AACE/AME/ETA GuidelinesAmerican Association Of Clinical Endocrinologists, Associazione Medici Endocrinologi, And European Thyroid Association Medical Guidelines For Clinical Practice For The Diagnosis And Management Of Thyroid Nodules
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INTRODUCTION
This document was prepared as a collaborative effort between 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 diagnostic and therapeutic aspects of thyroid nodular disease but not thyroid cancer management.
The AACE protocol for standardized production of clinical practice guidelines was followed to rate the evidence level
THYROID NODULES: THE SCOPE OF THE PROBLEM
Thyroid nodules are a common clinical finding, with an estimated prevalence on the basis of palpation that ranges from 3% to 7% 1., 2.. The prevalence of clinically inapparent thyroid nodules is estimated with US at 20% to 76% in the general population, with a prevalence similar to that reported from autopsy data 3., 4., 5.. Moreover, 20% to 48% of patients with 1 palpable thyroid nodule are found to have additional nodules on US investigation 5., 6.. Thyroid nodules are more common in elderly
History and Physical Examination
Both benign and malignant disorders can cause thyroid nodules (Box 1) (9). Hence, the clinical importance of newly diagnosed thyroid nodules is primarily the exclusion of malignant thyroid lesions 6., 10. (Box 2). In iodine-deficient areas, however, local symptoms, functional autonomy, and hyperthyroidism are common clinical problems (11).
When to Perform Thyroid US
High-resolution US is the most sensitive test available to detect thyroid lesions, measure their dimensions, identify their structure, and evaluate diffuse changes in the thyroid gland 33., 34..
If results of palpation are normal, US should be performed when a thyroid disorder is suspected on clinical grounds or if risk factors have been recognized (Box 2). The physical finding of suspicious neck adenopathy warrants US examination of both lymph nodes and thyroid gland because of the risk of a
Thyroid FNA Biopsy
Clinical management of thyroid nodules should be guided by the combination of US evaluation and FNA biopsy (Fig 1, Fig. 2) (8). FNA biopsy is currently the best triage test for the preoperative evaluation of thyroid nodules 56., 57., 58..
Because the most common cause of a false-negative cytologic diagnosis is sampling error (56), cytologic diagnosis is more reliable and the nondiagnostic rate is lower when FNA biopsy is performed with US guidance (UGFNA) 59., 60., 61.. UGFNA biopsy is strongly
Assessment of Thyroid Function
The high sensitivity of the TSH assay for detecting even subtle thyroid dysfunction makes it the most useful laboratory test in the initial evaluation of thyroid nodules (77). Measuring serum levels of free thyroid hormones and TPOAb or anti–TSH-receptor antibody (TRAb) should be the second diagnostic step, which is necessary for confirmation and the subsequent definition of thyroid dysfunction if the TSH concentration is outside the reference range (78).
TSH Assay
Third-generation TSH chemiluminometric
Thyroid Scintigraphy
Thyroid scintigraphy is the only technique that allows for assessment of thyroid regional function and detection of areas of AFTN (100).
Diagnostic Accuracy
On the basis of the pattern of radionuclide uptake, nodules may be classified as hyperfunctioning (“hot”), hypofunctioning (“cold”), or indeterminate (100). Hot nodules almost never represent clinically significant malignant lesions, whereas cold or indeterminate nodules have a reported malignancy risk of 3% to 15% 42., 101., 102., 103..
Because most thyroid
MANAGEMENT AND THERAPY
Clinical management of thyroid nodules should be guided by the results of US evaluation and FNA biopsy 8., 112. (Fig 1, Fig. 2).
Thyroid Nodule During Pregnancy
Most cases of thyroid nodules during pregnancy are in patients with preexisting nodules who then become pregnant; occasionally, however, a thyroid nodule is detected for the first time during pregnancy. A thyroid nodule in a pregnant woman should be managed in the same way as in nonpregnant women, except for avoiding the use of radioactive agents for both diagnostic and therapeutic purposes 151., 153.. Thyroid nodule diagnosis during pregnancy necessitates FNA biopsy if findings are suspicious,
Development and Use of the Guidelines: Methods of Bibliographic Research
We searched for primary evidence to support the current guidelines by using a “clinical question” method. Each topic covered by the guidelines was translated to a related question. Accordingly, the bibliographic research was conducted by selecting the studies able to yield a methodologically reliable answer to each question.
The first step was to select pertinent published reports. The United States National Library of Medicine Medical Subject Headings (MeSH) database was used as a termino-logic
Ultrasonography
US is the most valuable technique for evaluating thyroid anatomy because it provides accurate information about thyroid size, shape, and texture. In most patients, US examination is considered the criterion standard for detecting nodular thyroid disease; its high resolution currently can distinguish thyroid lesions as small as 1 or 2 mm in diameter. Hence, US examination has a pivotal role in localizing, counting, and measuring palpable and nonpalpable thyroid nodules. Tips for a good US
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.
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 have any
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American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules are systematically developed statements to assist health care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied.
These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.
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Task Force Committee Members are listed on the second page and in the Acknowledgment.
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Cochairpersons.