The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

Abstract

Objective: To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. Background: Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. Methods: The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. Results: These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. Conclusions: Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Preoperative Serum Calcitonin and Its Correlation with Extent of Lymph Node Metastasis in Medullary Thyroid Carcinoma

“…The extent of lymph node dissection at the time of thyroidectomy is an ongoing discussion. Because the central node compartment is the site of primary lymphatic drainage from the thyroid, and LNM occurs during the early course of MTC [ 20 , 21 ], the guidelines of the ATA/European Thyroid Association (ETA), the British Thyroid Association (BTA), and the American Association of Endocrine Surgeons (AAES) recommend central node compartment dissection regardless of unequivocal evidence of cervical LNM [ 9 , 16 , 22 ]. However, the NCCN guidelines recommend total thyroidectomy with cervical dissection for primary tumors greater than 1.0 cm in diameter or bilateral thyroid disease [ 15 ].…”

“…Prophylactic lateral node dissection is more controversial. The preoperative serum calcitonin level and ultrasound findings can be helpful for determining the need for lateral node dissection [ 9 , 16 ]. Machens et al reported preoperative serum calcitonin levels based on the pathologic extent of disease [ 17 ].…”

“…The standard initial treatment for MTC is surgery, and surgery is the only curative treatment option [ 9 , 15 , 16 ]. However, the extent of initial surgery for MTC is controversial because of the possibility of complications and its unknown benefits.…”

“…By contrast, despite the general agreement that the therapeutic procedure for both sporadic and familial MTC is total thyroidectomy with central lymph node dissection, the National Comprehensive Center Network (NCCN) guidelines suggest that central neck dissection may not be necessary for MTCs ≤1 cm [ 15 ]. Based on a previous study reporting that ipsilateral and contralateral lateral lymph node metastasis (LNM) is associated with basal serum calcitonin levels exceeding 20 and 200 pg/mL, respectively [ 17 ], the current guidelines suggest that lateral lymph node dissection may be considered as a result of the serum calcitonin level and the results of ultrasound scans [ 9 , 16 ]. However, previous studies have reported threshold calcitonin levels depending only on the presence of LNM [ 12 , 17 , 18 ].…”

Thyroid Nodule Molecular Testing: Is It Ready for Prime Time?

“…The ongoing evolution of these tests, combined with academic, clinical, and commercial interests, suggests that these molecular tests are now firmly part of the diagnostic armamentarium for thyroid nodules. Indeed, medical societal guidelines have continued to include discussion on molecular testing as diagnostic adjuncts for indeterminate thyroid nodules ( 1 – 3 , 14 – 16 ).…”