AACE/ACE/AME Guidelines
American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules - 2016 Update Appendix

https://doi.org/10.4158/EP161208.GLGet rights and content

Abstract

Thyroid nodules are detected in up to 50 to 60% of healthy subjects. Most nodules do not cause clinically significant symptoms, and as a result, the main challenge in their management is to rule out malignancy, with ultrasonography (US) and fine-needle aspiration (FNA) biopsy serving as diagnostic cornerstones. The key issues discussed in these guidelines are as follows: (1) US-based categorization of the malignancy risk and indications for US-guided FNA (henceforth, FNA), (2) cytologic classification of FNA samples, (3) the roles of immunocyto-chemistry and molecular testing applied to thyroid FNA, (4) therapeutic options, and (5) follow-up strategy. Thyroid nodule management during pregnancy and in children are also addressed. On the basis of US features, thyroid nodules may be categorized into 3 groups: low-, intermediate-and high-malignancy risk. FNA should be considered for nodules < 10 mm diameter only when suspicious US signs are present, while nodules < 5 mm should be monitored rather than biopsied. A classification scheme of 5 categories (nondiagnostic, benign, indeterminate, suspicious for malignancy, or malignant) is recommended for the cytologic report. Indeterminate lesions are further subdivided into 2 subclasses to more accurately stratify the risk of malignancy. At present, no single cytochemical or genetic marker can definitely rule out malignancy in indeterminate nodules. Nevertheless, these tools should be considered together with clinical data, US signs, elastographic pattern, or results of other imaging techniques to improve the management of these lesions. Most thyroid nodules do not require any treatment, and levothyroxine (LT4 suppressive therapy is not recommended. Percutaneous ethanol injection (PEI) should be the first-line treatment option for relapsing, benign cystic lesions, while US-guided thermal ablation treatments may be considered for solid or mixed symptomatic benign thyroid nodules. Surgery remains the treatment of choice for malignant or suspicious nodules. The present document updates previous guidelines released in 2006 and 2010 by the American Association of Clinical Endocrinologists (AACE) and Associazione Medici Endocrinologi (AME).

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A complete list of the AACE/ACE/AME Thyroid Nodule Task Force can be found in the Acknowledgements section of this publication. on behalf of the AACE/ACE/AME Task Force on Thyroid Nodules* DOI:10.4158/EP161208.GL To purchase reprints of this article, please visit: www.aace.com/reprints.

American Association of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE) and Associazione Medici Endocrinologi (AME) 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.

The first edition of the AACE/ACE/AME Guidelines for the Diagnosis and Management of Thyroid Nodules was published in 2006 after extensive review of the literature by representatives of endocrinologists, endocrine surgeons, and thyroid pathologists and with accurate external refereeing. These guidelines were updated in 2010 by a task-force group representing experts from the same scientific societies and from the European Thyroid Association on the basis of advances in diagnosis and management of thyroid nodules. The Task Force now editing this third edition of the guidelines on behalf of AACE/ACE/AME includes new contributors and referees. This updated edition incorporates recent scientific evidence, includes the use of new diagnostic tools and treatments, and addresses avoiding unnecessary diagnostic procedures and risk of medical or surgical overtreatment. The importance of patient information and participation in clinical decision making and the role of a multidisciplinary approach to thyroid nodular disease are fully considered.

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 revision is 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 and preference.

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