Updated Guidelines for Management of Thyroid Disease in Adults

Thyroidectomy is a commonly performed surgical procedure for the partial/complete removal of the thyroid gland. According to the United states data, over 100,000 thyroid operations are performed annually in the US alone. In order to have a uniform and evidence-based treatment for the management of thyroid disease, various guidelines are published by different surgical associations. Of this, the guidelines by the American Thyroid Association (ATA) are the most commonly followed worldwide.

Recently a panel of 19 experts in thyroid disorders, constituted by the American Association of Endocrine Surgeons has come up with an executive summary for the management of thyroid disease in adults, based on the ATA guidelines.

This updated summary covers the complete management of thyroid disease in adults, ranging from Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of SurgeryPreoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches Laryngology Familial Thyroid CancerPostoperative Care and Complications, Cancer Management, and Reoperation.

The 2020 Guidelines for Management of Thyroid Disease in Adults can be summarized as follows

Initial evaluation

  • Recommendation 1: Evaluation of thyroid disease should include specific inquiry about personal history, family history, clinical characteristics, and symptoms. (Strong recommendation, low quality of evidence)
  • Recommendation 2: The preoperative physical examination should include voice assessment. (Strong recommendation, moderate-quality evidence)
  • Recommendation 3: Thyroid-stimulating hormone (TSH)should be measured in patients with nodular thyroid disease. Additional laboratory studies may help in specific circumstances. (Strong recommendation, low-quality evidence)

Imaging

  • Recommendation 4: A diagnostic Ultrasound (US) should be performed in all patients with a suspected thyroid nodule. (Strong recommendation, high-quality evidence)
  • Recommendation 5:
    • a. US assessment of bilateral central and lateral lymph nodes (LN) compartments should be performed in the preoperative evaluation of patients with cytologic evidence of thyroid carcinoma. (Strong recommendation, low quality of evidence).
    • b. US assessment of bilateral central and lateral LN compartments may be performed in the preoperative evaluation of patients with indeterminate cytologic evidence of thyroid carcinoma. (Strong recommendation, insufficient evidence).
  • Recommendation 6: Computed tomography (CT) or Magnetic Resonance Imaging (MRI) with intravenous contrast should be used preoperatively as an adjunct to US in selected patients with clinical suspicion for advanced locoregional Thyroid Cancer (TC) (Strong recommendation, low quality of evidence)

Fine Needle Aspiration Biopsy (FNAB)

  • Recommendation 7:
    • a. FNAB is a standard component of thyroid nodule evaluation, and its indications should follow established guidelines based on US characteristics, size, and clinical findings. (Strong recommendation, moderate-quality evidence)
    • b. FNAB of a sonographically suspicious cervical LN should be performed when the results will alter the treatment plan. (Strong recommendation, low-quality evidence)
  • Recommendation 8: In most circumstances, FNAB yield and adequacy may be optimized using US-guidance, with or without onsite cytologic assessment. (Strong recommendation, moderate-quality evidence)
  • Recommendation 9: The Bethesda System for Reporting Thyroid Cytopathology should be used to report and stratify the risk of malignancy in a thyroid nodule. (Strong recommendation, high-quality evidence)

Molecular Testing

  • Recommendation 10: If thyroidectomy is preferred for clinical reasons, then molecular testing (MT) is unnecessary. (Strong recommendation, moderate-quality evidence)
  • Recommendation 11: When the need for thyroidectomy is unclear after consideration of clinical, imaging, and cytologic features, MT may be considered as a diagnostic adjunct for cytologically indeterminate nodules. (Strong recommendation, moderate-quality evidence)
  • Recommendation 12: Accuracy of MT relies on institutional malignancy rates and should be locally examined for optimal extrapolation of results to TC risk. (Strong recommendation, moderate-quality evidence)

Indications Extend and Outcomes of Surgery

  • Recommendation 13: Patients with a thyroid nodule, goiter, or thyroiditis who exhibit local compressive symptoms or progressive enlargement should be considered for thyroidectomy. (Strong recommendation, low-quality evidence)
  • Recommendation 14: Thyroidectomy is one of several options for the treatment of hyperthyroidism and should be preferentially considered when RAI or medical therapy is contraindicated or undesirable. (Strong recommendation, moderate-quality evidence)
  • Recommendation 15: For nodules that are cytologically categorized as Bethesda III, clinical factors, radiologic features, and patient preference should inform decision-making regarding whether to proceed with repeat biopsy, MT, diagnostic thyroidectomy, or observation. (Strong recommendation, moderate-quality evidence)
  • Recommendation 16: Diagnostic thyroidectomy and/or MT are accepted options for patients with nodules cytologically categorized as Bethesda IV. (Strong recommendation, moderate-quality evidence)
  • Recommendation 17: Thyroidectomy is indicated for thyroid nodules >1 cm cytologically categorized as Bethesda V or VI. (Strong recommendation, moderate-quality evidence)
  • Recommendation 18: When possible, thyroidectomy should be performed by a high-volume thyroid surgeon. (Strong recommendation, moderate-quality evidence)

Pre-operative Care

  • Recommendation 19: Antimicrobial prophylaxis is not necessary in most cases of standard transcervical thyroid surgery. (Strong recommendation, high-quality evidence)
  • Recommendation 20: Before thyroidectomy, in the absence of contraindications, a single preoperative dose of dexamethasone should be considered to reduce nausea, vomiting, and pain. (Strong recommendation, high-quality evidence)
  • Recommendation 21: If surgery is chosen as a treatment for Graves disease (GD):
    • a. Ideally patients should be rendered clinically euthyroid preoperatively. (Strong recommendation, low-quality evidence)
    • b. A potassium iodide-containing preparation can be considered before surgery. (Weak recommendation, low-quality evidence)
  • Recommendation 22: Gastric bypass patients should be counseled about a higher risk of severe postoperative hypocalcemia after total or completion thyroidectomy. (Strong recommendation, low-quality evidence)
  • Recommendation 23: Before thyroid surgery for GD, calcium and 25-hydroxy vitamin D levels may be assessed and repleted or supplemented prophylactically. (Strong recommendation, moderate-quality evidence)
  • Recommendation 24: Chemical venous thromboembolism (VTE) prophylaxis should be reserved for selected patients determined to be at high risk for VTE after thyroidectomy. (Strong recommendation, low-quality evidence)

Initial thyroidectomy

  • Recommendation 25: The superior pole vessels should be ligated close to the thyroid capsule to avoid potential External Branch of Superior Laryngeal Nerve (EBSLN) injury. (Strong recommendation, insufficient evidence)
  • Recommendation 26: The Recurrent Laryngeal Nerve (RLN) should be identified to help preserve it. (Strong recommendation, low-quality evidence)
  • Recommendation 27:
    • a. Dissection should be performed along the thyroid capsule to help preserve the parathyroid glands. (Strong recommendation, low-quality evidence)
    • b. If a parathyroid gland cannot be preserved, parathyroid autotransplantation should be performed. (Strong recommendation, low-quality evidence)

Peri-operative tissue diagnosis

  • Recommendation 28: Core needle biopsy (CNB) should be rarely utilized in the initial evaluation of a thyroid nodule. (Strong recommendation, low–quality evidence)
  • Recommendation 29: Thyroid Intraoperative pathologic evaluation (IOPE) should only be utilized in settings in which the information it provides has a high likelihood of altering the operative procedure. (Strong recommendation, low–quality evidence)
  • Recommendation 30: IOPE is of value in confirming the identification of parathyroid tissue. (Strong recommendation, moderate-quality evidence)
  • Recommendation 31: IOPE is of value in the identification of cervical lymph node (CLN) metastases when the information may alter the extent of surgery. (Strong recommendation, moderate-quality evidence)
  • Recommendation 32: A standardized synoptic pathology report is recommended when reporting thyroid neoplasms. (Strong recommendation, low–quality evidence)

Lymphnode dissection

  • Recommendation 33: During initial thyroidectomy for papillary thyroid carcinoma (PTC), the central compartment should be assessed for suspicious lymphadenopathy. If clinical or imaged lymph node metastasis (LNM) is present (ie macroscopic disease), a therapeutic central compartment neck dissection (CND) is recommended. (Strong recommendation, high-quality evidence)
  • Recommendation 34:
    • a. A compartment-oriented therapeutic lateral Neck Dissection (ND) is recommended for lateral LNM. (Strong recommendation, high-quality evidence)
    • b. Prophylactic lateral ND is not indicated for PTC. (Strong recommendation, high-quality evidence)

Concurrent Parathyroidectomy

  • Recommendation 35: Hypercalcemia should be evaluated preoperatively in a patient being evaluated for thyroid surgery. (Strong recommendation, low-quality evidence)
  • Recommendation 36: Patients undergoing initial thyroidectomy who are diagnosed with primary hyperparathyroidism should undergo concurrent parathyroidectomy. (Strong recommendation, moderate-quality evidence)
  • Recommendation 37: Evaluation for concomitant hyperparathyroidism (HPT) is recommended in patients scheduled to undergo thyroid surgery who have a history of familial hyperparathyroidism. (Strong recommendation, moderate-quality evidence)

Hypothyroid conditions

  • Recommendation 38: In patients with moderate to severe Graves’ ophthalmopathy, total thyroidectomy should be considered as first-line definitive treatment. (Strong recommendation, moderate-quality evidence)
  • Recommendation 39: Due to the higher risk and greater technical difficulty, thyroidectomy in Graves disease is best performed by high volume thyroid surgeons. (Strong recommendation, low-quality evidence)

Goiter

  • Recommendation 40:
    • a. When surgery is indicated, total thyroidectomy is preferred for the treatment of bilateral goiter. (Strong recommendation, low-quality evidence)
    • b. When the contralateral lobe is normal, lobectomy and isthmusectomy are recommended for the treatment of unilateral goiter. (Strong recommendation, low-quality evidence)
  • Recommendation 41: Cross-sectional imaging of goiter is recommended if there is a concern for a substernal component. (Strong recommendation, moderate-quality evidence)
  • Recommendation 42: When performing surgery for substernal goiter, good communication, preparation, and cooperation of experienced surgical and anesthesia teams are recommended. (Strong recommendation, low-quality evidence)

Adjuncts and Approaches

  • Recommendation 43: Although it does not prevent RLN injury, intraoperative recurrent laryngeal nerve monitoring (RLNM) is safe and may assist the surgeon during initial or reoperative thyroidectomy. (Strong recommendation, moderate-quality evidence)
  • Recommendation 44: During planned total thyroidectomy, after completion of the initial lobectomy, if RLNM results suggest a loss of function, the surgeon may consider stopping the operation for possible completion at a later date. (Strong recommendation, low-quality evidence)
  • Recommendation 45: Rapid parathormone (PTH) measurement during or after total or completion thyroidectomy may help to manage patients at risk for hypocalcemia. (Weak recommendation, moderate-quality evidence)
  • Recommendation 46: Remote-access thyroidectomy should only be performed in carefully selected patients, by surgeons experienced in the approach. (Strong recommendation, low-quality evidence)

Laryngology

  • Recommendation 47: In preoperative discussion of thyroidectomy, the surgeon should disclose to the patient the possibility, likelihood, and implications of permanent laryngeal dysfunction. (Strong recommendation, moderate-quality evidence)
  • Recommendation 48: Before thyroidectomy, laryngeal examination should be performed in patients determined to have vocal abnormalities as assessed by the surgeon, preexisting laryngeal disorders, previous at-risk surgery, or locally advanced TC.(Strong recommendation, low-quality evidence)
  • Recommendation 49: Voice assessment should be performed at the postoperative visit. (Strong recommendation, low-quality evidence)
  • Recommendation 50: After thyroidectomy, laryngeal examination should be performed in patients with known or suspected new RLN dysfunction or aspiration. (Strong recommendation, moderate-quality evidence)
  • Recommendation 51: If vocal fold motion impairment is suspected or identified, early referral of the patient to a laryngologist is recommended. (Strong recommendation, moderate-quality evidence)

Familial Thyroid Cancer

  • Recommendation 52: Germline genetic testing should include pre- and post-test counseling by a knowledgeable health care provider. (Strong recommendation, low-quality evidence)
  • Recommendation 53: Differentiated thyroid cancer (DTC) screening should be performed in at-risk individuals from families with 3 or more affected first-degree relatives. (Strong recommendation, low-quality evidence)
  • Recommendation 54: All patients diagnosed with MTC should undergo genetic testing for a germline RET mutation. (Strong recommendation, high-quality evidence)
  • Recommendation 55: An experienced multidisciplinary care team should manage patients diagnosed with MEN2A and MEN2B. (Strong recommendation, low-quality evidence)

Post operative care and Complications

  • Recommendation 56:
    • a. Use of nonopioid and nonpharmacologic therapies and patient education should be the first-line pain management after thyroidectomy. (Strong recommendation, moderate-quality evidence)
    • b. If opioids are prescribed for postoperative pain management, the lowest effective dose of immediate-release opioids (<10 oral morphine equivalents) should be prescribed. (Strong recommendation, moderate-quality evidence)
  • Recommendation 57: Patients at higher risk for cervical hematoma should be considered for overnight observation following thyroid surgery. (Weak recommendation, moderate-quality evidence)
  • Recommendation 58: Patients with suspected hematoma after thyroidectomy should be evaluated immediately with appropriate intervention as indicated. (Strong recommendation, low-quality evidence)
  • Recommendation 59: If unilateral RLN transection occurs during thyroidectomy, an attempt should be made at repair. (Strong recommendation, moderate-quality evidence)
  • Recommendation 60: To prevent and/or manage postoperative symptoms of hypocalcemia following total or completion thyroidectomy, a strategy for calcium and/or vitamin D supplementation should be considered. (Strong recommendation, moderate-quality evidence)
  • Recommendation 61: Patients with significant post-thyroidectomy hypocalcemia should receive oral calcium as first-line therapy, calcitriol as necessary, and intravenous calcium in severe or refractory situations. (Strong recommendation, low-quality evidence)

Cancer management

  • Recommendation 62: An active surveillance protocol for papillary thyroid microcarcinoma (PTMC) may be appropriate for carefully selected, informed, and compliant patients. (Strong recommendation, moderate-quality evidence)
  • Recommendation 63: A validated postoperative staging system such as the AJCC TNM for thyroid cancer staging should be used in TC care. (Strong recommendation, moderate-quality evidence)
  • Recommendation 64: Consider completion thyroidectomy for high-risk disease and/or when postoperative radioactive iodine (RAI) therapy is indicated. (Strong recommendation, moderate-quality evidence)
  • Recommendation 65: Total thyroidectomy should be performed for patients undergoing prophylactic thyroidectomy for medullary TC. (Strong recommendation, moderate-quality evidence)

Re-operation

  • Recommendation 66: Selected patients with stable, low volume persistent or recurrent LNM can undergo active surveillance. (Weak recommendation, low-quality evidence)

References

  1. Patel KN, Yip L, Lubitz CC, Grubbs EG, Miller BS, Shen W, Angelos P, Chen H, Doherty GM, Fahey III TJ, Kebebew E. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Annals of Surgery. 2020 Mar 1;271(3):e21-93.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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