Thyroid carcinomas are fairly uncommon and include disease types that range from indolent localised papillary carcinomas to the fulminant and lethal anaplastic disease. Several attempts to formulate a consensus about treatment of thyroid carcinoma have resulted in published guidelines for diagnosis and initial disease management. Multimodality treatments are widely recommended, although there is little evidence from prospective trials to support this approach. Surgical resection to achieve local disease control remains the cornerstone of primary treatment for most thyroid cancers, and is often followed by adjuvant radioiodine treatment for papillary and follicular types of disease. Thyroid hormone replacement therapy is used not only to rectify postsurgical hypothyroidism, but also because there is evidence to suggest that high doses that suppress thyroid stimulating hormone prevent disease recurrence in patients with papillary or follicular carcinomas. Treatment for progressive metastatic disease is often of limited benefit, and there is a pressing need for novel approaches in treatment of patients at high risk of disease-related death. In families with inherited thyroid cancer syndromes, early diagnosis and intervention based on genetic testing might prevent poor disease outcomes. Care should be carefully coordinated by members of an experienced multidisciplinary team, and patients should be provided with education about diagnosis, prognosis, and treatment options to allow them to make informed contributions to decisions about their care.

A set of minimum clinical guidelines for use by primary care physicians in the evaluation and management of patients with thyroid nodules or thyroid cancer was developed by consensus by an 11-member Standards of Care Committee (the authors of the article) of the American Thyroid Association, New York, NY. The participants were selected by the committee chairman and by the president of the American Thyroid Association based on their clinical experience. The committee members represented different geographic areas within the United States, to reflect different practice patterns. The guidelines were developed based on the expert opinion of the committee participants, as well as on previously published information. Each committee participant was initially assigned to write a section of the document and to submit it to the committee chairman, who revised and assembled the sections into a complete draft document, which was then circulated among all committee members for further revision. Several of the committee members further revised and refined the document, which was then submitted to the entire membership of the American Thyroid Association for written comments and suggestions, many of which were incorporated into a final draft document, which was reviewed and approved by the Executive Council of the American Thyroid Association.

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines.Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.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, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

This systematic review and meta-analysis collected data for evaluating the effect of surgical extent on overall survival (OS) and recurrence-free survival (RFS) in patients with papillary thyroid cancer (PTC).

Recurrent laryngeal nerve (RLN) injury is an intractable complication of thyroidectomy. Intraoperative nerve monitoring (IONM) was designed to prevent RLN injury. However, the results concerning the protective effect of IONM on RLN injury are still controversial. We searched all eligible databases from 1980 to 2017. Meta-analysis was performed to evaluate the effect of IONM on RLN injury. Sensitivity analysis was also conducted to check the stability of our results. There were 34 studies included in the analysis. Overall analysis found a significant decrease in total injury (RR = 0.68, 95%CI: 0.55 to 0.83), transient injury (RR = 0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD = -0.0026, 95%CI: -0.0039 to -0.0012) with IONM. Subgroup analysis found IONM played a preventive role of total, transient and permanent injury in patients undergoing bilateral thyroidectomy. IONM also reduced the incidence of total and transient injury for malignancy cases. Operations with IONM were associated with fewer total and transient RLN injuries in operation volume < 300 NARs per year and fewer total and permanent RLN injuries in operation volume >= 300 NARs per year. The application of IONM could reduce the RLN injury of thyroidectomy. Particularly, we recommend routine IONM for use in bilateral operations and malignancy operations.

Initial treatments for patients with differentiated thyroid cancer are supported primarily by single-institution, retrospective studies, with limited follow-up and low event rates. We report updated analyses of long-term outcomes after treatment in patients with differentiated thyroid cancer.The objective was to examine effects of initial therapies on outcomes.This was a prospective multi-institutional registry.A total of 4941 patients, median follow-up, 6 years, participated.Interventions included total/near-total thyroidectomy (T/NTT), postoperative radioiodine (RAI), and thyroid hormone suppression therapy (THST).Main outcome measures were overall survival (OS) and disease-free survival using product limit and proportional hazards analyses.Improved OS was noted in NTCTCS stage III patients who received RAI (risk ratio [RR], 0.66; P =.04) and stage IV patients who received both T/NTT and RAI (RR, 0.66 and 0.70; combined P =.049). In all stages, moderate THST (TSH maintained subnormal-normal) was associated with significantly improved OS (RR stages I-IV: 0.13, 0.09, 0.13, 0.33) and disease-free survival (RR stages I-III: 0.52, 0.40, 0.18); no additional survival benefit was achieved with more aggressive THST (TSH maintained undetectable-subnormal). This remained true, even when distant metastatic disease was diagnosed during follow-up. Lower initial stage and moderate THST were independent predictors of improved OS during follow-up years 1-3.We confirm previous findings that T/NTT followed by RAI is associated with benefit in high-risk patients, but not in low-risk patients. In contrast with earlier reports, moderate THST is associated with better outcomes across all stages, and aggressive THST may not be warranted even in patients diagnosed with distant metastatic disease during follow-up. Moderate THST continued at least 3 years after diagnosis may be indicated in high-risk patients.

Since papillary thyroid cancer (PTC) patients with pre-ablation stimulated thyroglobulin (s-Tg) < 1 ng/mL generally have a favorable prognosis, is TSH suppression still necessary in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL after initial therapy? The aim of this study was to assess the rate of disease recurrence in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL according to TSH levels measured 1 year after initial therapy.A retrospective series of intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL was analyzed. Disease status was defined as the presence or absence of structural disease during late follow-up. Patients were grouped according to TSH level at 1 year: group 1, TSH < 0.1 mIU/L; group 2, TSH 0.1‒0.5 mIU/L; group 3, 0.5‒2 mIU/L; group 4, >2 mIU/L.This study included 166 patients (78.3% females, median age 44 years) of whom the risk of recurrence was intermediate in 97 (58.4%) and high in 69 (41.6%). The response to initial therapy at 1 year was excellent in 163 patients (98.2%) and indeterminate in 3 (1.8%). Group 1 consisted of 63 patients (38%), group 2 of 47 (28%), group 3 of 28 (17%), and group 4 of 28 (17%). During a median follow-up duration of 5.8 years, disease recurrence was observed in only 4 patients (2.4%). The rate of disease recurrence was not significantly different between the TSH groups.TSH suppression before the first response to treatment assessment does not seem to influence the rate of disease recurrence after initial therapy in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL.

TSH suppression therapy has been used to decrease thyroid cancer recurrence. However, validation of effects through studies providing a high level of evidence has been lacking.This single-center, open-label, randomized controlled trial tested the hypothesis that disease-free survival (DFS) for papillary thyroid carcinoma (PTC) in patients without TSH suppression is not inferior to that in patients with TSH suppression.Participants were randomly assigned to receive postoperative TSH suppression therapy (group A) or not (group B). Before assignment, patients were stratified into groups with low- and high-risk PTC according to the AMES (age, metastasis, extension, size) risk-group classification.For patients assigned to group A, L-T(4) was administered to keep serum TSH levels below 0.01 μU/ml. TSH levels were adjusted to within normal ranges for patients assigned to group B. Recurrence was evaluated by neck ultrasonography and chest computed tomography.Eligible participants were recruited from 1996-2005, with 218 patients assigned to group A and 215 patients to group B. Analysis was performed on an intention-to-treat basis. DFS did not differ significantly between groups. The 95% confidence interval of the hazard ratio for recurrence was 0.85-1.27 according to Cox proportional hazard modeling, within the margin of 2.12 required to declare 10% noninferiority.DFS for patients without TSH suppression was not inferior by more than 10% to DFS for patients with TSH suppression. Thyroid-conserving surgery without TSH suppression should be considered for patients with low-risk PTC to avoid potential adverse effects of TSH suppression.

Pregnancy may be associated with an increased risk of recurrence/progression of differentiated thyroid cancer (DTC). However, it is unclear if the impact of pregnancy would differ based on pre-pregnancy response to therapy status. The objective of this study was to investigate the risk of recurrence/progression of DTC, applying the response to therapy assessments to pre-pregnancy status as recommended by the 2015 American Thyroid Association thyroid cancer guidelines.This was a retrospective review of 235 women followed at Memorial Sloan Kettering Cancer Center for DTC who had a term pregnancy after initial treatment for DTC between 1997 and 2015.Structural disease recurrence/progression after pregnancy was documented in 5% (11/235) of the patients. When evaluated 3-12 months after delivery, patients who had an excellent, indeterminate, or biochemical incomplete response before pregnancy continued to show no evidence of structurally identifiable disease. Conversely, in women with a structural incomplete response to therapy prior to pregnancy, structural progression (defined as ≥3 mm increase in the size of known disease or identification of new metastatic foci) was identified after delivery in 29% (11/38). However, additional therapy was recommended during the first postpartum years in only 8% (3/38) of those patients who had a structural incomplete response to therapy prior to pregnancy, while the remainder (92%) continued to be followed with observation.None of the patients with an excellent, indeterminate, or biochemical incomplete response to therapy prior to pregnancy developed structurally identifiable disease after a full-term delivery. Even though structural disease progression was seen in almost a third of the patients with known structural disease prior to pregnancy, only a minority of these patients had changes sufficient to warrant additional therapy. These data confirm that pre-pregnancy response to therapy status is an excellent predictor of pregnancy-associated disease progression in women previously treated for DTC.

Pregnancy-related hormones may stimulate thyroid cancer growth, but whether pregnancy affects the prognoses of patients with lung metastases from differentiated thyroid cancer (DTC-LM) after surgery and radioiodine therapy is unclear.To assess the impact of pregnancy on DTC-LM through the comparison of prognoses between female patients with DTC-LM who did and did not become pregnant after surgery and radioiodine therapy.We retrospectively analyzed the records of 124 female patients aged 16-35 years who underwent surgery and radioiodine therapy for DTC-LM. These patients were divided into pregnancy group (n=37) and non-pregnancy group (n=87) according to whether they became pregnant after surgery and radioiodine therapy, regardless of whether they had a pregnant history before treatment.The 5- and 10-years PFS rates were 94.52% and 63.22% in pregnancy group versus 89.82% and 58.13% in non-pregnancy group. The 5- and 10-years cumulative OS rates of pregnancy group is 97.30% and 85.77% versus 93.50% and 81.95% in non-pregnancy group (all P>0.05). The median time of follow-up in the pregnancy and non-pregnancy group was 82 months (25-136 months) and 68 months (13-133 months), respectively. Non- 131I-avid LM and primary tumors needing repeated resection were independent predictors of poor PFS for patients in pregnancy group.Pregnancy does not affect the prognoses of patients with DTC-LM after surgery and radioiodine therapy. Non- 131I avid LM and repeated primary tumor surgeries are independent risk factors for poor prognoses of pregnant patients.© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.