Thyroid nodules ATA guideline 2017

Presenter:
Dr.Anil Yadav
Resident (Phase-B)
Department of Endocrinology
BSMMU
WELCOME TO JOURNAL
CLUB

2015 American Thyroid Association
Management Guidelines for Adult
Patients with Thyroid Nodules and
Differentiated Thyroid Cancer
Source : American Thyroid Association
Volume : 26( 1)
Published in : 2016,January.

Authors
 Bryan R. Haugen
 Erik K. Alexander Keith
 Gerard M. Doherty
 Susan J. Mandel
 Yuri E. Nikiforov
 Furio Pacini
 Gregory W. Randolph
 Anna M. Sawka Martin
 Schlumberger
 Kathryn G. Schuff
 Steven I. Sherman
 Julie Ann Sosa
 David L. Steward
 R. Michael Tuttle
 LeonardWartofsky

Introduction
Thyroid nodule :
 A discrete lesion within the thyroid gland
 Radiologically distinct from the surrounding
thyroid parenchyma.
 May be palpable or non palpable
 Prevalence of palpable thyroid nodules :5% in
women and 1% in men living in iodine-
sufﬁcient parts of the world .

Introduction
 Non-palpable nodules detected on USG or
other anatomic imaging studies are termed
incidentally discovered nodules or
‘‘incidentalomas.’’

Introduction (cont..)
 High-resolution USG can detect thyroid
nodules in 19%–68% of randomly selected
individuals, with higher frequencies in women
and the elderly.
 Non-palpable nodules have the same risk of
malignancy as do sonographically conﬁrmed
palpable nodules of the same size.

 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.
 The clinical importance of thyroid nodules
rests with the need to exclude thyroid cancer,
which occurs in 7%–15% of cases depending
on age, sex, radiation exposure history, family
history, and other factors.

• Generally, only nodules >1cm should be
evaluated, since they have a greater potential
to be clinically signiﬁcant cancers.
• Occasionally, there may be nodules <1cm that
require further evaluation because of clinical
symptoms or associated lymphadenopathy.

With the discovery of a thyroid nodule,
complete history and physical examination
focusing on the thyroid gland and adjacent
cervical lymph nodes should be performed.

Pertinent historical factors predicting
malignancy include:
–a history of childhood head and neck
irradiation,
–total body irradiation for bone marrow
transplantation
–exposure to ionizing radiation from fallout
in childhood or adolescence

–familial thyroid carcinoma, or thyroid cancer
syndrome in a first-degree relative,
–rapid nodule growth and/or hoarseness.

Pertinent physical findings suggesting possible
malignancy include
–vocal cord paralysis,
–cervical lymphadenopathy, and
–fixation of the nodule to surrounding
tissues.

Purpose
To inform clinicians, patients, researchers, and
health policy makers about the best available
evidence (and its limitations), relating to the
diagnosis and treatment of adult patients with
thyroid nodules.

Method
• A task force chair of specialists with complementary
expertise (endocrinology, surgery, nuclear medicine,
radiology, pathology, oncology, molecular diagnostics,
and epidemiology) was appointed by the ATA
President with approval of the Board.
• Upon discussion among the panel members and the
Chair with other Chairs of other ATA guideline
committees, the American College of Physicians’ (ACP)
Grading System was adopted

What is the appropriate laboratory and
imaging evaluation for patients with
clinically or incidentally discovered thyroid
nodules?

Serum thyrotropin measurement ( TSH )
Recommendation
 Serum thyrotropin (TSH) should be measured
during the initial evaluation of a patient with a
thyroid nodule.
 If the serum TSH is subnormal, a radionuclide
(preferably 123I thyroid scan should be
performed.
(Strong recommendation, Moderate-quality
evidence)

Serum thyrotropin measurement(TSH) ( CONT..)
 If the serum TSH is normal or elevated, a
radionuclide scan should not be performed as
the initial imaging evaluation.
evidence)

Serum thyrotropin measurement ( TSH) ( CONT.. )
• A higher serum TSH level, even within the
upper part of the reference range, is
associated with increased risk of malignancy
in a thyroid nodule, as well as more advanced
stage thyroid cancer

Serum thyrotropin measurement ( TSH) ( CONT.. )
• If TSH low, risk of malignancy depends on
radio uptake scan:
–Tracer uptake : hyperfunctioning “hot”
nodule- rarely harbor malignancy, no
cytologic evaluation is necessary.
–Tracer uptake is equal to the surrounding
thyroid isofunctioning “warm” nodule
–Uptake : nonfunctioning “cold”nodule

Thyroid sonography
Recommendation
Thyroid sonography with survey of the cervical
lymph nodes should be performed in all
patients with known or suspected thyroid
nodules.
(Strong recommendation, High-quality
evidence)

Thyroid sonography (cont…)
Thyroid US can answer the following:
–Is there truly a nodule?
–How large is the nodule?
–What is the nodule’s pattern of ultrasound
imaging characteristics?

–Is suspicious cervical lymphadenopathy
present?
–Is the nodule greater than 50% cystic?
– Is the nodule located posteriorly in the
thyroid gland?

• Sonography features that are associated with thyroid
cancer include:
– microcalcifications,
– nodule hypoechogenicity compared with the
surrounding thyroid or strap muscles,
– irregular margins (defined as either infiltrative,
microlobulated or spiculated), and
– A shape taller than wide measured on a transverse
view.

Sonographic patterns, estimated risk of malignancy, and fine-needle
aspiration guidance for thyroid nodules
Sonograp
hic
pattern
US features Estimat
ed risk
of
malign
ancy %
FNA size
cutoff
(largest
dimension)
High
suspicion
Solid hypoechoic nodule or
solid hypoechoic component
of a partially cystic
nodule with one or more of
the following features:
a)Irregular margins
(infiltrative, microlobulated),
b)Microcalcifications,
c)Taller than wide shape,
>70–90 Recommend
FNA at
≥1 cm

d) Rim calcifications
with small extrusive
soft tissue
component,
e)Evidence of ETE
Intermed
iate
suspicion
Hypoechoic solid
nodule with smooth
margins without mic
rocalcifications, ETE,
or taller than wide
shape
10–20 Recommend
FNA at ≥1 cm

Low
suspicion
Isoechoic or
hyperechoic solid
nodule, or partially
cystic nodule with
eccentric solid
areas, without micr
ocalcification,
irregular margin or
ETE, or taller than
wide shape.
5–10 Recommend
FNA at
≥1.5 cm

Very low
suspicion
Spongiform or
partially cystic
nodules without any
of the sonographic
features described in
low, intermediate, or
high suspicion
patterns
<3 Consider
FNA at
≥2 cm
Observation
without FNA
is also a
reasonable
option
Benign Purely cystic nodules
(no solid component)
<1 No biopsy
b

Serum thyroglobulin (Tg)
Recommendation
Routine measurement of serum thyroglobulin
(Tg) for initial evaluation of thyroid nodules is
not recommended.
evidence)

Serum calcitonin measurement
Recommendation :
The panel cannot recommend either for or
against routine measurement of serum
calcitonin in patients with thyroid nodules.
(No recommendation, Insufﬁcient evidence)

FNAC
Recommendation
FNA is the procedure of choice in the evaluation
of thyroid nodules, when clinically indicated.
evidence)

Recommendation for Diagnostic FNA of a thyroid
nodule based on sonographic pattern
Recommendation
1.Thyroid nodule diagnostic FNA is
recommended for :
(A) Nodules ≥1cm in greatest dimension with
high suspicion sonographic pattern.
(Strong recommendation, Moderate quality evidence)

B)Nodules ≥1cm in greatest dimension with
intermediate suspicion sonographic pattern.
(Strong recommendation, Low-quality evidence)
C)Nodules ≥1.5cm in greatest dimension with
low suspicion sonographic pattern.
(Weak recommendation, Low-quality evidence)

2) Thyroid nodule diagnostic FNA may be
considered for:
(D) Nodules ≥2cm in greatest dimension with
very low suspicion sonographic pattern (e.g.,
spongiform). Observation without FNA is
also a reasonable option.
(Weak recommendation, Moderate-quality
evidence)

3) Thyroid nodule diagnostic FNA is not required
for :
(E) Nodules that do not meet the above
criteria.
(F) Nodules that are purely cystic.
evidence)

Thyroid nodule FNA cytology should be
reported using diagnostic groups outlined in
the:
Bethesda System for Reporting Thyroid
Cytopathology

Nondiagnostic cytology
Recommendation
(A) For a nodule with an initial nondiagnostic
cytology result, FNA should be repeated with
US guidance and, if available, on-site cytologic
evaluation
evidence)

(B) Repeatedly nondiagnostic nodules without a
high suspicion sonographic pattern require
close observation or surgical excision for
histopathologic diagnosis

Recommendation
(C) Surgery should be considered for
histopathologic diagnosis if the cytologically
nondiagnostic nodule has a high suspicion
sonographic pattern, growth of the nodule
(>20% in two dimensions) is detected during
US surveillance, or clinical risk factors for
malignancy are present

Benign cytology
Recommendation
If the nodule is benign on cytology, further
immediate diagnostic studies or treatment are
not required
(Strong recommendation, High-quality evidence)

Malignant cytology
Recommendation
If a cytology result is diagnostic for primary
thyroid malignancy, surgery is generally
recommended.
(Strong recommendation, Moderate-quality evidence

An alternative active surveillance management
approach can be considered in:
 patients with very low risk tumors
 patients at high surgical risk because of co-
morbid conditions,
 patients expected to have a relatively short
remaining life span
 Patients with concurrent medical or surgical
issues that need to be addressed prior to
thyroid surgery.

Indeterminate cytology
(AUS/FLUS, FN, SUSP)
What are the principles of the molecular
testing of FNA samples?

Recommendation
If molecular testing is being considered, patients
should be counseled regarding the potential
benefits and limitations of testing and about the
possible uncertainties in the therapeutic and
long-term clinical implications of results.
(Strong recommendation,Low-quality evidence)

Recommendation
If intended for clinical use, molecular testing
should be performed in Clinical Laboratory
Improvement Amendments/College of American
Pathologists (CLIA/CAP)-certified molecular
laboratories, or the international equivalent
because reported quality assurance practices
may be superior compared to other settings.

AUS/FLUS cytology
Recommendation
(A) For nodules with AUS/FLUS cytology, after
consideration of worrisome clinical &
sonographic features, investigations such as
repeat FNA/molecular testing may be used to
supplement malignancy risk assessment in lieu
of proceeding directly with a strategy of either
surveillance or diagnostic surgery. Informed
patient preference & feasibility should be
considered in clinical decision-making.
(Weak recommendation, Moderate-quality evidence)

AUS/FLUS cytology
(B) If repeat FNA cytology, molecular testing, or
both are not performed or inconclusive, either
surveillance or diagnostic surgical excision
may be performed for an AUS/ FLUS thyroid
nodule, depending on clinical risk factors,
sonographic pattern, and patient preference.

Follicular neoplasm/suspicious for follicular neoplasm
cytology
Recommendation
(A) Diagnostic surgical excision is the long-established
standard of care for the management of FN/SFN
cytology nodules. However, after consideration of
clinical and sonographic features, molecular testing
may be used to supplement malignancy risk
assessment data in lieu of proceeding directly with
surgery. Informed patient preference and feasibility
should be considered in clinical decision-making.
(Weak recommendation, Moderate-quality
evidence)

Follicular neoplasm/suspicious for follicular
neoplasm cytology
(B) If molecular testing is either not performed
or inconclusive, surgical excision may be
considered for removal and definitive diagnosis
of an FN/SFN thyroid nodule.
(Strong recommendation, Low-quality
evidence)

Suspicious for malignancy cytology
Recommendation
If the cytology is reported as suspicious for
papillary carcinoma (SUSP), surgical
management should be similar to that of
malignant cytology, depending on clinical
risk factors, sonographic features, patient
preference, and possibly results of
mutational testing (if performed).

What is the utility of 18FDG-PET scanning to
predict malignant or benign disease when FNA
cytology is indeterminate (AUS/FLUS, FN, SUSP)?

18 FDG-PET scan
Recommendation
18FDG-PET imaging is not routinely
recommended for the evaluation of thyroid
nodules with indeterminate cytology.
(Weak recommendation, Moderate-quality evidence)

18 FDG-PET scan
Recommendation
 Focal [18 F]ﬂuorodeoxyglucose positron emission
tomography (18FDG-PET) uptake within a
sonographically conﬁrmed thyroid nodule conveys an
increased risk of thyroid cancer, and FNA is
recommended for those nodules ≥ 1cm.
(Strong recommendation, Moderate-quality evidence)

18 FDG-PET scan
 Diffuse 18FDG-PET uptake, in conjunction
with sonographic and clinical evidence of
chronic lymphocytic thyroiditis, does not
require further imaging or FNA.
(Strong recommendation, Moderate-qualityevidence)

What is the appropriate operation for
cytologically indeterminate thyroid
nodules?

Recommendation
When surgery is considered for patients with a
solitary, cytologically indeterminate nodule,
thyroid lobectomy is the recommended initial
surgical approach. This approach may be
modiﬁed based on clinical or sonographic
characteristics, patient preference, and/or
molecular testing when performed

Recommendation
Because of increased risk for malignancy, total
thyroidectomy may be preferred in patients with
indeterminate nodules that are cytologically
suspicious for malignancy, positive for known
mutations speciﬁc for carcinoma, sonographically
suspicious, or large (>4cm), or in patients with
familial thyroid carcinoma or history of radiation
exposure, if completion thyroidectomy would be
recommended based on the indeterminate nodule
being malignant following lobectomy.

How should multinodular thyroid glands
(i.e., two or more clinically relevant
nodules) be evaluated for malignancy?

Recommendation
Patients with multiple thyroid nodules˃1cm should
be evaluated in the same fashion as patients with a
solitary nodule ˃1cm, excepting that each nodule that
is >1cm carries an independent risk of malignancy
and therefore multiple nodules may require FNA.
evidence)

When multiple nodules˃1cm are present, FNA
should be performed preferentially based upon
nodule sonographic pattern and respective size
cutoff
evidence)

Recommendation
If none of the nodules has a high or moderate
suspicion sonographic pattern, and multiple
sonographically similar very low or low suspicion
pattern nodules coalesce with no intervening
normal parenchyma, the likelihood of malignancy is
low and it is reasonable to aspirate the largest
nodules (≥2cm) or continue surveillance without
FNA.

Recommendation
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 (preferably 123I)
thyroid scan should be considered and directly
compared to the US images to determine
functionality of each nodule ≥1cm.

FNA should then be considered only for those
isofunctioning or nonfunctioning nodules,
among which those with high suspicion
sonographic pattern should be aspirated
preferentially.

What are the best methods for long term
follow-up of patients with thyroid nodules ?

Recommendations for initial follow-up of
nodules with benign FNA cytology
Recommendation
 Nodules with high suspicion US pattern:
repeat US and US-guided FNA within 12
months.
evidence)

• Nodules with low to intermediate suspicion
US pattern: repeat US at 12–24 months.

Recommendations for initial follow-up of
nodules with benign FNA cytology
Nodules with very low suspicion US pattern
(including spongiform nodules): repeating FNA
to detect a missed malignancy is limited. If US is
repeated, it should be done at 24 months.
(Weak recommendation, Low-quality
evidence)

Recommendation for follow-up of nodules with
two benign FNA cytology results
If a nodule has undergone repeat US-guided
FNA with a second benign cytology result, US
surveillance for this nodule for continued risk of
malignancy is no longer indicated.
evidence)

Follow-up for nodules that do not meet
FNA criteria
Recommendation
• Nodules with high suspicion US pattern:
repeat US in 6–12 months.
 Nodules with low to intermediate suspicion
US pattern: consider repeat US at 12–24
months.

Follow-up for nodules that do not
meet FNA criteria
Recommendation:
• Nodules >1cm with very low suspicion US
pattern and pure cyst: the utility and time
interval of surveillance US for risk of
malignancy is not known. If US is repeated, it
should be at≥24 months.

• Nodules ≤1cm with very low suspicion US
pattern (including spongiform nodules) and
pure cysts do not require routine sonographic
follow-up.

What is the role of medical or surgical therapy
for benign thyroid nodules?

Recommendation
Routine TSH suppression therapy for benign
thyroid nodules in iodine sufﬁcient populations
is not recommended. Though modest responses
to therapy can be detected, the potential harm
outweighs beneﬁt for most patients.
evidence)

Recommendation
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 150lg
iodine) is recommended.
evidence)

Recommendation
(A) Surgery may be considered for growing
nodules that are benign after repeat FNA if they
are large (>4cm), causing compressive or
structural symptoms, or based upon clinical
concern.

(B) Patients with growing nodules that are
benign after FNA should be regularly monitored.
Most asymptomatic nodules demonstrating
modest growth should be followed without
intervention.
(Strong recommendation, Low-quality
evidence)

Recommendation
Recurrent cystic thyroid nodules with benign
cytology should be considered for surgical
removal or percutaneous ethanol injection (PEI)
based on compressive symptoms and cosmetic
concerns. Asymptomatic cystic nodules may be
followed conservatively.

Recommendation
There are no data to guide recommendations on
the use of thyroid hormone therapy in patients
with growing nodules that are benign on
cytology.

How should thyroid nodules In pregnant
women be managed ?

FNA for thyroid nodules discovered during
pregnancy
Recommendation
• FNA of clinically relevant thyroid nodules
should be performed in euthyroid and
hypothyroid pregnant women.
evidence)

FNA for thyroid nodules discovered
during pregnancy
• For women with suppressed serum TSH levels
that persist beyond 16 weeks gestation, FNA
may be deferred until after pregnancy and
cessation of lactation. At that time, a
radionuclide scan can be performed to
evaluate nodule function if the serum TSH
remains suppressed.
evidence)

Approaches to pregnant patients with
malignant or indeterminate cytology
• PTC discovered by cytology in early
pregnancy should be monitored
sonographically.
• If it grows progressively before 24-26 weeks
gestation, or if US reveals cervical lymph
nodes that are suspicious for metastatic
disease, surgery should be considered during
pregnancy.

Approaches to pregnant patients with
malignant or indeterminate cytology
• However, if the disease remains stable by mid-
gestation,or if it is diagnosed in the second
half of pregnancy, surgery may be deferred
until delivery
• In pregnant women with FNA that is
suspicious for or diagnostic of PTC, thyroid
hormone therapy to keep the serum TSH 0.1-
1.0mU/L is recommended.

Take home message
• The clinical importance to evaluate thyroid
nodule is to exclude thyroid carcinoma.
• High resolution US can detect thyroid nodules
upto 19-68% with higher frequencies in
women & elderly.
• Minimize potential harm from overtreatment
of patients at low risk and appropriately treat
and monitor those patients at higher risk.

Take home message
• Non-palpable nodules have the same risk of
malignancy as do sonographically confirmed
palpable nodules of the same size.
• FNA is choice , most accurate & cost effective
method of procedure in evaluation of thyroid
nodule.
• FNA should be repeated after 3 month to
prevent false-positive interpretation due to
biopsy induced reactive/ reparative changes.

Take home message
• Most nodules with non-diagnostic cytology
interpretation are benign.
• Slight enlargement of nodules throughout
gestation dose not implies malignant
transformation.
• Avoid radio-nuclied scan in pregnancy.

Thyroid nodules ATA guideline 2017

Thyroid nodules ATA guideline 2017

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