Surgical Management of Thyroid Disease Clinical Practice Guidelines (2020)

American Association of Endocrine Surgeons (AAES)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 28, 2020

The guidelines on surgical management of thyroid disease were released in March 2020 by the American Association of Endocrine Surgeons (AAES).[1]

Initial Evaluation

Evaluation of thyroid disease should include specific inquiry about personal and family history, clinical characteristics, and symptoms. Preoperative physical examination should include voice assessment.

Thyroid-stimulating hormone (TSH) should be measured in patients with nodular thyroid disease. Additional laboratory studies may help in specific circumstances.

Imaging

Diagnostic ultrasonography (US) should be performed in all patients with a suspected thyroid nodule.

US assessment of bilateral central and lateral lymph node (LN) compartments should be performed in the preoperative evaluation of patients with cytologic evidence of thyroid carcinoma and may be performed in the preoperative evaluation of those with indeterminate cytologic evidence.

Computed tomography (CT) or magnetic resonance imaging (MRI) with intravenous (IV) contrast should be used preoperatively as an adjunct to US in selected patients with clinical suspicion for advanced locoregional thyroid cancer.

Fine-Needle Aspiration Biopsy Diagnosis

Indications for fine-needle aspiration biopsy (FNAB) should follow established guidelines based on US characteristics, size, and clinical findings. FNAB of a sonographically suspicious cervical LN (CLN) should be performed when the results will alter the treatment plan.

In most circumstances, FNAB yield and adequacy may be optimized by using US guidance, with or without on-site cytologic assessment.

The Bethesda System for Reporting Thyroid Cytopathology should be used to report and stratify the risk of malignancy in a thyroid nodule.

Molecular Testing

If thyroidectomy is preferred for clinical reasons, molecular testing (MT) is unnecessary.

When the need for thyroidectomy is unclear after consideration of clinical, imaging, and cytologic features, MT may be considered as a diagnostic adjunct for cytologically indeterminate nodules.

The accuracy of MT relies on institutional malignancy rates and should be locally examined for optimal extrapolation of results to thyroid cancer risk.

Indications, Extent, and Outcomes of Surgery

Patients with a thyroid nodule, goiter or thyroiditis who exhibit local compressive symptoms or progressive enlargement should be considered for thyroidectomy.

Thyroidectomy is one of several options for treatment of hyperthyroidism and should be preferentially considered when radioactive iodine (RAI) or medical therapy is contraindicated or undesirable.

For nodules cytologically categorized as Bethesda III, clinical factors, radiologic features, and patient preference should inform decisions about proceeding with repeat biopsy, MT, diagnostic thyroidectomy, or observation.

Diagnostic thyroidectomy, MT, and a combination of the two are all accepted options for patients with nodules cytologically categorized as Bethesda IV.

Thyroidectomy is indicated for thyroid nodules >1 cm cytologically categorized as Bethesda V or VI.

When possible, thyroidectomy should be performed by a high-volume thyroid surgeon.

Antimicrobial prophylaxis is not necessary in most cases of standard transcervical thyroid surgery.

Before thyroidectomy, in the absence of contraindications, a single preoperative dose of dexamethasone should be considered to reduce nausea, vomiting, and pain.

If surgery is chosen to treat Graves disease (GD), patients should be rendered clinically euthyroid preoperatively. A potassium iodide–containing preparation can be considered before surgery.

Gastric bypass patients should be counseled about a higher risk of severe postoperative hypocalcemia after total or completion thyroidectomy.

Before thyroid surgery for GD, calcium and 25-hydroxy vitamin D levels may be assessed and replenished or supplemented prophylactically.

Chemical venous thromboembolism (VTE) prophylaxis should be reserved for selected patients determined to be at high risk for VTE after thyroidectomy.

Initial Thyroidectomy

The superior-pole vessels should be ligated close to the thyroid capsule to avoid potential injury to the external branch of the superior laryngeal nerve (EBSLN).

The recurrent laryngeal nerve (RLN) should be identified so as to help preserve it.

Dissection should be performed along the thyroid capsule to help preserve the parathyroid glands. If a parathyroid gland cannot be preserved, parathyroid autotransplantation should be performed.

Perioperative Tissue Diagnosis

Core needle biopsy should be rarely utilized in the initial evaluation of a thyroid nodule.

Intraoperative pathologic evaluation (IOPE) of the thyroid should be performed only in settings where the information it provides has a high likelihood of altering the operative procedure.

IOPE has value in confirming identification of parathyroid tissue. It has value in identification of CLN metastases when the information may alter the extent of surgery.

A standardized synoptic pathology report is recommended for reporting thyroid neoplasms.

Nodal Dissection

During initial thyroidectomy for papillary thyroid cancer (PTC), the central compartment should be assessed for suspicious lymphadenopathy. If clinical or imaged LN metastasis (LNM) is present (ie, macroscopic disease), a therapeutic central compartment nodal dissection (ND) is recommended.

A compartment-oriented therapeutic lateral ND is recommended for lateral LNM. Prophylactic lateral ND is not indicated for PTC.

Concurrent Parathyroidectomy

Hypercalcemia should be evaluated preoperatively in a patient being evaluated for thyroid surgery.

Patients undergoing initial thyroidectomy who are diagnosed with primary hyperparathyroidism (pHPT) should undergo concurrent parathyroidectomy.

Evaluation for hyperparathyroidism is recommended in patients scheduled to undergo thyroid surgery who have a history of familial pHPT.

Hyperthyroid Conditions

In patients with moderate-to-severe Graves ophthalmopathy, total thyroidectomy should be considered as first-line definitive treatment.

Because of the higher risk and greater technical difficulty, thyroidectomy for GD is best performed by high-volume thyroid surgeons.

Goiter

When surgery is indicated, total thyroidectomy is preferred for treatment of bilateral goiter. When the contralateral lobe is normal, lobectomy with isthmusectomy is recommended for treatment of unilateral goiter.

Cross-sectional imaging of goiter is recommended if there is concern for a substernal component.

In the performance of surgery for substernal goiter, good communication, preparation, and cooperation of experienced surgical and anesthesia teams are recommended.

Adjuncts and Approaches

Although RLN monitoring (RLNM) does not prevent RLN injury, it is safe and may assist the surgeon during initial or reoperative thyroidectomy.

During planned total thyroidectomy, after completion of the initial lobectomy, if RLNM suggests loss of function, the surgeon may consider stopping the operation for possible completion later.

Rapid parathyroid hormone (PTH) measurement during or after total or completion thyroidectomy may help in managing patients at risk for hypocalcemia.

Remote-access thyroidectomy should be performed only in carefully selected patients and only by surgeons experienced in the approach.

Laryngology

In preoperative discussion of thyroidectomy, the surgeon should disclose to the patient the possibility, likelihood, and implications of permanent vocal-fold dysfunction.

Before thyroidectomy, laryngeal examination should be performed in patients determined to have vocal abnormalities as assessed by the surgeon, preexisting laryngeal disorders, previous at-risk surgery, or locally advanced thyroid cancer.

Voice assessment should be performed at the postoperative visit.

After thyroidectomy, laryngeal examination should be performed in patients with known or suspected new RLN dysfunction or aspiration.

If vocal-fold motion impairment is suspected or identified, early referral of the patient to a laryngologist is recommended.

Familial Thyroid Cancer

Germline genetic testing should include pretest and posttest counseling by a knowledgeable healthcare provider.

Differentiated thyroid cancer (DTC) screening should be performed in at-risk individuals from families with three or more affected first-degree relatives.

All patients diagnosed with medullary thyroid cancer (MTC) should undergo genetic testing for a germline RET mutation.

An experienced multidisciplinary care team should manage patients diagnosed with multiple endocrine neoplasia (MEN) 2A or 2B.

Postoperative Care and Complications

First-line pain management after thyroidectomy should consist of nonopioid and nonpharmacologic therapies and patient education. If opioids are prescribed for postoperative pain, the lowest effective dose of immediate-release opioids (< 10 oral morphine equivalents) should be given.

Patients at higher risk for cervical hematoma should be considered for overnight observation after thyroidectomy.

Patients with suspected hematoma after thyroidectomy should be evaluated immediately with appropriate intervention as indicated.

If unilateral RLN transection occurs during thyroidectomy, repair should be attempted.

To prevent or manage postoperative symptoms of hypocalcemia after total or completion thyroidectomy, supplementation with calcium, vitamin D, or both should be considered.

Patients with significant postthyroidectomy hypocalcemia should receive oral calcium as first-line therapy, calcitriol as necessary, and IV calcium in severe or refractory situations.

Cancer Management

An active surveillance protocol for papillary thyroid microcarcinoma (PTMC) may be appropriate for carefully selected, informed, and compliant patients.

A validated postoperative staging system such as the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification should be used in thyroid cancer care.

Completion thyroidectomy should be considered for high-risk disease or when postoperative RAI therapy is indicated.

Total thyroidectomy should be performed for patients undergoing prophylactic thyroidectomy for MTC.

Reoperation

Selected patients with stable, low-volume persistent or recurrent LNM can undergo active surveillance.

For more information, please go to Thyroidectomy, Thyroid Cancer, and Parathyroidectomy.

For more Clinical Practice Guidelines, please go to Guidelines.

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