The 2015 guidelines recommended some key changes to surgical treatment of thyroid nodules. One primary change was the recommendation for hemithyroidectomy for low-risk thyroid cancer instead of a more aggressive total thyroidectomy and elective central node dissection for these cancers. “Prior to the 2015 guidelines, if a patient had a cancer 10 mm or more, he or she got a total thyroidectomy,” said Dr. Terris.“Now you can have only a hemithyroidectomy for cancers up to 40 mm, and that is clinically important because we’re saving many patients from the risk of significant harm.”
Explore This IssueFebruary 2020
Dr. Shindo also highlighted the significant changes in the new 2015 guidelines with regard to the extent of surgery for thyroid cancer, saying that the guidelines state that hemithyroidectomy alone may be sufficient initial treatment for low-risk papillary and follicular carcinoma in cancer between 1 and 4 cm in the absence of lymph node metastasis. But she also said that one of the limitations of the guideline was that it did not emphasize the need to correlate ultrasound images with the clinical picture to ensure an accurate assessment.
“For example, if a clinician doesn’t review the ultrasound images, they may miss an extra thyroid extension or some of the other aggressive-looking features and decide on a conservative surgical approach,” she said. “In order to take a conservative approach with surgery, or even doing the biopsy, it requires that the clinician looks at the imaging studies.”
If molecular testing is going to be used, patients should be counseled regarding the potential benefits and limitations of the testing and about possible uncertainties in the therapeutic and long-term clinical implications of the results. —Maisie Shindo, MD
Failure to correlate the imaging findings with the clinical picture could lead to undertreating or overtreating the patient, she said.
Dr. Steward emphasized that using a more conservative surgical approach of lobectomy versus total thyroidectomy preserves the vulnerable structures around the thyroid gland: the laryngeal nerves and parathyroid glands. “This has the goal of reducing patient morbidity and complications from overtreatment of cancers that have very low risk of mortality,” he said.
Greg Randolph, MD, professor of otolaryngology-head and neck surgery and the Claire and John Bertucci Endowed Chair in thyroid surgical oncology at Harvard Medical School in Boston, highlighted a number of recommendations in the 2015 ATA guideline that have had a significant impact on practice, particularly for stressing the important role of otolaryngologists in the management of thyroid cancer.
For example, he described ATA guideline Recommendation 40, which states that all patients who undergo thyroid surgery should have their voice evaluated prior to surgery. “If a patient presents with a voice abnormality, that is an important finding that may suggest a cancer extending outside the thyroid gland and invading into the recurrent laryngeal nerve,” he said.
He also highlighted Recommendation 41, which states the need for a preoperative laryngeal exam (in addition to voice evaluation) in all patients with a voice abnormality, with a history of surgery of the neck or chest that could have injured the vagus or laryngeal nerve, or with evidence of extrathyroid extension or significant central neck nodal metastases. “In these three circumstances, you need to exam the larynx prior to surgery,” he said.
All of these recommendations, he said, were incorporated into the ATA 2015 guidelines based on evidence first published in the Clinical Practice Guidelines: Improving Voice Outcomes After Thyroid Surgery by the American Academy of Otolaryngology–Head and Neck Surgery in 2013 (Otolaryngol Head Neck Surg. 2013;148(6 Suppl):S1-37).