This document provides guidelines for evaluating and managing thyroid nodules and differentiated thyroid cancer. It recommends that thyroid sonography be performed on all patients with known or suspected thyroid nodules to evaluate the thyroid parenchyma, nodule characteristics, and cervical lymph nodes. Nodules are classified based on sonographic features into categories of high, intermediate, low, or very low suspicion of malignancy. It provides treatment recommendations based on nodule size, characteristics, extrathyroidal extension, and lymph node involvement.

2. 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)
RECOMMENDATION 6
2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules
and Differentiated Thyroid Cancer
U/S Thyroid ?

3. • Thyroid parenchyma (homogeneous or heterogeneous)
• Gland size; size, location
• Sonographic characteristics of any nodule(s) :
- composition (solid, cystic proportion,or spongiform)
- echogenicity
- margins
- presence and type of calcifications
- shape : taller than wide ?
- vascularity
• The presence or absence of any suspicious cervical lymph nodes in the
central or lateral compartments.
Ultrasound should evaluate the following:

5. • Solid hypoechoic nodule or a solid hypoechoic component in a partially
cystic nodule with one or more of the following features:
 Irregular margins (specifically defined as infiltrative,microlobulated, or
spiculated)
 Microcalcifications
 Taller than wide shape (transverse view)
 Disrupted rim calcifications with small extrusive hypoechoic soft tissue
component
 Evidence of extrathyroidal extension.
High suspicion [malignancy risk >70%–90%
Likely to be PTCRecommend FNA at >1 cm

6. • Hypoechoic solid nodule with a smooth regular margin,
• Without : microcalcifications
extrathyroidal extension
taller than wide shape
• This appearance has the highest sensitivity (60%–80%) for PTC,
Intermediate suspicion [malignancy risk 10%–20%]
Recommend FNA at >1 cm

7. • Isoechoic or hyperechoic solid nodule
• partially cystic nodule with eccentric uniformly solid areas
• Without - microcalcifications
- irregular margin
- extrathyroidal extension,
- taller than wide shape
• Only about 15%–20% of thyroid cancers are iso- or
hyperechoic
Low suspicion [malignancy risk 5%–10%]
Recommend FNA at >1.5 cm

8. • Spongiform
• partially cystic nodules
• without any of the sonographic features described in the low,
intermediate, or high suspicion patterns
• a low risk of malignancy (<3%)
Very low suspicion [<3%]
Consider FNA at > 2 cm
Observation without FNA is also a reasonable option

9. • Purely cystic nodules are very unlikely to be malignant
• fine-needle biopsy is not indicated for diagnostic purposes
Benign [<1%]
No biopsy

13. Operative approach for a biopsy diagnostic for
follicular cell derived malignancy
RECOMMENDATION 35

14. Operative approach for a biopsy diagnostic for
follicular cell derived malignancy
• Thyroid cancer >4 cm
• Gross extrathyroidal
extension (clinical T4)
• Clinically apparent
metastatic disease to
nodes (clinical N1)
• Distant sites (clinical M1)
A near-total or total thyroidectomy
(Strong recommendation, Moderate-quality evidence)
• Older age (>45 years)
• contralateral thyroid nodules
• Hx of RT to the head and neck
• familial DTC
In special group that plans for
RAI therapy or to facilitate
follow-up strategies or address
suspicions of bilateral disease

15. • Thyroid cancer >1 cm and <4 cm
• without extrathyroidal extension
• without clinical evidence of any lymph node metastases
(cN0)
lobectomyNear total or total thyroidectomy Or
Operative approach for a biopsy diagnostic for
follicular cell derived malignancy
• low-risk papillary and
follicular carcinomas
• may choose total thyroidectomy to
enable RAI therapy postop
(Strong recommendation, Moderate-quality evidence)
• 10-year overall survival (90.4% for total thyroidectomy vs. 90.8% for lobectomy)
• 10-year cause-specific survival (96.8% for total thyroidectomy vs. 98.6% for lobectomy)
• proper patient selection, loco-regional recurrence rates of less than 1%–4%

16. Operative approach for a biopsy diagnostic for follicular
cell derived malignancy
• Thyroid cancer <1 cm ; small,unifocal, intrathyroidal carcinomas
• without extrathyroidal extension
• without clinical evidence of any lymph node metastases (cN0)
• Absence of prior head and neck radiation
• No familial thyroid carcinoma
thyroid lobectomy
(Strong recommendation, Moderate-quality evidence)

17. AJCC 7th Edition/TNM Classification
System for Differentiated Thyroid Carcinoma

18. Lymph node dissection

19. Lymph node dissection
• For patient with clinically
involved central node
(strong recommendation)
Central compartment (level VI) dissection
Therapeutic
• The role of prophylactic central
node dissection in cN0 disease is
still unclear
• Should be considered in patient
with PTC with advanced primary
tumor (T3 or T4) or clinically
involved lateral neck node (N1b).
(weak recommendation)
• Thyroidectomy without
prophylactic central node
dissection is appropriate for small
(T1 or T2) PTC, noninvasive and
most of follicular cancers.
(strong recommendation)
Prophylactic

20. Lymph node dissection
Lateral compartment dissection
(level II-V, level VII, rarely level I)
• Should be performed for patient with biopsy-proven
metastatic lateral cervical node
(strong recommendation)
Therapeutic

21. RAI ablation

22. RAI ablation
• Goal of administration of RAI after
thyroidectomy
1. RAI remnant ablation (facilitate detection of
recurrence disease)
2. RAI adjuvant therapy (improve disease-free
survival)
3. RAI therapy (treat persistent disease)

24. RAI ablation
• RAI adjuvant therapy is routinely recommended after
total thyroidectomy in ATA high risk
(strong recommendation)
• RAI adjuvant therapy should be considered after
total thyroidectomy in ATA intermediate risk
(weak recommendation)

25. • Gross extrathyroidal extension
• Distant metastasis
• Incomplete tumor resection
• Pathological N1 with node ≥ 3 cm In largest diameter
• Follicular carcinoma with extensive vascular invasion
RAI ablation
ATA high risk

27. • RAI remnant ablation is not routinely
recommended after thyroidectomy in papillary
microcarcinoma (tumor < 1 cm) in absence of
adverse features.
(strong recommendation)
• RAI remnant ablation is not routinely
recommended after thyroidectomy in ATA low
risk patient.
(weak recommendation)
RAI ablation

28. Papillary thyroid cancer with
• No gross extrathyroidal extension, no metastasis, complete
resection of tumor
• Tumor does not have aggressive histology (tall cell, hobnail
variant, columnar cell carcinoma)
• No vascular invasion
• Clinical N0 or ≤ 5 pathological N1 micrometastases (< 0.2 cm)
ATA low risk
RAI ablation

29. • Intrathyroidal encapsulated follicular variant PTC
• Intrathyroidal papillary microcarcinoma, unifocal or
multifocal, including BRAF mutation
• Intrathyroidal well-diff. follicular carcinoma and no or
minimal vascular invasion (<4 foci)
ATA low risk
RAI ablation

30. TSH suppression

31. TSH suppression
• For high risk patient, initial TSH suppression
to below 0.1 mU/L is recommended. (strong
recommendation)
• For intermediate risk patient, initial TSH
suppression to 0.1-0.5 mU/L is recommended.
(weak recommendation)

32. TSH suppression
• For low risk patient who underwent lobectomy, TSH
may be maintained at 0.5-2 mU/L. (weak
recommendation)
• For low risk patient who underwent remnant ablation
with undetectable serumTg, TSH may be maintained at
0.5-2 mU/L. (weak recommendation)
• For low risk patient who underwent remnant ablation
with low serumTg, TSH may be maintained at 0.1-0.5
mU/L. (weak recommendation)

33. Thank you
Any question ?