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Thyroid. 2019 Jan 7. doi: 10.1089/thy.2017.0129. [Epub ahead of print]

European Perspective on 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: Proceedings of an Interactive International Symposium.

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1 Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany.
2 Department of Nuclear Medicine, School of Medicine, Izmir Ekonomi Universitesi, Izmir, Turkey.
3 University Hospital of São João, Medical Faculty and Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal.
4 Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland.
5 Division of Medical Oncology, Department of Oncology, The Mayo Clinic, Rochester, Minnesota.
6 Endocrine Unit, Evgenidion Hospital, University of Athens, Athens, Greece.
7 Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
8 Department of Nuclear Medicine and Endocrine Oncology, Maria Sklodowska-Curie Memorial Institute and Centre of Oncology, Gliwice Branch, Gliwice, Poland.
9 Departments of Nuclear Medicine and Positron Emission Tomography/Computed Tomography, Radiology Center, Vienna, Austria.
10 Thyroid and Endocrine Tumor Unit, Pitié-Salpêtrière Sorbonne University Hospital, Paris, France.
11 Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine, Johannes Gutenberg University Mainz, Mainz, Germany.
12 Thyroid Therapy Unit, The Royal Marsden Hospital, London, United Kingdom.
13 Department of Ear, Nose, and Throat Surgery, NHS Lothian and University of Edinburgh, Edinburgh, United Kingdom.
14 Department of Medicine, Division of Endocrinology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
15 Department of Surgery, University of California at San Francisco-UCSF, San Francisco, California.
16 Department of Endocrinology, Memorial Sloan-Kettering Cancer Center, New York, New York.
17 Department of Medicine, Washington Hospital Center, Washington, DC.
18 Department of Endocrinology and Metabolism, Endocrine Tumor Center at WTZ, Essen University Hospital, Essen, Germany.



The American Thyroid Association (ATA) management guidelines for patients with thyroid nodules and differentiated thyroid cancer (DTC) are highly influential practice recommendations. The latest revision appeared in 2015 ("ATA 2015"). These guidelines were developed predominantly by North American experts. European experts frequently have different perspectives, given epidemiological, technological/methodological, practice organization, and medicolegal differences between the respective regions.


Divergent viewpoints were the focus of an invited symposium organized by the European Association of Nuclear Medicine involving 17 European thyroidologists, four ATA Guidelines Taskforce members, and an audience of 200 international experts. The group discussed the preoperative assessment of thyroid nodules, surgery and the role of pathology, radioiodine (RAI) therapy (RAIT), the assessment of initial therapy and dynamic risk stratification, and the treatment of persistent disease, recurrences, and advanced thyroid cancer. The dialogue resulted in this position paper contrasting European and ATA 2015 perspectives on key issues. One difference pertains to the permissiveness of ATA 2015 regarding lobectomy for primary tumors ≤4 cm. European panelists cited preclusion of RAIT, potential need for completion thyroidectomy, frequent inability to avoid chronic thyroid hormone replacement, and limitations of supportive evidence as arguments against widely applying lobectomy. Significant divergence involved ATA 2015's guidance regarding RAIT. European panelists favored wider use of postoperative RAIT than does ATA 2015. Rationales included the modality's association with favorable patient outcomes and generally limited toxicity, and lack of high-quality evidence supporting withholding RAIT. Additionally, European panelists favored recombinant human thyrotropin (rhTSH) in more settings than does ATA 2015, citing avoidance of hypothyroid morbidity and quality-of-life impairment, without apparent sacrifice in oncologic outcomes. Based on clinical evidence plus theoretical advantages, European experts advocated dosimetric versus fixed-activity RAIT approaches for advanced DTC. European panelists noted that the ATA 2015 risk-stratification system requires information sometimes unavailable in everyday practice. ATA 2015 recommendations regarding RAI-refractory DTC should consider potential palliative benefits of RAIT in patients who also have RAI-susceptible lesions.


European panelists suggested modifications to approximately one-third of ATA 2015 recommendations. Varying European and ATA 2015 perspectives can stimulate analysis and discussion of the literature and performance of primary research to resolve discrepant recommendations and potentially improve patient outcomes.


differentiated thyroid cancer (DTC); disease management; guidelines; pathology; risk stratification; thyroid nodules


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