The 2015 American Thyroid Association guidelines outline the management strategies for thyroid nodules and differentiated thyroid cancer, emphasizing the importance of histological diagnosis and appropriate surgical interventions. Lobectomy is recommended for solitary indeterminate nodules, while total thyroidectomy may be indicated based on certain risk factors. The guidelines also detail the goals of initial therapy for differentiated thyroid carcinoma, which include improving survival rates and accurate disease staging, alongside discussions about the role of postoperative care and risk stratification.

1. 2015 AMERICAN THYROID ASSOCIATION
MANAGEMENT
GUIDELINES FOR ADULT PATIENTS WITH
THYROID NODULES AND DIFFERENTIATED
THYROID CANCER
The American Thyroid Association Guidelines Task
Force
on Thyroid Nodules and Differentiated Thyroid Cancer
Dr Milan Sedhai
3rd year resident
ENT-HNS
IOM

4. What is the appropriate operation
for cytologically indeterminate
thyroid nodules?

5. • Primary goal: To establish a histological diagnosis and definitive
removal, while reducing the risks associated with remedial
surgery in the previously operated field if the nodule proves to be
malignant
• Appropriate surgeries:
• Lobectomy (hemithyroidectomy) with or without
isthmusectomy,
• Near-total thyroidectomy: Removal of all grossly visible
thyroid tissue, leaving only a small amount [<1 g] of tissue
adjacent to the recurrent laryngeal nerve near the ligament of
Berry, or
• Total thyroidectomy : Removal of all grossly visible thyroid

6. • Inappropriate surgeries:
• Partial lobectomy : Removal of the nodule alone,
• Subtotal thyroidectomy: Leaving >1g of tissue with the posterior
capsule on the uninvolved side
• Indeterminate nodules excluded here:
• Cytologically classified as AUS/FLUS or FN and that are positive for
known RAS mutations associated with thyroid carcinoma (84% risk of
malignancy) considered cytologically suspicious for malignancy
• Cytologically classified as AUS/FLUS or FN or SUSP and that are
positive for known BRAFV600E, RET/PTC, or PAX8/ppargamma
mutations (>95% risk of malignancy)  cytologically diagnosed
thyroid carcinoma

7. Recommendation 19 (SR)
• Solitary, cytologically indeterminate nodule
(AUS/FLUS or FN or SUSP) : Thyroid lobectomy
(recommended initial surgical approach)
• Basis for modification:
• Clinical or sonographic characteristics,
• Patient preference, and/or
• Molecular testing when performed

8. Recommendation 20 A (SR)
Total thyroidectomy (due to increased risk of malignancy)
• Indeterminate nodules: (AUS/FLUS or FN or SUSP)
• Cytologically suspicious for malignancy,
• Positive for known mutations specific for carcinoma,
• Sonographically suspicious,
• Large (>4 cm),
• 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)

9. Recommendation 20 B (WR)
Total or near-total thyroidectomy
Indeterminate nodules:
• Bilateral nodular disease,
• Those with significant medical comorbidities,
• Those who prefer to undergo bilateral thyroidectomy to
avoid the possibility of requiring a future surgery on the
contralateral lobe
(Assuming completion thyroidectomy would be recommended if the
indeterminate nodule proved malignant following lobectomy)

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

11. Recommendation 25 (SR)
• Routine TSH suppression therapy for benign
thyroid nodules in iodine sufficient populations 
Not recommended
• Harm outweighs benefit

12. Recommendation 26 (SR)
• Patients with benign, solid, or mostly solid nodules
should have adequate iodine intake
• If inadequate dietary intake is found or suspected, daily
supplementation (containing 150 mcg iodine) is
recommended

13. Recommendation 27 (A) (WR)
• Surgery may be considered for growing nodules that are
benign after repeat FNA if
 They are large (>4 cm),
 Causing compressive or structural symptoms, or
 Based upon clinical concern

14. Recommendation 27 (B) (SR)
• Patients with growing nodules that are benign after FNA
should be regularly monitored
• Most asymptomatic nodules demonstrating modest
growth should be followed without intervention

15. Recommendation 28 (WR)
• Recurrent cystic thyroid nodules with benign
cytology:
• 60-90% recurrence (fluid reaccumulation)
• Considered for surgical removal (hemithyroidectomy)
or percutaneous ethanol injection (PEI) based on
compressive symptoms and cosmetic concerns
• Asymptomatic cystic nodules: Followed conservatively

16. Recommendation 29 (NR)
• No data to guide recommendations on the use of
thyroid hormone therapy in patients with growing
nodules that are benign on cytology

17. Differentiated thyroid carcinoma
• Papillary cancer: 85%
• Follicular histology, including conventional and
oncocytic (Hu¨rthle cell) carcinomas: 12%
• Poorly differentiated : <3%

18. GOALS OF INITIAL THERAPY OF
DTC
• General goals:
To improve overall and disease-specific survival, reduce
the risk of persistent/recurrent disease and associated
morbidity, and permit accurate disease staging and risk
stratification, while minimizing treatment-related
morbidity and unnecessary therapy

19. 1. Primary tumor removal, disease that has extended beyond the
thyroid capsule, and clinically significant lymph node
metastases
• Completeness of surgical resection: Determinant of outcome
• Residual metastatic lymph nodes: The most common site of
disease persistence/recurrence
2. Minimize the risk of disease recurrence and metastatic spread
• Adequate surgery: The most important treatment variable
influencing prognosis
• RAI treatment, TSH suppression, and other treatments:
adjunctive roles
GOALS OF INITIAL THERAPY OF
DTC

20. 4. Facilitate postoperative treatment with RAI
5. Permit accurate staging and risk stratification of the disease
• Accurate postoperative risk assessment
• To guide initial prognostication, disease management, and
follow-up strategies
6. Permit accurate long-term surveillance for disease recurrence
7. Minimize treatment-related morbidity and complications
GOALS OF INITIAL THERAPY OF
DTC

21. Operative approach for a biopsy
diagnostic for follicular
cell–derived malignancy

22. Recommendation 35 (A) (SR)
• Near-total or total thyroidectomy and gross
removal of all primary tumor (unless
contraindicated):
• For patients with thyroid cancer >4 cm, or
• With gross extrathyroidal extension (clinical T4), or
• Clinically apparent metastatic disease to nodes
(clinical N1) or
• Distant sites (clinical M1)

23. Recommendation 35 (B) (SR)
• Bilateral procedure (near-total or total thyroidectomy) or a
unilateral procedure (lobectomy)
For patients with thyroid cancer >1 cm and <4 cm without
extrathyroidal extension, and without clinical evidence of any
lymph node metastases (cN0)
• Thyroid lobectomy alone: Sufficient for initial treatment for low-
risk papillary and follicular carcinomas
May opt for total thyroidectomy to enable RAI therapy or
To enhance follow-up based upon disease features and/or
patient preferences

24. Recommendation 35 (C) (SR)
• Thyroid lobectomy:
• If surgery chosen for patients with thyroid cancer <1 cm
without extrathyroidal extension and cN0
• Recommended for:
• Age less than 45 years
• Small, unifocal, intrathyroidal carcinomas
• In the absence of:
• Prior head and neck radiation
• Familial thyroid carcinoma, or
• Clinically detectable cervical nodal metastases

25. Total thyroidectomy VS Lobectomy
• Bilimoria et al, 52173 PTC patients
• Higher 10-year relative overall survival for total thyroidectomy
Vs thyroid lobectomy (98.4% vs. 97.1%, respectively, p <
0.05) and
• A lower 10-year recurrence rate (7.7% vs. 9.8%, respectively,
p < 0.05)
• Haigh et al, 5432 PTC patients (4612 TT vs 829 Lobectomy)
• No difference in 10-year overall survival between total
thyroidectomy and thyroid lobectomy when risk stratified by
the AMES classification system

26. Total thyroidectomy VS Lobectomy
• Barney et al, 23605 DTC patients (12598 TT vs 3266 lobectomy)
• No difference in 10-year overall survival (90.4% for total
thyroidectomy vs. 90.8% for lobectomy) or
• 10-year cause-specific survival (96.8% for total thyroidectomy
vs. 98.6% for lobectomy)
• Mendelsohn et al., 22,724 PTC patients (16,760 TT vs 5964
lobectomy)
• No differences in overall survival or disease specific survival

27. Total thyroidectomy VS Lobectomy
• Given the propensity for PTC to be multifocal (often involving
both lobes): Studies demonstrated lower risk of loco-regional
disease recurrence following total thyroidectomy as compared to
thyroid lobectomy
• However, with proper patient selection, loco-regional recurrence
rates of less than 1%–4% and completion thyroidectomy
rates of <10% can be achieved following thyroid lobectomy
• The few recurrences that develop during long-term follow-up are
readily detected and appropriately treated with no impact
on survival

28. Total thyroidectomy VS Lobectomy
• Near-total or total thyroidectomy recommended:
• If the overall strategy is to include RAI therapy postoperatively
• If the primary thyroid carcinoma is >4 cm,
• Gross extrathyroidal extension, or
• Regional or distant metastases (clinically)
• Bilateral thyroidectomy (total or near-total) or a unilateral
procedure (thyroid lobectomy):
• For tumors that are between 1 and 4 cm in size,

29. Referral to high volume surgeons
(>100 cases/year)
• Associated, on average, with superior outcomes.
• Reasonable to consider sending patients with more extensive
disease and concern for grossly invasive disease to a high-volume
surgeon experienced in the management of advanced thyroid
cancer
• However, even high-volume surgeons have a higher overall
postoperative complication rate when performing total thyroidectomy
compared with lobectomy (7.6% vs 14.5%)

30. Lymph node dissection

31. Recommendation 36 (A) (SR)
• Therapeutic central-compartment (level VI) neck
dissection for patients with clinically involved central
nodes should accompany total thyroidectomy to
provide clearance of disease from the central neck.

32. Recommendation 36 (B) (WR)
• Prophylactic central-compartment neck dissection (ipsilateral or
bilateral) considerations:
• Papillary thyroid carcinoma with clinically uninvolved central neck
lymph nodes (cN0) who have advanced primary tumors (T3 or
T4) or
• Clinically involved lateral neck nodes (cN1b), or
• If the information will be used to plan further steps in therapy

33. Recommendation 36 (C) (SR)
• Thyroidectomy without prophylactic central neck dissection:
• Small (T1 or T2), noninvasive clinically node-negative PTC (cN0)
and
• For most follicular cancers.

34. Recommendation 37 (SR)
• Therapeutic lateral neck compartmental lymph node
dissection:
• For patients with biopsy-proven metastatic lateral
cervical lymphadenopathy

35. Value of Neck dissection
• The SEER database study: 9904 patients with PTC,
multivariate analysis
• Lymph node metastases, age >45 years, distant metastasis,
and large tumor size significantly predicted poor overall
survival outcome
• Another SEER registry study:
• Cervical lymph node metastases conferred an independent
risk of decreased survival, but only in patients with follicular
cancer and patients with papillary cancer over age 45 years

36. Value of Neck dissection
• A recent comprehensive analysis of the National Cancer
Data Base and SEER:
• Small but Significantly increased risk of death for patients
younger than 45 years with lymph node metastases VS
younger patients without involved lymph nodes,
• Having incrementally more metastatic lymph nodes up to
six involved nodes confers additional mortality risk in this age
group

37. Value of Prophylactic Neck dissection
• Suggested to improve disease-specific survival, local recurrence,
and post-treatment Tg levels (Limited and imperfect data)
• Several studies:
• No improvement in long-term patient outcome, while
increasing the likelihood of temporary morbidity, including
hypocalcemia.
• May decrease the need for repeated RAI treatments

38. Pathological value of Prophylactic central
compartment Neck dissection and molecular
testing
Prophylactic neck dissection:
Clinically No Pathologically pN1a
AJCC stage I AJCC stage III
Outcome I: Microscopic nodal upstaging Excess utilization of RAI and
follow-up
Outcome II: Demonstration of uninvolved lymph nodes by prophylactic
dissection  may decrease the use of RAI for some groups
Concluding statement: However, microscopic nodal positivity does not
carry the recurrence risk of macroscopic clinically detectable disease
BRAFV600E mutation status in the primary tumor should not impact the
decision for prophylactic central neck dissection (Limited PPV for
recurrence)

39. Value of Prophylactic lateral compartment
Neck dissection
For patients in whom nodal disease is evident clinically on
preoperative US and nodal FNA cytology or Tg washout
measurement or at the time of surgery, surgical resection by
compartmental node dissection may reduce the risk of
recurrence and possibly mortality

40. Completion thyroidectomy

41. Recommendation 38 (A) (SR)
• Completion thyroidectomy should be offered to patients for whom a
bilateral thyroidectomy would have been recommended had the
diagnosis been available before the initial surgery.
• Therapeutic central neck lymph node dissection should be included if
the lymph nodes are clinically involved.
• Thyroid lobectomy alone may be sufficient treatment for low-risk
papillary and follicular carcinomas

42. Recommendation 38 (B) (WR)
• RAI ablation in lieu of completion thyroidectomy:
• Not recommended routinely
• May be used to ablate the remnant lobe in selected
cases

43. Need for completion thyroidectomy
• When the diagnosis of malignancy is made following
lobectomy for an indeterminate or nondiagnostic biopsy
• To provide complete resection of multicentric disease and
to allow for efficient RAI therapy

44. Completion thyroidectomy
• The surgical risks of two-stage thyroidectomy (lobectomy
followed by completion thyroidectomy) are similar to those
of a near-total or total thyroidectomy
• Ablation of the remaining lobe with RAI has been used as
an alternative to completion thyroidectomy

45. What is the appropriate perioperative
approach to voice and parathyroid issues?

46. Preoperative care communication

47. Recommendation 39 (SR)
• Prior to surgery, the surgeon should communicate with
the patient regarding surgical risks, including nerve and
parathyroid injury, through the informed consent
process and communicate with associated physicians,
including anesthesia personnel, regarding important
findings elicited during the preoperative workup

48. Recommendation 43 (SR)
• The parathyroid glands and their blood supply
should be preserved during thyroid surgery.

49. Postoperative care

50. Recommendation 44 (SR)
• Patients should have their voice assessed in the
postoperative period.
• Formal laryngeal exam should be performed if
the voice is abnormal

51. Recommendation 45 (SR)
• Important intraoperative findings and details of
postoperative care should be communicated by
the surgeon to the patient and other physicians
who are important in the patient’s postoperative
care

52. What are the basic principles of
histopathologic evaluation of
thyroidectomy samples?

53. Recommendation 46 (A) (SR)
• In addition to the basic tumor features required for AJCC/UICC
thyroid cancer staging including status of resection margins,
pathology reports should contain information helpful for risk
assessment:
• The presence of vascular invasion and the number of invaded
vessels,
• Number of lymph nodes examined and involved with tumor,
• Size of the largest metastatic focus to the lymph node, and
• Presence or absence of extranodal extension of the metastatic
tumor

54. Recommendation 46 (B) (SR)
• Identification and reporting of histopathologic variants of
thyroid carcinoma:
• Associated with more unfavorable outcomes (e.g., tall
cell, columnar cell, and hobnail variants of PTC;
widely invasive FTC; poorly differentiated
carcinoma) or
• More favorable outcomes (e.g., encapsulated
follicular variant of PTC without invasion,
minimally invasive FTC)

55. Recommendation 46 (C) (WR)
• Identification and reporting of histopathologic variants
associated with familial syndromes
• Cribriform-morular variant of papillary carcinoma
often associated with FAP,
• Follicular or papillary carcinoma associated with
PTEN-hamartoma tumor syndrome

56. What is the role of postoperative staging
systems and risk stratification in the
management of DTC?

57. Postoperative staging

58. Recommendation 47 (SR)
• AJCC/UICC staging is recommended for all
patients with DTC, based on its utility in
predicting disease mortality, and its requirement
for cancer registries

59. AJCC/UICC TNM Staging

61. What initial stratification system should be
used to estimate the risk of
persistent/recurrent disease?

62. Recommendation 48 (A) (SR)
• The 2009 ATA Initial Risk Stratification System
recommended for DTC patients treated with
thyroidectomy, based on its utility in predicting risk of
disease recurrence and/or persistence

63. Recommendation 48 (B) (WR)
• Additional prognostic variables: (Not included in the 2009
ATA Initial Risk Stratification system)
• The extent of lymph node involvement,
• Mutational status, and/or
• The degree of vascular invasion in FTC
(The Modified Initial Risk Stratification system)
• Benefits not established

64. Recommendation 48 (C) (WR)
• While not routinely recommended for initial postoperative
risk stratification in DTC, the mutational status of
BRAF, and potentially other mutations such as TERT,
have the potential to refine risk estimates when
interpreted in the context of other clinico-pathologic risk
factors

65. ATA low risk

66. ATA intermediate risk

67. ATA high risk

68. Value of risk stratification

69. Initial therapy:
Lobectomy
RAI remanant ablation
therapy not
recommended
Initial TSH goal:
1. Tg<0.2 ng/ml, TSH:0.5-2 mU/L
2. Tg>0.2 ng/ml, TSH:0.1-0.5 mU/L
Initial therapy: Total
thyroidectomy
RAI remanant ablation
therapy not
recommended
Initial TSH target:
0.5-2 mU/L
ATA low risk

70. Initial therapy: Total thyroidectomy with
therapeutic neck dissection +/-
RAI remanant ablation therapy Considered
(Remanant ablation: 30 mCi
Adjuvant therapy: upto 120 mCi)
Initial TSH goal:
TSH:0.1-0.5 mU/L
ATA intermediate risk

71. Initial therapy: Total thyroidectomy
with therapeutic neck dissection +/-
RAI remanant ablation therapy MUST
(Adjuvant therapy: upto 120 mCi)
Initial TSH goal:
TSH: <0.1 mU/L
ATA high risk

72. THANK
YOU