Definitive Surgical Management of Thyroid Disease in Adults: AAES Guidelines

The American Association of Endocrine Surgeons has released its 2020 guidelines on Definitive Surgical Management of Thyroid Disease in Adults. The evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

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 United States.

Major recommendations are -

Recommendation 1:Evaluation of thyroid disease should include specific inquiry about personal history, family history, clinical characteristics, and symptoms. (Strong recommendation, low quality of evidence)

Recommendation 2: The preoperative physical examination should include voice assessment. (Strong recommendation, moderate-quality evidence)

Recommendation 3: TSH should be measured in patients with nodular thyroid disease. Additional laboratory studies may help in specific circumstances. (Strong recommendation, low-quality evidence)

Recommendation 4: The diagnostic US should be performed in all patients with a suspected thyroid nodule. (Strong recommendation, high-quality evidence)

Recommendation 5: a. US assessment of bilateral central and lateral LN compartments should be performed in the preoperative evaluation of patients with cytologic evidence of thyroid carcinoma. (Strong recommendation, low quality of evidence).

b. US assessment of bilateral central and lateral LN compartments may be performed in the preoperative evaluation of patients with indeterminate cytologic evidence of thyroid carcinoma. (Strong recommendation, insufficient evidence).

Recommendation 6: CT or MRI with intravenous contrast should be used preoperatively as an adjunct to US in selected patients with clinical suspicion for advanced locoregional thyroid cancer (Strong recommendation, low quality of evidence)

Recommendation 7: a. FNAB is a standard component of thyroid nodule evaluation, and its indications should follow established guidelines based on US characteristics, size, and clinical findings. (Strong recommendation, moderate-quality evidence)

b. FNAB of a sonographically suspicious cervical LN should be performed when the results will alter the treatment plan. (Strong recommendation, low-quality evidence)

Recommendation 8: In most circumstances, FNAB yield and adequacy may be optimized using US-guidance, with or without onsite cytologic assessment. (Strong recommendation, moderate-quality evidence)

Recommendation 9: The Bethesda System for Reporting Thyroid Cytopathology should be used to report and stratify the risk of malignancy in a thyroid nodule. (Strong recommendation, high-quality evidence)

Recommendation 10: If thyroidectomy is preferred for clinical reasons, then MT is unnecessary. (Strong recommendation, moderate-quality evidence)

Recommendation 11: 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. (Strong recommendation, moderate-quality evidence)

Recommendation 12: Accuracy of MT relies on institutional malignancy rates and should be locally examined for optimal extrapolation of results to thyroid cancer risk. (Strong recommendation, moderate-quality evidence)

Recommendation 13: Patients with a thyroid nodule, goiter or thyroiditis who exhibit local compressive symptoms or progressive enlargement should be considered for thyroidectomy. (Strong recommendation, low-quality evidence)

Recommendation 14: Thyroidectomy is one of several options for the treatment of hyperthyroidism and should be preferentially considered when RAI or medical therapy is contraindicated or undesirable. (Strong recommendation, moderate-quality evidence)

Recommendation 15: For nodules that are cytologically categorized as Bethesda III, clinical factors, radiologic features, and patient preference should inform decision-making regarding whether to proceed with repeat biopsy, MT, diagnostic thyroidectomy, or observation. (Strong recommendation, moderate-quality evidence)

Recommendation 16: Diagnostic thyroidectomy and/or MT are accepted options for patients with nodules cytologically categorized as Bethesda IV. (Strong recommendation, moderate-quality evidence)

Recommendation 17: Thyroidectomy is indicated for thyroid nodules >1 cm cytologically categorized as Bethesda V or VI. (Strong recommendation, moderate-quality evidence)

Recommendation 18: When possible, thyroidectomy should be performed by a high-volume thyroid surgeon. (Strong recommendation, moderate-quality evidence)

Recommendation 19: Antimicrobial prophylaxis is not necessary in most cases of standard transcervical thyroid surgery. (Strong recommendation, high-quality evidence)

Recommendation 20: Prior to thyroidectomy, in the absence of contraindications, a single preoperative dose of dexamethasone should be considered to reduce nausea, vomiting, and pain. (Strong recommendation, high-quality evidence)

Recommendation 21: If surgery is chosen as a treatment for GD: a. Ideally, patients should be rendered clinically euthyroid preoperatively. (Strong recommendation, low-quality evidence)

b. A potassium iodide containing preparation can be considered prior to surgery. (Weak recommendation, low-quality evidence)

Recommendation 22: Gastric bypass patients should be counseled about a higher risk of severe postoperative hypocalcemia after total or completion thyroidectomy. (Strong recommendation, low-quality evidence)

Recommendation 23: Prior to thyroid surgery for GD, calcium and 25-hydroxy vitamin D levels may be assessed and repleted or supplemented prophylactically. (Strong recommendation, moderate-quality evidence)

Recommendation 24: Chemical VTE prophylaxis should be reserved for selected patients determined to be at high risk for VTE after thyroidectomy. (Strong recommendation, low-quality evidence)

Recommendation 25: The superior pole vessels should be ligated close to the thyroid capsule to avoid potential EBSLN injury. (Strong recommendation, insufficient evidence)

Recommendation 26: The RLN should be identified to help preserve it. (Strong recommendation, low-quality evidence)

Recommendation 27: a. Dissection should be performed along the thyroid capsule to help preserve the parathyroid glands. (Strong recommendation, low-quality evidence)

b. If a parathyroid gland cannot be preserved, parathyroid autotransplantation should be performed. (Strong recommendation, low-quality evidence)

Recommendation 28: Core needle biopsy should be rarely utilized in the initial evaluation of a thyroid nodule. (Strong recommendation, low–quality evidence)

Recommendation 29: Thyroid IOPE should only be utilized in settings in which the information it provides has a high likelihood of altering the operative procedure. (Strong recommendation, low–quality evidence)

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Recommendation 30: IOPE has value in confirming the identification of parathyroid tissue. (Strong recommendation, moderate-quality evidence)

Recommendation 31: IOPE has value in the identification of CLN metastases when the information may alter the extent of surgery. (Strong recommendation, moderate-quality evidence)

Recommendation 32: A standardized synoptic pathology report is recommended when reporting thyroid neoplasms. (Strong recommendation, low–quality evidence)

Recommendation 33: During initial thyroidectomy for PTC, the central compartment should be assessed for suspicious lymphadenopathy. If clinical or imaged LNM is present (ie, macroscopic disease), a therapeutic CND is recommended. (Strong recommendation, high-quality evidence)

Recommendation 34: a. A compartment-oriented therapeutic lateral ND is recommended for lateral LNM. (Strong recommendation, high-quality evidence)

b. Prophylactic lateral ND is not indicated for PTC. (Strong recommendation, high-quality evidence)

Recommendation 35: Hypercalcemia should be evaluated preoperatively in a patient being evaluated for thyroid surgery. (Strong recommendation, low-quality evidence)

Recommendation 36: Patients undergoing initial thyroidectomy who are diagnosed with primary hyperparathyroidism should undergo concurrent parathyroidectomy. (Strong recommendation, moderate-quality evidence)

Recommendation 37: Evaluation for HPT is recommended in patients scheduled to undergo thyroid surgery who have a history of familial pHPT. (Strong recommendation, moderate-quality evidence)

Recommendation 38: In patients with moderate to severe Graves ophthalmopathy, total thyroidectomy should be considered as first-line definitive treatment. (Strong recommendation, moderate-quality evidence)

Recommendation 39: Due to the higher risk and greater technical difficulty, thyroidectomy in Graves disease is best performed by high volume thyroid surgeons. (Strong recommendation, low-quality evidence)

Recommendation 40: a. When surgery is indicated, total thyroidectomy is preferred for the treatment of bilateral goitre. (Strong recommendation, low-quality evidence)

b. When the contralateral lobe is normal, lobectomy and isthmusectomy is recommended for the treatment of unilateral goitre.(Strong recommendation, low-quality evidence)

Recommendation 41: Cross-sectional imaging of goitre is recommended if there is a concern for a substernal component. (Strong recommendation, moderate-quality evidence)

Recommendation 42: When performing surgery for substernal goitre, good communication, preparation and cooperation of experienced surgical and anesthesia teams is recommended. (Strong recommendation, low-quality evidence)

Recommendation 43: While it does not prevent RLN injury, RLNM is safe and may assist the surgeon during initial or re-operative thyroidectomy. (Strong recommendation, moderate-quality evidence)

Recommendation 44: During planned total thyroidectomy, after completion of the initial lobectomy, if RLNM results suggest a loss of function, the surgeon may consider stopping the operation for possible completion at a later date. (Strong recommendation,low-quality evidence)

Recommendation 45: Rapid PTH measurement during or after total or completion thyroidectomy may help to manage patients at risk for hypocalcemia. (Weak recommendation, moderate-quality evidence)

Recommendation 46: Remote-access thyroidectomy should only be performed in carefully selected patients, by surgeons experienced in the approach. (Strong recommendation, low-quality evidence)

Recommendation 47: In the preoperative discussion of thyroidectomy, the surgeon should disclose to the patient the possibility, likelihood, and implications of permanent vocal fold dysfunction.(Strong recommendation, moderate-quality evidence)

Recommendation 48: Prior to thyroidectomy, the laryngeal examination should be performed in patients determined to have vocal abnormalities as assessed by the surgeon, pre-existing laryngeal disorders, prior at-risk surgery, or locally advanced thyroid cancer. (Strong recommendation, low-quality evidence)

Recommendation 49: Voice assessment should be performed at the postoperative visit. (Strong recommendation, low-quality evidence)

Recommendation 50: After thyroidectomy, the laryngeal examination should be performed in patients with known or suspected new RLN dysfunction or aspiration. (Strong recommendation, moderate-quality evidence)

Recommendation 51: If vocal fold motion impairment is suspected or identified, early referral of the patient to a laryngologist is recommended. (Strong recommendation, moderate-quality evidence)

Recommendation 52: Germline genetic testing should include pre- and post-test counseling by a knowledgeable health care provider. (Strong recommendation, low-quality evidence)

Recommendation 53: DTC screening should be performed in at-risk individuals from families with three or more affected first-degree relatives. (Strong recommendation, low-quality evidence)

Recommendation 54: All patients diagnosed with MTC should undergo genetic testing for a germline RET mutation. (Strong recommendation, high-quality evidence)

Recommendation 55: An experienced multidisciplinary care team should manage patients diagnosed with MEN2A and MEN2B. (Strong recommendation, low-quality evidence)

Recommendation 56: a. The use of nonopioid and nonpharmacologic therapies and patient education should be the first-line pain management after thyroidectomy. (Strong recommendation, moderate-quality evidence)

b. If opioids are prescribed for postoperative pain management, the lowest effective dose of immediate-release opioids (< 10 oral morphine equivalents) should be prescribed. (Strong recommendation, moderate-quality evidence)

Recommendation 57: Patients at higher risk for cervical hematoma should be considered for overnight observation following thyroidectomy. (Weak recommendation, moderate-quality evidence)

Recommendation 58: Patients with suspected hematoma after thyroidectomy should be evaluated immediately with appropriate intervention as indicated. (Strong recommendation, low-quality evidence)

Recommendation 59: If unilateral RLN transection occurs during thyroidectomy, an attempt should be made at repair. (Strong recommendation, moderate-quality evidence)

Recommendation 60: To prevent and/or manage postoperative symptoms of hypocalcemia following total or completion thyroidectomy, a strategy for calcium and/or vitamin D supplementation should be considered. (Strong recommendation, moderate-quality evidence)

Recommendation 61: Patients with significant post-thyroidectomy hypocalcemia should receive oral calcium as first-line therapy, calcitriol as necessary, and intravenous calcium in severe or refractory situations. (Strong recommendation, low-quality evidence)

Recommendation 62: An active surveillance protocol for PTMC may be appropriate for carefully selected, informed, and compliant patients. (Strong recommendation, moderate-quality evidence)

Recommendation 63: A validated postoperative staging system such as the AJCC TNM classification should be used in thyroid cancer care. (Strong recommendation, moderate-quality evidence)

Recommendation 64: Consider completion thyroidectomy for high-risk disease and/or when postoperative RAI therapy is indicated. (Strong recommendation, moderate-quality evidence)

Recommendation 65: Total thyroidectomy should be performed for patients undergoing prophylactic thyroidectomy for medullary thyroid cancer. (Strong recommendation, moderate-quality evidence)

Recommendation 66: Selected patients with stable, low-volume persistent or recurrent LNM can undergo active surveillance. (Weak recommendation, low-quality evidence)

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