First Guidelines to Address Thyroid Disease Surgery

Nancy A. Melville

March 02, 2020

The American Association of Endocrine Surgeons (AAES) has issued a
first-of-its-kind set of clinical guidelines for the surgical treatment of thyroid disease, offering evidence-based recommendations on the wide-ranging aspects of thyroidectomy and the management of benign as well as malignant thyroid nodules and cancer.

Whereas various endocrine and thyroid societies issue guidelines on many aspects of management of thyroid disease, the new AAES guidelines are the first focusing specifically on surgical management of thyroid disease in adults.

"These guidelines truly focus on the surgical decision-making and management of thyroid disease; however, there is something for all clinicians who take care of patients with thyroid disease," lead author Kepal N. Patel, MD, of NYU Langone Health in New York City, told Medscape Medical News.

The guidelines, published this week in the Annals of Surgery, include a total of 66 recommendations from a multidisciplinary panel of 19 experts. The group reviewed medical literature spanning from 1985 to 2018. (The authors of the guidelines report no conflicts of interest, although the article lists several disclosures.)

More than 100,000 thyroidectomies are performed each year in the United States alone, and as surgical indications and treatment paradigms evolve, the need for surgical guidance is more important than ever, Patel said.

"Such transformations have propagated differences in clinical interpretation and management, and as a result, clinical uncertainty and even controversy have emerged," he said.

"Recognizing the importance of these changes, the AAES determined that evidence-based clinical guidelines were necessary to enhance the safe and effective surgical treatment of benign and malignant thyroid disease."

Key areas addressed in the guidelines include the addition of new cytologic and pathologic diagnostic criteria, molecular profiling tests, operative techniques and adjuncts, and the nuances surrounding the sometimes challenging newer concept of 'borderline' thyroid tumors, Patel noted.

In terms of imaging recommendations, for instance, the guidelines recommend the preoperative use of CT or MRI:

"CT or MRI with intravenous contrast should be used preoperatively as an adjunct to ultrasound in selected patients with clinical suspicion for advanced locoregional thyroid cancer," the guidelines state, citing the recommendation as being "strong," with a "low quality of evidence." (Recommendation 6).

Further diagnostic recommendations cover issues including voice assessment, the risk for vocal fold dysfunction related to thyroid disease and surgery, and the use of fine-needle aspiration biopsy in evaluating suspicious thyroid nodules and lymph nodes.

The guidelines also address the indications for thyroidectomy, with recommendations regarding the extent and outcomes of surgery spanning different categories of thyroid disease.

A key recommendation along those lines, for instance, indicates that, when possible, thyroidectomy should be performed by surgeons who perform a high volume of such procedures.

Approaches for safe and effective perioperative management are also covered, including measures to prevent complications and the use of thyroid tissue diagnosis during surgery, such as core needle biopsy of the thyroid and cervical lymph nodes and incisional biopsy of the thyroid, nodal dissection, and concurrent parathyroidectomy.

Recommendations further address the optimal management of thyroid cancer, with an emphasis on a personalized, evidence-based approach tailored to the patient's situation and preferences.

The authors underscore that, as technology rapidly evolves, "in the future, this work will certainly and rightly need to be done again."

In the meantime, the recommendations should be relevant to "the target audience [of] the practicing surgeon in a community hospital, academic center, or training program."

An AAES press release notes that "the members of the expert panel hope their efforts will meet the need for evidence-based recommendations to 'define practice, personalize care, stratify risk, reduce healthcare costs, improve outcomes, and identify rational challenges for future efforts.' "

Ann Surg. Published online March 2, 2020. Full text

Nancy A. Melville is a freelance journalist based in York, Maine. She regularly covers thyroid disease. Her work has appeared in publications including WebMD, Dermatology Times, United Press International, and other health/medical news services.

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