U/S Thyroid ?

RECOMMENDATION 6
Thyroid sonography with survey of the cervical lymph nodes
should be performed in all patients with known or
suspected thyroid nodules.

(Strong recommendation, High-quality evidence)

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules
and Differentiated Thyroid Cancer
Ultrasound should evaluate the following:
• Thyroid parenchyma (homogeneous or heterogeneous)

• Gland size; size, location

• Sonographic characteristics of any nodule(s) :

- composition (solid, cystic proportion,or spongiform)
- echogenicity
- margins
- presence and type of calcifications
- shape : taller than wide ?
- vascularity

• The presence or absence of any suspicious cervical lymph nodes in the

central or lateral compartments.
 High suspicion [malignancy risk >70%–90%

• Solid hypoechoic nodule or a solid hypoechoic component in a partially

cystic nodule with one or more of the following features:

 Irregular margins (specifically defined as infiltrative,microlobulated, or

spiculated)
 Microcalcifications
 Taller than wide shape (transverse view)
 Disrupted rim calcifications with small extrusive hypoechoic soft tissue
component
 Evidence of extrathyroidal extension.

Recommend FNA at >1 cm Likely to be PTC

 Intermediate suspicion [malignancy risk 10%–20%]

• Hypoechoic solid nodule with a smooth regular margin,

• Without : microcalcifications
extrathyroidal extension
taller than wide shape

• This appearance has the highest

sensitivity (60%–80%) for PTC,
Recommend FNA at >1 cm
 Low suspicion [malignancy risk 5%–10%]

• Isoechoic or hyperechoic solid nodule

• partially cystic nodule with eccentric uniformly solid areas

• Without - microcalcifications
- irregular margin
- extrathyroidal extension,
- taller than wide shape
• Only about 15%–20% of thyroid cancers are iso- or
hyperechoic
Recommend FNA at >1.5 cm
 Very low suspicion [<3%]

• Spongiform
• partially cystic nodules
• without any of the sonographic features described in the low,
intermediate, or high suspicion patterns
• a low risk of malignancy (<3%)

Consider FNA at > 2 cm

Observation without FNA is also a reasonable option
 Benign [<1%]

• Purely cystic nodules are very unlikely to be malignant

• fine-needle biopsy is not indicated for diagnostic purposes

No biopsy
 RECOMMENDATION 35
Operative approach for a biopsy diagnostic for
follicular cell derived malignancy
Operative approach for a biopsy diagnostic for
follicular cell derived malignancy

• Thyroid cancer >4 cm In special group that plans for

• Gross extrathyroidal RAI therapy or to facilitate
extension (clinical T4) follow-up strategies or address
suspicions of bilateral disease
• Clinically apparent
metastatic disease to • Older age (>45 years)
nodes (clinical N1) • contralateral thyroid nodules
• Distant sites (clinical • Hx of RT to the head and neck
M1) • familial DTC

A near-total or total thyroidectomy

(Strong recommendation, Moderate-quality evidence)
 Operative approach for a biopsy diagnostic for
follicular cell derived malignancy

• Thyroid cancer >1 cm and <4 cm

• without extrathyroidal extension
• without clinical evidence of any lymph node metastases
(cN0)

Near total or total thyroidectomy Or lobectomy

• may choose total thyroidectomy to • low-risk papillary and
enable RAI therapy postop follicular carcinomas

• 10-year overall survival (90.4% for total thyroidectomy vs. 90.8% for lobectomy)
• 10-year cause-specific survival (96.8% for total thyroidectomy vs. 98.6% for lobectomy)
• proper patient selection, loco-regional recurrence rates of less than 1%–4%

(Strong recommendation, Moderate-quality evidence)

Operative approach for a biopsy diagnostic for follicular
cell derived malignancy

• Thyroid cancer <1 cm ; small,unifocal, intrathyroidal carcinomas

• without extrathyroidal extension
• without clinical evidence of any lymph node metastases (cN0)
• Absence of prior head and neck radiation
• No familial thyroid carcinoma

thyroid lobectomy

(Strong recommendation, Moderate-quality evidence)

 AJCC 7th Edition/TNM Classification
System for Differentiated Thyroid Carcinoma
Lymph node dissection
 Lymph node dissection
Central compartment (level VI) dissection

Therapeutic Prophylactic
• The role of prophylactic central
• For patient with clinically node dissection in cN0 disease is
involved central node still unclear

• Should be considered in patient

(strong recommendation) with PTC with advanced primary
tumor (T3 or T4) or clinically
involved lateral neck node (N1b).
(weak recommendation)

• Thyroidectomy without
prophylactic central node
dissection is appropriate for small
(T1 or T2) PTC, noninvasive and
most of follicular cancers.
(strong recommendation)
 Lymph node dissection
Lateral compartment dissection
(level II-V, level VII, rarely level I)

Therapeutic
• Should be performed for patient with biopsy-proven
metastatic lateral cervical node
(strong recommendation)
RAI ablation
 RAI ablation
• Goal of administration of RAI after
thyroidectomy
1. RAI remnant ablation (facilitate detection of
recurrence disease)
2. RAI adjuvant therapy (improve disease-free
survival)
3. RAI therapy (treat persistent disease)
 RAI ablation
• RAI adjuvant therapy is routinely recommended after
total thyroidectomy in ATA high risk
(strong recommendation)

• RAI adjuvant therapy should be considered after

total thyroidectomy in ATA intermediate risk
(weak recommendation)
 RAI ablation
ATA high risk
• Gross extrathyroidal extension
• Distant metastasis
• Incomplete tumor resection
• Pathological N1 with node ≥ 3 cm In largest diameter
• Follicular carcinoma with extensive vascular invasion
 RAI ablation
• RAI remnant ablation is not routinely
recommended after thyroidectomy in papillary
microcarcinoma (tumor < 1 cm) in absence of
adverse features.
(strong recommendation)

• RAI remnant ablation is not routinely

recommended after thyroidectomy in ATA low
risk patient.
(weak recommendation)
 RAI ablation
ATA low risk
Papillary thyroid cancer with

•
No gross extrathyroidal extension, no metastasis, complete
resection of tumor

•
Tumor does not have aggressive histology (tall cell, hobnail
variant, columnar cell carcinoma)

•
No vascular invasion

•
Clinical N0 or ≤ 5 pathological N1 micrometastases (< 0.2
cm)
 RAI ablation
ATA low risk
• Intrathyroidal encapsulated follicular variant PTC

• Intrathyroidal papillary microcarcinoma, unifocal or

multifocal, including BRAF mutation

• Intrathyroidal well-diff. follicular carcinoma and no or

minimal vascular invasion (<4 foci)
TSH suppression
 TSH suppression
• For high risk patient, initial TSH suppression
to below 0.1 mU/L is recommended. (strong
recommendation)

• For intermediate risk patient, initial TSH

suppression to 0.1-0.5 mU/L is recommended.
(weak recommendation)
 TSH suppression
• For low risk patient who underwent lobectomy, TSH
may be maintained at 0.5-2 mU/L. (weak
recommendation)

• For low risk patient who underwent remnant ablation

with undetectable serumTg, TSH may be maintained at
0.5-2 mU/L. (weak recommendation)

• For low risk patient who underwent remnant ablation

with low serumTg, TSH may be maintained at 0.1-0.5
mU/L. (weak recommendation)
Thank you