Elsevier

Endocrine Practice

Volume 16, Supplement 1, May–June 2010, Pages 1-43
Endocrine Practice

AACE/AME/ETA Guidelines
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

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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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REFERENCES (214)

  • H. Gharib et al.

    Fine-needle aspiration biopsy of thyroid nodules

    Endocr Pract.

    (1995)
  • B. Hamberger et al.

    Fine-needle aspiration biopsy of thyroid nodules

    impact on thyroid practice and cost of care. Am J Med.

    (1982)
  • W.M. Tunbridge et al.

    The spectrum of thyroid disease in a community: The Whickham survey

    Clin Endocrinol (Oxf).

    (1977)
  • L. Hegedüs

    Clinical practice. The thyroid nodule

    N Engl J Med.

    (2004)
  • Ross DS. Diagnostic approach to and treatment of thyroid nodules. I. In: Rose BD, ed. UpToDate. Wellesley, MA:...
  • J.D. Mortensen et al.

    Gross and microscopic findings in clinically normal thyroid glands

    J Clin Endocrinol Metab.

    (1955)
  • S. Ezzat et al.

    Thyroid incidentalomas: Prevalence by palpation and ultrasonography

    Arch Intern Med.

    (1994)
  • G.H. Tan et al.

    Thyroid incidentalomas: Management approaches to nonpalpable nodules discovered incidentally on thyroid imaging

    Ann Intern Med.

    (1997)
  • J.B. Vander et al.

    The significance of nontoxic thyroid nodules: Final report of a 15-year study of the incidence of thyroid malignancy

    Ann Intern Med.

    (1968)
  • Rosai J, Carcangiu ML, DeLellis RA. Tumors of the thyroid gland. Washington DC: Armed Forces Institute of Pathology,...
  • A. Belfiore et al.

    High frequency of cancer in cold thyroid nodules occurring at young age

    Acta Endocrinol (Copenh).

    (1989)
  • F. Aghini-Lombardi et al.

    The spectrum of thyroid disorders in an iodine-deficient community: The Pescopagano survey

    J Clin Endocrinol Metab.

    (1999)
  • K.C. Loh

    Familial nonmedullary thyroid carcinoma: A meta-review of case series

    Thyroid.

    (1997)
  • M.K. Punales et al.

    Clinical and oncological features of children and young adults with multiple endocrine neoplasia type 2A

    Thyroid.

    (2008)
  • M.A. Rosenbaum et al.

    Contemporary management of papillary carcinoma of the thyroid gland

    Expert Rev Anticancer Ther.

    (2009)
  • A. Corrias et al.

    Accuracy of fine needle aspiration biopsy of thyroid nodules in detecting malignancy in childhood: Comparison with conventional clinical, laboratory, and imaging approaches

    J Clin Endocrinol Metab.

    (2001)
  • J. Gough et al.

    Thyroid incidentaloma: An evidence-based assessment of management strategy

    World J Surg.

    (2008)
  • S.B. Christensen et al.

    Prediction of malignancy in the solitary thyroid nodule by physical examination, thyroid scan, fine-needle biopsy and serum thyroglobulin: A prospective study of 100 surgically treated patients

    Acta Chir Scand

    (1984)
  • J.F. Hamming et al.

    The value of fine-needle aspiration biopsy in patients with nodular thyroid disease divided into groups of suspicion of malignant neoplasms on clinical grounds [erratum in: Arch Intern Med 1990;150:1088]

    Arch Intern Med.

    (1990)
  • E. Papini

    The dilemma of non-palpable thyroid nodules

    J Endocrinol Invest.

    (2003)
  • E. Papini et al.

    Risk of malignancy in nonpalpable thyroid nodules: Predictive value of ultrasound and color-Doppler features

    J Clin Endocrinol Metab.

    (2002)
  • G.H. Tan et al.

    Solitary thyroid nodule: Comparison between palpation and ultrasonography

    Arch Intern Med.

    (1995)
  • A.E. Jarlov et al.

    Observer variation in the clinical and laboratory evaluation of patients with thyroid dysfunction and goiter

    Thyroid.

    (1998)
  • K. Boelaert et al.

    Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration

    J Clin Endocrinol Metab.

    (2006)
  • M.W. Ashcraft et al.

    Management of thyroid nodules. II: Scanning techniques, thyroid suppressive therapy, and fine needle aspiration

    Head Neck Surg.

    (1981)
  • Y. Yano et al.

    Recent outcome of Graves’ disease patients with papillary thyroid cancer

    Eur J Endocrinol.

    (2007)
  • S.K. Shetty et al.

    Significance of incidental thyroid lesions detected on CT: Correlation among CT, sonography, and pathology [erratum in: AJR Am J Roentgenol. 2007;188:8]

    AJR Am J Roentgenol.

    (2006)
  • A.A. Razek et al.

    Role of apparent diffusion coefficient values in differentiation between malignant and benign solitary thyroid nodules

    AJNR Am J Neuroradiol.

    (2008)
  • C. Are et al.

    FDG-PET detected thyroid incidentalomas: need for further investigation?

    Ann Surg Oncol.

    (2007)
  • J.Y. Choi et al.

    Focal thyroid lesions incidentally identified by integrated 18F-fDg PET/CT: Clinical significance and improved characterization

    J Nucl Med.

    (2006)
  • L.M. Hurtado-Lopez et al.

    Combined use of fine-needle aspiration biopsy, MIBI scans and frozen section biopsy offers the best diagnostic accuracy in the assessment of the hypofunctioning solitary thyroid nodule

    Eur J Nucl Med Mol Imaging.

    (2004)
  • H.J. Baskin

    Ultrasound of thyroid nodules

  • L. Solbiati et al.

    Ultrasound of thyroid, parathyroid glands and neck lymph nodes

    Eur Radiol.

    (2001)
  • M.C. Frates et al.

    Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography

    J Clin Endocrinol Metab.

    (2006)
  • W.J. Moon et al.

    Thyroid Study Group, Korean Society of Neuro- and Head and Neck Radiology. Benign and malignant thyroid nodules: US differentiation: Multicenter retrospective study

    Radiology.

    (2008)
  • E.K. Kim et al.

    New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid

    AJR Am J Roentgenol.

    (2002)
  • C. Cappelli et al.

    Thyroid nodule shape suggests malignancy

    Eur J Endocrinol.

    (2006)
  • E. Horvath et al.

    An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management

    J Clin Endocrinol Metab.

    (2009)
  • J.P. Campbell et al.

    Management of the thyroid nodule

    Head Neck.

    (1989)
  • A. Frasoldati et al.

    Diagnosis of neck recurrences in patients with differentiated thyroid carcinoma

    Cancer.

    (2003)
  • Cited by (0)

    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.

    *

    Task Force Committee Members are listed on the second page and in the Acknowledgment.

    *

    Cochairpersons.

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