Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. Methods: The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Gr...

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2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines. Methods: Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force. Results: The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, a...

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Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer

Activating mutation in the tyrosine kinase JAK2 in polycythemia vera, essential thrombocythemia, and myeloid metaplasia with myelofibrosis.

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Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.

European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium Furio Pacini, Martin Schlumberger, Henning Dralle, Rossella Elisei, Johannes W A Smit, Wilmar Wiersinga and the European Thyroid Cancer Taskforce Section of Endocrinology and Metabolism, University of Siena, Via Bracci, 53100 Siena, Italy, Service de Medicine Nucleaire, Institut Gustave Roussy, Villejuif, France, Department of General, Visceral and Vascular Surgery, University of Halle, Germany, Department of Endocrinology, University of Pisa, Italy, Department of Endocrinology and Metabolic Disease, Leiden University Medical Center, The Netherlands and Department of Endocrinology and Metabolism, University of Amsterdam, The Netherlands

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European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium

This retrospective investigation was undertaken to clarify the pattern of nodal metastasis in papillary (PTC) and medullary (MTC) thyroid carcinoma. Nodal metastases are associated with recurrence of both PTCs and MTCs. The extent of lymph node dissection is controversial owing to the lack of reliable diagnostic criteria for nodal metastases other than histopathology. Between November 1994 and October 1999 a total of 296 patients (134 PTCs, 162 MTCs) underwent total thyroidectomy in conjunction with a standard resection of at least the cervicocentral lymph node compartment. Of 10,446 sampled lymph nodes, 1641 were positive. All nodes were related to their respective cervicomediastinal compartments. The ipsilateral cervicolateral compartment was involved almost as often as the cervicocentral compartment in primary PTC (29% vs. 32%), reoperative PTC (21% vs. 37%), primary MTC (34% vs. 34%), and reoperative MTC (49% vs. 65%). The contralateral cervicolateral and mediastinal compartments were more rarely affected, and were least affected in the primary setting. From these data was derived an individualized surgical strategy for PTC and MTC. This concept rests on the joint resection of cervicocentral and ipsilateral cervicolateral compartments. Depending on tumor entity, surgical status, and primary tumor diameter, additional compartments may have to be cleared.

Pattern of Nodal Metastasis for Primary and Reoperative Thyroid Cancer

INTRODUCTION: Anastomotic leakage is a major problem in colorectal surgery and in particular in operations for low rectal cancer. The present study investigates the question whether a protective stoma can reduce the (clinical and radiologic) anastomotic leakage rate and/or the rate of leakage requiring surgery. METHODS: The investigation took the form of a prospective multicenter study involving 75 German hospitals and was performed between January 1, 1999, and December 31, 1999. A comparison was made of the postoperative results of procedures performed with and those performed without a protective stoma in patients undergoing low anterior rectal resection. In addition, logistic regression using the target criteria, overall anastomotic leakage and anastomotic leakage requiring surgery, was applied. RESULTS: Among the 3,695 operations performed for carcinoma of the rectum or colon, 482 were low anterior resections. In 334 patients (69.3 percent) no protective stoma was constructed, whereas 148 (30.7 percent) received such protection. Age, American Society of Anesthesiologists physical status, and body mass index were identical in both groups. In the group receiving a protective stoma, however, neoadjuvant radiochemotherapy was more common, the tumors were lower—and thus the total mesorectal excision rate higher, the intraoperative complication rate was higher, and the duration of the operation was longer. The differences were all significant. The major criterion (overall anastomotic leakage rate) was identical in the two groups, but the rate of leakage requiring surgery was significantly lower in patients receiving a protective stoma (P = 0.028). The logistic regression revealed that use of a protective stoma is a predictor of protection against anastomotic leakage requiring surgery. The distance of the tumor from the anal verge and the duration of the operation are further predictors. CONCLUSION: The particular benefit of a covering stoma is reduction in the rate of leaks requiring surgery and thus in the severe consequences of an anastomotic leakage.

Value of a Protective Stoma in Low Anterior Resections for Rectal Cancer

Background: Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications in thyroid surgery. No prospective studies are available that evaluate if the additional use of intraoperative neuromonitoring reduces the rate of RLN palsy.

Methods: Between January 1 and December 31, 1998, surgery for histologically benign goiter with intraoperative identification with and without additional intraoperative RLN neuromonitoring was performed on 4,382 patients in 45 hospitals. Data were collected prospectively by questionnaire.

Results: The rate of transient and permanent RLN palsy based on nerves at risk were 1.4% and 0.4% with intraoperative neuromonitoring. These rates were significantly lower (P <0.05) compared with intraoperative visual RLN identification without intraoperative neuromonitoring which resulted in rates of 2.1% and 0.8%, respectively. A multivariate logistic regression analysis confirmed that the use of intraoperative neuromonitoring decreases the rate of postoperative transient (P <0.008) and permanent (P <0.004) RLN palsies as an independent factor by 0.58 and 0.30, respectively.

Conclusions: Intraoperative neuromonitoring of the RLN in thyroid surgery is recommended because of significantly lower rates of transient and permanent RLN palsy rates in comparison with conventional RLN identification.

Intraoperative neuromonitoring of surgery for benign goiter

In hereditary medullary thyroid carcinoma (MTC), few genotype-phenotype correlations have been established. RET genotypes (exons 10, 11, 13, and 14) of 63 patients with hereditary MTC (from November 1994 to October 1999) were correlated with age at diagnosis, sex, the TNM system, and basal calcitonin levels. Mutations in exons 10, 11, 13, and 14 were demonstrated in 22% (14 of 63), 54% (34 of 63), 21% (13 of 63), and 3% (2 of 63). The median ages at diagnosis differed significantly (38, 27, 52, and 62 yr; P = 0.003). When grouped by cysteine codons (exons 10 and 11 vs. exons 13 and 14), this difference became even more evident (30 vs. 56 yr; P = 0.001). Apart from age at diagnosis, no other significant associations were noted. Based hereon, three MTC risk groups were devised according to genotype: a high risk group (codons 634 and 618) with the youngest ages of 3 and 7 yr at diagnosis; an intermediate risk group (codons 790, 620, and 611) with ages of 12, 34, and 42 yr; and a low risk group (codons 768 and 804) with ages of 47 and 60 yr, respectively. Age at diagnosis was unrelated to specific nucleotide and amino acid exchange within each codon. The current data demonstrate that there is a significant genotype-phenotype correlation, allowing for a more individualized approach to the timing and extent of prophylactic surgery.

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Genotype-phenotype correlations in hereditary medullary thyroid carcinoma: oncological features and biochemical properties.

Loss of heterozygosity of chromosome 3p21 is one of the most frequent alterations in solid tumors, including thyroid carcinomas. Recently, we have characterized the novel tumor suppressor gene RASSF1 located in this locus. The RASSF1A isoform is epigenetically inactivated in a variety of human primary tumors. In this study, we investigated the expression and methylation status of the RASSF1 gene in thyroid carcinoma. In nine thyroid cancer cell lines, the RASSF1A promoter CpG island was methylated completely, and expression was absent. Treatment of these cell lines with the DNA methylation inhibitor 5-aza-2'-deoxycytidine reactivated the transcription of RASSF1A. The methylation status of the RASSF1A promoter was analyzed in 38 primary thyroid tumors, including 1 poorly differentiated thyroid carcinoma, 5 medullary thyroid carcinoma (MTC), 10 follicular thyroid carcinoma (FTC), 9 undifferentiated thyroid carcinoma (UTC), and 13 papillary thyroid carcinoma (PTC). In 71% of thyroid carcinomas, the RASSF1A CpG island was hypermethylated. Methylation frequency was higher in the aggressive forms of thyroid carcinoma and was found in 80% of MTC, in 78% of UTC, and in 70% of FTC, compared with 62% in the more benign PTC. RASSF1A inactivation was detected in all stages of thyroid carcinoma scored by Tumor-Node-Metastasis classification. Additionally, we analyzed the methylation frequency of the CpG island of cell cycle inhibitor p16(INK4a) in the same thyroid tumors. The p16 gene was inactivated in 56 and 25% of cell lines and primary tumors, respectively. p16 methylation was detected in 56% of UTC, 10% of FTC, and 25% of PTC but not in MTC. In UTC, which belongs to the most aggressive carcinomas in humans, the most common combined inactivation of RASSF1A and p16 was detected. In general, 90% of tumors with p16 inactivation were also silenced for RASSF1A expression. However, RASSF1A hypermethylation was detected three times more frequently in thyroid cancers. Thus, RASSF1A inactivation may play a crucial role in the malignancy of thyroid carcinoma.

https://cancerres.aacrjournals.org/content/canres/62/13/3698.full.pdf

Henning Dralle

Papers

Pattern of Nodal Metastasis for Primary and Reoperative Thyroid Cancer

Value of a Protective Stoma in Low Anterior Resections for Rectal Cancer

Intraoperative neuromonitoring of surgery for benign goiter

Genotype-phenotype correlations in hereditary medullary thyroid carcinoma: oncological features and biochemical properties.

Frequent epigenetic silencing of the CpG island promoter of RASSF1A in thyroid carcinoma.