2015 American Thyroid Association Management Guidelines ...

1 1 1 Thyroid 2015 American Thyroid Association DOI: 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid CancerBryan R. Haugen, (Chair)*, Erik K. Alexander, , Keith C. Bible, , , Gerard M. Doherty, , Susan J. Mandel, , , Yuri E. Nikiforov, , , Furio Pacini, , Gregory W. Randolph, , Anna M. Sawka, , , Martin Schlumberger, , Kathryn Schuff, , Steven I. Sherman, , Julie Ann Sosa, , David L. Steward, , R.

2 Michael Tuttle, , and Leonard Wartofsky, *Authors are listed in alphabetical order and were appointed by ATA to independently formulate the content of this manuscript. None of the scientific or medical content of the manuscript was dictated by the ATA. 1 University of Colorado School of Medicine, Aurora, Colorado. 2 Brigham and Women s Hospital, Harvard Medical School, Boston, Massachusettes. 3 The Mayo Clinic, Rochester, Minnesota. 4 Boston Medical Center, Boston, Massachusettes. 5 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. 6 University of Pittsburgh Medical Center, Pittsburgh, Pennsylvannia.

3 7 The University of Siena, Siena, Italy. 8 Massachusettes Eye and Ear Infirmary, Massachusettes General Hospital, Harvard Medical School, Boston, Massachusettes. 9 University Health Network, University of Toronto , Toronto, Canada. 10 Institute Gustave Roussy and University Paris Sud, Villejuif, France. 11 Oregon Health and Science University, Portland, Oregon. 12 University of Texas Anderson Cancer Center, Houston, Texas. 13 Duke University School of Medicine, Durham, North Carolina. 14 University of Cincinnati Medical Center, Cincinnati, Ohio. 15 Memorial Sloan-Kettering Cancer Center, New York, New York.

4 16 MedStar Washington Hospital Center, Washington, DC. Running title: ATA Thyroid Nodule/DTC Guidelines Page 1 of 411 Thyroid Downloaded from by on 11/04/15. For personal use 2 ABSTRACT Background: Thyroid nodules are a common clinical problem, and differentiated Thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association s Guidelines for the Management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these Guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and Management of Thyroid nodules and differentiated Thyroid cancer.

5 Methods: The specific clinical questions addressed in these Guidelines were based on prior versions of the Guidelines , stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including: electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians (ACP) Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions.

6 We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed and communicated to the ATA and task force members. Results: The revised Guidelines for the Management of Thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers and Management of benign Thyroid nodules.

7 Recommendations regarding the initial Management of Thyroid cancer include those relating to screening for Thyroid cancer, staging and Page 2 of 411 Thyroid Downloaded from by on 11/04/15. For personal use 3 risk assessment , surgical Management , radioiodine remnant ablation and therapy, and TSH suppression therapy using levothyroxine. Recommendations related to long-term Management of differentiated Thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, Thyroid hormone therapy, Management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

8 Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the Management of Thyroid nodules and differentiated Thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders. Page 3 of 411 Thyroid Downloaded from by on 11/04/15. For personal use 4 INTRODUCTION Thyroid NODULES are a common clinical problem. Epidemiologic studies have shown the prevalence of palpable Thyroid nodules to be approximately 5% in women and 1% in men living in iodine-sufficient parts of the world (1;2). In contrast, high-resolution ultrasound (US) can detect Thyroid nodules in 19 68% of randomly selected individuals with higher frequencies in women and the elderly (3;4).

9 The clinical importance of Thyroid nodules rests with the need to exclude Thyroid cancer, which occurs in 7 15% depending on age, sex, radiation exposure history, family history, and other factors (5;6). Differentiated Thyroid cancer (DTC), which includes papillary and follicular cancer, comprises the vast majority (>90%) of all Thyroid cancers (7). In the United States, approximately 63,000 new cases of Thyroid cancer were predicted to be diagnosed in 2014 (8) compared with 37,200 in 2009 when the last ATA Guidelines were published. The yearly incidence has nearly tripled from per 100,000 in 1975 to per 100,000 in 2009 (9).

10 Almost the entire change has been attributed to an increase in the incidence of papillary Thyroid cancer (PTC). Moreover, 25% of the new Thyroid cancers diagnosed in 1988-89 were < 1cm compared with 39% of the new Thyroid cancer diagnoses in 2008-9 (9). This tumor shift may be due to the increasing use of neck ultrasonography or other imaging and early diagnosis and treatment (10), trends that are changing the initial treatment and follow-up for many patients with Thyroid cancer. A recent population based study from Olmsted County reported the doubling of Thyroid cancer incidence from 2000-2012 compared to the prior decade as entirely attributable to clinically occult cancers detected incidentally on imaging or pathology (11).