed interobserver co efficie... |
US exams. The false-negative rate of a benign cy- tology diagnosis was 1.1%. Of the four missed cancers, onbaseline US imaging three were hypoechoic and solid and one was isoechoic with microcalcifications; none was spon- giform or mixed cystic solid and noncalcified (ATA very lowsuspicion pattern). During sonographic su... |
help inform decision-makingabout long-term surveillance. Additional research would bevaluable because indefinite follow-up of nodules with benign cytology is costly and may be unnecessary. Recent investigations of repeat US-guided FNA in nodules with initial benign cytology show higher detection rates for missed maligna... |
suspicious US features versus 1.3% of those withoutsuspicious characteristic that grew, using criteria of a 50% vol- ume increase. These studies indicate that the use of suspi- cious US characteristics rather than nodule growth shouldbe the indication for repeat FNA despite an initial benign cytology diagnosis. Repeat ... |
at least aslong that between the initial benign FNA cytology result and first follow-up. However, even if a repeat US is not indicated based on a benign cytology, US pattern, or stability in nodulesize, larger nodules may require monitoring for growth that could result in symptoms and thus prompt surgical interven- tion... |
not meet FNA criteria &RECOMMENDATION 24 Nodules may be detected on US that do not meet criteriafor FNA at initial imaging (Recommendation 8). Thestrategy for sonographic follow-up of these nodules should be based upon the nodule’s sonographic pattern. (A) Nodules with high suspicion US pattern: repeat US in 6–12 month... |
adults have thyroid nodules. The vast majority of these are subcentimeter, and FNA evaluation is generally not indicated. In addition, based upon both sonographic pattern and size cutoffs (Re-commendation 8), many nodules >1 cm may also be followed without FNA. Although no prospective studies address the optimal cost-e... |
unlikely to change during 5-year sonographic follow-up, and the risk of malignancy is exceedingly low. The findings from studies correlating sonographic features and malignancy risk inaspirated nodules can be extrapolated to inform a follow-upstrategy for this group of nodules that do not meet FNA criteria at the time o... |
High-quality evidence) &RECOMMENDATION 26 Individual patients with benign, solid, or mostly solid nodules should have adequate iodine intake. If inadequate dietary intake is found or suspected, a daily supplement (containing 150 lg iodine) is recommended. (Strong recommendation, Moderate-quality evidence) &RECOMMENDATI... |
the use of thyroid hormone therapy in patients with growing nodulesthat are benign on cytology. (No recommendation, Insufficient evidence) Evidence from multiple prospective, RCTs, and from three meta-analyses suggest that thyroid hormone supplementationin doses that suppress the serum TSH to subnormal levels may result... |
of cardiac arrhythmias andosteoporosis, as well as adverse symptomatology. Together, t h e s ed a t ac o n fi r mt h a tL T 4suppressive therapy demonstrates modest (though usually clinically insignificant) efficacy innodule volume reduction, but increases the risk of adverse consequences related to iatrogenic thyrotoxico... |
data, and the efficacy of nonsuppressive LT 4remains unproven. Cystic nodules that are cytologically benign can be monitored for recurrence (fluid reaccumulation), which can be seen in 60%–90% of patients (250,251). For those patients with subse-quent recurrent symptomatic cyst ic fluid accumulation, surgical removal, gen... |
preg- nancy &RECOMMENDATION 30 (A) FNA of clinically relevant thyroid nodules (refer to section [A10]) should be performed in euthyroid and hy- pothyroid pregnant women. (Strong recommendation, Moderate-quality evidence)(B) For women with suppressed serum TSH levels that persist beyond 16 weeks gestation, FNA may be de... |
time, a radionuclide scan can be performed to evaluate nodule function if the serum TSH remains suppressed. (Strong recommendation, Moderate-quality evidence) It is uncertain if thyroid nodules discovered in pregnant women are more likely to be malignant than those found in nonpregnant women, since there are no populat... |
performed during pregnancy is associated with greater risk of complications, longer hospital stays, and higher costs (259). [A30] Approaches to pregnant patients with malignant or indeterminate cytology &RECOMMENDATION 31 PTC discovered by cytology in early pregnancy should be monitored sonographically. If it grows sub... |
cancer diagnosed during gestation is not known. Because higher serum TSH levels may be correlated with a more advanced stage of cancer at surgery(260), if the patient’s serum TSH is >2 mU/L, it may be rea- sonable to initiate thyroid hormone therapy to maintain the TSH between 0.3 to 2.0 mU/L for the remainder of gesta... |
was found tobe>10 ng/mL during 131I ablation in many cases, suggesting the extent of thyroidectomy and/or tumor resection may havebeen limited in this cohort and therefore contributed to bio- chemical persistence of disease. Vannucchi et al. (263) fol- lowed a small cohort of 10 patients with DTC duringpregnancy or wit... |
in the evaluation of DTC or clinically relevant, cytologicallyindeterminate thyroid nodules detected during pregnancy. However, the application of molecular testing in pregnant women with indeterminate cytology remains uncertain.There are no published data validating the performance of any molecular marker in this popu... |
gestation (264). However, PTC discovered during pregnancy does not behave moreaggressively than that diagnosed in a similar-aged group ofnonpregnant women (258,265). A retrospective study of pregnant women with DTC found no difference in either recurrence or survival rates b etween women operated dur- ing or after preg... |
epithelial cells, accounts for the vast majority of thyroid cancers. Of the differentiated cancers, papillary cancercomprises about 85% of cases compared to about 12% that have follicular histology, including conventional and onco- cytic (Hu ¨rthle cell) carcinomas, and <3% that are poorly28 HAUGEN ET AL. |
differentiated tumors (268). In general, stage for stage, the prognoses of PTC and follicular cancer are similar (266,269). [B2] Goals of initial therapy of DTC The basic goals of initial therapy for patients with DTC are to improve overall and disease-specific survival, reduce the risk of persistent/recurrent disease a... |
at least some patients (273–275). 3. Facilitate postoperative treatment with RAI, where appropriate. For patients undergoing RAI remnant ablation, or RAI treatment of presumed (adjuvant therapy) or known (therapy) residual or metastaticdisease, removal of all normal thyroid tissue is an important element of initial sur... |
especially lateral neck compartments) lymph nodes is recommended for all patients undergoing thyroidectomy for malignant orsuspicious for malignancy cytologic or molecular findings. (Strong recommendation, Moderate-quality evidence)(B) US-guided FNA of sonographically suspicious lymph nodes ‡8–10 mm in the smallest diam... |
of micrometastases are likely less signifi- cant compared to macrometastases. Preoperative US identifies suspicious cervical adenopathy in 20%–31% of cases, poten-tially altering the surgical ap proach (287,288) in as many as 20% of patients (289–291). However, preoperative US identifies only half of the lymph nodes found... |
microcalcifications (100%), and peripheral vascularity (82%). Of these, the onlyone with sufficient sensitivity was peripheral vascularity (86%). The others had sensitivities of <60% and would not be adequate to use as a single criterion for identification ofmalignant involvement (292). As shown by earlier studies (293,29... |
delineation of cervical lymphnode levels I through VI. Confirmation of malignancy in lymph nodes with a sus- picious sonographic appearance is achieved by US-guided FNA aspiration for cytology and/or measurement of Tg in theneedle washout. A Tg concentration <1 ng/mL is reassuring, and the probability of N1 disease incr... |
a large lymph node with microcalcifications) (300). In a retrospective study of 241 lymph nodes in 220 patients whounderwent US-guided FNA with Tg in FNA (FNA-Tg)washout fluid measurements for suspicious lymph nodes, additional FNA-Tg helped to diagnose a metastatic lymph node with one or two suspicious US features but d... |
assays to date, which makes this additional diagnostic tool sometimes dif- ficult to interpret (305). Future standardization includingmatrix type (phosphate-buffered saline, Tg-free serum, etc.) and volume of diluent matrix would help with interpretation of a Tg washout. Accurate staging is important in determining the ... |
or bulky lymph node involve-ment. (Strong recommendation, Low-quality evidence)(B) Routine preoperative 18FDG-PET scanning is not rec- ommended. (Strong recommendation, Low-quality evidence) Since US evaluation is operator dependent and cannot al- ways adequately image deep anatomic structures and those acoustically sh... |
are above and below level III, respectively. The level I node compartment includes the submental and submandibular nodes, above the hyoid bone, and anterior to the posterior edge of the submandibular gland. Finally, the level V nodes are in the posteriortriangle, lateral to the lateral edge of the sternocleidomastoid m... |
some clinical settings. Patients displaying bulky or widely distributed nodal disease on initial US examination may present with involvement of nodal regions beyond typicalcervical regions, some of which maybe difficult to visualizeon routine preoperative US, including the mediastinum, infra- clavicular, retropharyngeal... |
and US had greater sensitivity than CT at predicting lateral compartment metastases ( p=0.041) (308). However, another study showed that combined preopera- tive mapping with US and CT was superior to US alone in the preoperative detection of nodal disease, especially in thecentral neck (309). The sensitivities of MRI a... |
preoperative planning to accurately delineate theextent of laryngeal, tracheal, esophageal, or vascular in-volvement (309,313). Endoscopy of the trachea and or esophagus, with or without ultrasonography, at the beginning of the initial operation looking for evidence of intraluminalextension can also be helpful in cases... |
the need for ster- notomy and/or tracheal or laryngeal resection/reconstruction,which would likely require assembling additional resources and personnel in preparation for surgery. Neck CT with contrast can therefore be useful in delineating the extent oflaryngeal, tracheal, and/or esophageal involvement in tumors disp... |
IV contrast causing a clinically significant delay in subsequent whole-body scans (WBSs) orRAI treatment after the imaging followed by surgery is gen-erally unfounded (315). The benefit gained from improved anatomic imaging generally outweighs any potential risk of a several week delay in RAI imaging or therapy. When the... |
CancerTreatment Cooperative Study (a large thyroid cancer registry that included 11 North American centers and enrolled pa- tients between 1987 and 2011), serum anti-Tg antibody statuswas not significantly associated with stage of disease onmultivariate analysis, or with disease-free or overall survival on univariate or... |
of any lymph node metastases (cN0), the initialsurgical procedure can be either a bilateral procedure (near- total or total thyroidectomy) or a unilateral procedureATA THYROID NODULE/DTC GUIDELINES 31 |
(lobectomy). Thyroid lobectomy alone may be sufficient initial treatment for low-risk papillary and follicular car- cinomas; however, the treatment team may choose totalthyroidectomy to enable RAI therapy or to enhance follow-up based upon disease features and/or patient preferences. (Strong recommendation, Moderate-qua... |
for recurrent laryngeal nerve [RLN] involvement, or grossly invasive disease) to experi- enced surgeons, as both completeness of surgery and expe-rience of the surgeon can have a significant impact on clinicaloutcomes and complication rates (232,233,279,280). Pre- vious guidelines have endorsed total thyroidectomy as th... |
our cur- rent more selective approach to RAI ablation in these patientsrequires a critical reassessment of this indication. In some patients, the presence of the remaining lobe of the gland may obviate the lifelong need for exogenous thyroid hormonetherapy. Finally, as our follow-up management paradigm has moved away f... |
lower 10-year recurrence rate (7.7% vs. 9.8%, respectively, p<0.05). When analyzed by size of the primary tumor, statistically significant differences in survival andrecurrence were seen for all sizes >1 cm based on the extent of initial surgery. However, data on extrathyroidal extension, completeness of resection, and ... |
of differences re- ported for survival and recurrence between the total thyroid- ectomy and the lobectomy patients, it is quite possible that theslightly poorer outcomes seen in the lobectomy group could have been influenced by lobectomy patients with concurrent high risk features. Adam et al. (327) performed an updated... |
undergoing lobectomy) and found no difference in 10-year overall survival between total thyroid-ectomy and thyroid lobectomy when risk stratified by the AMES classification system. Interestingly, patients selected for thyroid lobectomy included 7% with extrathyroidal ex-tension, 1% with distant metastases, and 5% with pr... |
extent of surgery, and RAI use, no difference in overall survival or cause specific survival was seen with re- spect to the extent of initial surgery. Mendelsohn et al. (324) analyzed 22,724 PTC patients diagnosed between 1998 and 2001 (16,760 with total thyroidectomy, 5964 with lobecto- my) and found no differences in ... |
Consistent with the SEER data analyses, two single-center studies also confirmed that lobectomy is associated with excellent survival in properly selected patients (322,326).After a median follow-up of 8 years, only one disease-specific death was seen in a cohort of 889 PTC patients with T1–T2 tumors treated with either ... |
the few recurrences that develop during long-term follow-up arereadily detected and appropriately treated with no impact on survival (322,326,328). Therefore, we conclude that in properly selected low- to intermediate-risk patients (patients with unifocal tumors <4 cm, and no evidence of extrathyroidal extension or lym... |
disease is likely to significantly de- crease the mandate for total thyroidectomies in low- and intermediate-risk patients done solely to facilitate RAIremnant ablation and follow-up. Near-total or total thyroidectomy is necessary if the overall strategy is to include RAI therapy postoperatively, and thus isrecommended ... |
patient outcomes has been studied extensively over the last 20 years.Institutional studies examining outcomes following thy- roidectomy by high-volume surgeons have been published demonstrating overall safety. In one of the first studies ex-amining the relationship between surgeon volume and thy- roidectomy outcomes at ... |
surgeons had the lowest complication rates for patients who underwent total thyroidectomy for cancerat 7.5%; intermediate-volume surgeons had a rate of 13.4%, andlow-volume surgeons, 18.9% ( p<0.001). From robust population-level data such as these, it can be concluded that referral of patients to high-volume thyroidsu... |
rate when per- forming total thyroidectomy compared with lobectomy (333). Using the HCUP-NIS, these authors found that high-volume thyroid surgeons had a complication rate of 7.6% following thyroid lobectomy but a rate of 14.5% following total thyroidectomy. For low-volume surgeons, the compli-cation rates were 11.8% a... |
will be used to plan further steps in therapy. (Weak recommendation, Low-quality evidence) (C) Thyroidectomy without prophylactic central neck dissection is appropriate for small (T1 or T2), noninvasive,ATA THYROID NODULE/DTC GUIDELINES 33 |
clinically node-negative PTC (cN0) and for most follicular cancers. (Strong recommendation, Moderate-quality evidence) &RECOMMENDATION 37 Therapeutic lateral neck compartmental lymph node dis- section should be performed for patients with biopsy-proven metastatic lateral cervical lymphadenopathy. (Strong recommendation... |
metastases con- ferred an independent risk of decreased survival, but only inpatients with follicular cancer and patients with papillarycancer over age 45 years (337). However, characteristics of the lymph node metastases can further discriminate the risk of recurrence to the patient, especially in patients with clinic... |
studies is the conclusion that the effect of the presence or absence of lymph node metastases on overall survival, if present, is small. The cervical node sites are well-defined (341), and the most common site of nodal metastases is in the central neck, which is cervical level VI (Fig. 3). A recent consensus con-ference... |
disease remains unclear. Central compartment dissection (therapeuticor prophylactic) can be achieved with low morbidity by ex- perienced thyroid surgeons (349–351). The value for an in- dividual patient depends upon the utility of the staginginformation to the treatment team in specific patient cir-cumstances (351,352).... |
on long-term outcome is small at best (365,366). The use of staging information for the planning ofadjuvant therapy depends upon whether this information will affect the team-based decision-making for the individual patient. For these reasons, groups may elect to include pro-phylactic dissection for patients with some ... |
patients withclinically evident disease based on preoperative physicalexam, preoperative radiographic evaluation, or intraoperative demonstration of detectable disease (cN1) (335,359,367). The information from prophylactic central neck dissection must be used cautiously for staging information. Since mi- croscopic noda... |
risk ofnodal disease (369–371), although results across all patients with papillary thyroid carcinoma are mixed (372–375). However, the presence of a BRAFV600Emutation has a limited PPV for recurrence and therefore, BRAFV600Emutation status in the primary tumor should not impact the decision for prophylactic central ne... |
The preceding recommendations should be interpreted in light of available surgical expertise. For patients with small, noninvasive, cN0 tumors, the balance of risk and benefit mayfavor thyroid lobectomy and close intraoperative inspectionof the central compartment, with the plan adjusted to total thyroidectomy with comp... |
initial surgery. Therapeutic central neck lymph node dis- section should be included if the lymph nodes are clinicallyinvolved. Thyroid lobectomy alone may be sufficienttreatment for low-risk papillary and follicular carcinomas. (Strong recommendation, Moderate-quality evidence)(B) RAI ablation in lieu of completion thy... |
(382–384). The marginalutility of prophylactic lymph node dissection for cN0 disease argues against its application in re-operations. Ablation of the remaining lobe with RAI has been used as an alternative to completion thyroidectomy (385,386).There are limited data regarding the long-term outcomes of this approach. Th... |
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