New ATA Statements Address Thyroid Cancer Management

Miriam E Tucker

January 28, 2015

New consensus statements from the American Thyroid Association (ATA) address preoperative imaging for thyroid cancer surgery and the management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer.

The two documents, both written by task forces of the ATA's Surgical Affairs Committee, were published in the January 2015 issue of Thyroid. Both take in-depth looks at their respective topics and are meant to help guide practice in conjunction with the ATA's broader thyroid disease management guidelines, a revision of which is due out this year.

The imaging task force was chaired by Dr Michael W Yeh (chief of the section of endocrine surgery, University of California, Los Angeles). The recurrent/persistent disease management task force was chaired by Dr Ralph P Tufano (Charles W Cummings, MD, Professor and codirector of the Johns Hopkins Hospital Multidisciplinary Thyroid Tumor Center and director of the division of head and neck endocrine surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland).

Referring to both documents, Dr Yeh told Medscape Medical News: "This is part of an overall effort by the ATA to ensure the highest quality of care for patients with thyroid cancer. Part of that is bringing about evidence-based standards and guidelines to what we do. There's a lot of nonuniformity out there, and most of that is bad for patients. We wanted to make sure everybody gets the highest standards of care."

Of the imaging statement, he said: "The spirit of it is that in order to do a good operation you need good imaging….Inadequate lymph-node mapping is probably the single greatest deficit, so we spend the entire first part of the article on how to do a neck ultrasound for thyroid cancer. It's a very technical how-to article."

This is part of an overall effort by the ATA to ensure the highest quality of care for patients with thyroid cancer.

The other statement outlines the risks and benefits of surgical intervention vs active surveillance for patients with persistent or recurrent nodal disease. It is "aimed at all stakeholders who are contemplating next steps, to realize this is a very complicated process with a number of variables to include in the decision making," Dr Tufano said.

An important implication of both documents is: "There has to be more communication among the stakeholders involved in this process. Patients, endocrinologists, surgeons, pathologists, and radiologists all have to be communicating," he added.

An Imaging "How-to" for Thyroid Cancer

Ultrasound is used preoperatively in patients with known or suspected thyroid cancer to assess the primary tumor and to identify abnormal lymph nodes in the central and lateral neck. The first part of the imaging statement provides details on ultrasound equipment and scanning techniques and addresses assessment of both the primary tumor and the lymph nodes.

It details each of the features to assess in distinguishing benign from malignant lymph nodes, including shape, location, size, presence of calcifications, echogenicity, and vascularity.

"We spend a lot of time differentiating those. In the real world, this is done very poorly….We really want the practitioner to be both sensitive and specific in the differentiation of normal from abnormal lymph nodes in the evaluation of thyroid cancer," Dr Yeh explained.

For sonographically suspicious lymph nodes, the document then provides a "how-to" for ultrasound-guided fine-needle aspiration. For malignant cytology, use of ultrasound in the planning of both initial and revision surgery is covered.

A later section addresses situations in which the use of cross-sectional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) might be appropriate — such as incomplete imaging with ultrasound or if no ultrasound expertise is available — and also provides details on conducting the cross-sectional imaging. The document also addresses the use of functional imaging such as positron-emission tomography.

Because ultrasound — unlike CT or MRI — is user-dependent, the panel advises that expertise be based on experience, rather than completion of a specific course of training.

Dr Yeh told Medscape Medical News that he performs the ultrasounds for his patients, noting, "As a surgeon, I am accountable for the quality of their operation and for their long-term health."

However, "the guidelines say it can be done by anyone, as long as they have focused expertise in thyroid."

"One of our main emphases in the statement is that the quality of the operations hinges on the quality of the imaging, and you need to make an investment in the person who's doing the imaging.…That could be an endocrinologist, a radiologist, or a surgeon. It doesn't matter what the discipline. They just have to be into it."

Surgical Intervention or Active Surveillance?

Deciding how best to manage the patient with differentiated thyroid cancer and evidence of recurrent or persistent nodal disease can be challenging, Dr Tufano and colleagues note in their article.

One of our main emphases in the statement is that the quality of the operations hinges on the quality of the imaging.

"We follow patients very closely after their initial therapy with detailed ultrasound evaluations of the neck to look at the lymph nodes for evidence of metastasis, and we detect a lot of small nodal recurrences or persistent disease. We wrestle with whether we always have to treat those patients….In this review, we came up with a very complete list of variables for when to consider intervening," Dr Tufano told Medscape Medical News.

The document starts by outlining the classifications of recurrent and persistent disease, and local and regional recurrence.

The appropriate management of patients with nodal metastases might involve compartmental lymph-node dissection, active surveillance (watchful waiting with serial cervical ultrasound evaluations), radioactive iodine ablation therapy, external-beam radiation therapy, and/or nonsurgical, image-guided, minimally invasive ablative approaches.

In both the text and a table, the authors list the variables to consider, including absolute lymph-node size (active surveillance for 0.8 cm or smaller in the central compartment and less than 1 cm in the lateral compartment; surgery for larger nodes), rate of lymph-node growth on serial imaging, comorbidities for surgery, degree of invasion, long-term prognosis, and patient wishes.

Biological considerations include aggressive histology, extrathyroidal extension of primary tumor, and molecular prognosis for aggressive biology. Surgical/technical considerations include prior recurrences in the same or different compartments.

The paper also addresses technical considerations, parapharyngeal/retropharyngeal nodal disease, preoperative assessment, confirmation of disease, surgical technique, recurrent laryngeal-nerve invasion, and factors affecting the morbidity and efficacy of reoperation.

"In an ideal world, I could look at a molecular profile and predict what will happen. In the absence of that information, we have to use all these other criteria," Dr Tufano said.

As a result, even patients with very similar situations of recurrence or persistence may end up taking different paths.

"We were trying to make sure that providers for these patients were thinking about these variables and will include these variables in the decision-making process and share them with the patient."

Our job is to inform patients, very objectively, what we know and don't know.

"Our job is to inform patients, very objectively, what we know and don't know. And then the patients, with good psychosocial support and the ability to ask questions, make the decision for themselves that provides the most value," he concluded.

Dr Yeh and the other members of the imaging task force have no relevant financial relationships. Dr Tufano has no relevant financial relationships; disclosures for the coauthors are listed in the article.

Thyroid. 2015;25:3-14, 15-27. Yeh abstract, Tufano abstract

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