AACE/AME/ETA GuidelinesAmerican Association of ClinicalEndocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules: Executive Summary of Recommendations
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EXECUTIVE SUMMARY OF RECOMMENDATIONS
This is a summary constituting part of the Thyroid Nodule Guidelines document published by the American Association of Clinical Endocrinologists (AACE), the Associazione Medici Endocrinologi (Italian Association of Clinical Endocrinologists) (AME), and the European Thyroid Association (ETA). This guideline covers the diagnostic and therapeutic aspects of thyroid nodular disease but not thyroid cancer management.
The AACE protocol for standardized production of clinical practice guidelines was
THYROID NODULES: THE SCOPE OF THE PROBLEM
Thyroid nodules are common, with an estimated prevalence ranging from 3% to 7% on the basis of palpation. The prevalence of incidental thyroid nodules detected by ultrasonography (US) is estimated to be 20% to 76% in
the general population. Moreover, 20% to 48% of patients with 1 palpable thyroid nodule are found to have additional nodules when investigated by US.
History
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Record the following information (Grade B; BEL 2):
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Age
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Family history of thyroid disease or cancer
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Previous head or neck irradiation
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Rate of growth of the neck mass
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Dysphonia, dysphagia, or dyspnea
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Symptoms of hyperthyroidism orhypothyroidism
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Use of iodine-containing drugs or supplements
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Most nodules are asymptomatic, and absence ofsymptoms does not rule out malignancy (Grade C; BEL 3)
Physical Examination
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A careful physical examination of the thyroid gland and cervical lymph nodes is mandatory(Grade A; BEL 3)
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Record (Grade
When to Perform Thyroid US
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US evaluation is not recommended as a screening test in the general population or in patients with anormal thyroid gland on palpation and a low clinical risk of thyroid cancer (Grade C; BEL 3)
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US evaluation is recommended for (Grade B;BEL 3):
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Patients at risk for thyroid malignancy
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Patients with palpable thyroid nodules or MNGs
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Patients with lymphadenopathy suggestive of a malignant lesion
How to Describe US Findings
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Report should focus on risk stratification for malignancy (Grade C; BEL 4)
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Describe position, shape, size,
Thyroid FNA Biopsy
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Clinical management of thyroid nodules should be guided by the combination of US evaluation and FNA biopsy (Grade A; BEL 3)
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Cytologic diagnosis is more reliable and the nondiagnostic rate is lower when FNA biopsy is per- formed with US guidance (Grade B; BEL 3)
Cytologic Reporting
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Thyroid smears or liquid-based cytology should be reviewed by a cytopathologist with a special interest in thyroid disease (Grade C; BEL 3)
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The request form accompanying the cytologicspecimen should include all the relevant clinical and US
Laboratory Evaluation in Patients With Thyroid Nodules
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Always measure serum thyrotropin (TSH) (Grade A; BEL 3)
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If TSH level is decreased, measure free thyroxine and total or free triiodothyronine; if TSH levelis increased, measure free thyroxine and thyroid peroxidase antibodies (Grade B; BEL 3)
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Testing for antithyroglobulin antibodies shouldbe restricted to patients with US and clinical findings suggestive of chronic lymphocytic thyroiditis when serum levels of thyroid peroxidase are normal (Grade C; BEL 3)
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Assessment of serum thyroglobulin is not
When to Perform Thyroid Scintigraphy
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Perform scintigraphy for a thyroid nodule orMNG if the TSH level is below the lower limit of the reference range or if ectopic thyroid tissue or a retrosternal goiter is suspected (Grade B; BEL 3)
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In iodinedeficient regions, consider performingscintigraphy to exclude autonomy for a thyroid nodule or MNG even if TSH is normal (Grade C; BEL 3)
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How to Perform Thyroid Scintigraphy
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Either 123I or 99mTcO4 (sodium pertechnetate) can be used for thyroid scintigraphy (Grade B; BEL 3)
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131I thyroid uptake is
Nodules Nondiagnostic by FNA Biopsy (Class 1)
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If initial FNA biopsy is nondiagnostic,it shouldbe repeated with US guidance (Grade B; BEL 3)
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Most persistently nondiagnostic solid nodulesshould be surgically excised (Grade C; BEL 4)
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Core-needle biopsy may offer additional informa-tion in thyroid lesions with inadequate cytologic results of FNA biopsy (Grade C; BEL 3)
Follow-Up
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Cytologically benign nodules should be followed up (Grade C; BEL 3)
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Perform repeated clinical and US examination and TSH measurement in 6 to 18 months (Grade D)
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Perform repeated
Management of Thyroid Nodules During Pregnancy
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Thyroid nodules in pregnant women should bemanaged in the same way as in nonpregnant women; in the presence of suspicious clinical or US findings, diagnosis necessitates FNA biopsy (Grade C; BEL 3)
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Avoid use of radioactive agents for both diagnostic and therapeutic purposes (Grade A; BEL 2)
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During pregnancy, suppressive levothyroxinetherapy for thyroid nodules is not recommended (Grade C; BEL 3)
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For a growing thyroid nodule during pregnancy,follow-up should include US and FNA biopsy (Grade C; BEL 3
ACKNOWLEGMENT
AACE/AME/ETA Task Force on Thyroid Nodule Committee Members include the listed authors and Sofia Tseleni Balafouta, MD; Zubair Baloch, MD; Anna
Crescenzi, MD; Henning Dralle, MD; Roland Gärtner, MD; Rinaldo Guglielmi, MD; Jeffrey I. Mechanick, MD, FACP, FACN, FACE; Christoph Reiners, MD; Istvan Szabolcs, MD, PhD, DSc; Martha A. Zeiger, MD, FACS; and Michele Zini, MD.
DISCLOSURE
Primary Authors
Dr. Hossein Gharib reports that he does not have any relevant financial relationships with any commercial interests.
Dr. Enrico Papini reports that he does not have any relevant financial relationships with any commercial interests.
Dr. Ralf Paschke reports that he has receive speaker honoraria from Merck & Co, Inc, and sanofi-aventis U.S., LLC.
Dr. Daniel S. Duick reports that he has received speaker honorarium from Genzyme Corporation.
Dr. Roberto Valcavi reports that he does not
