Why the EANM has declined the ATA guidelines for thyroid cancer

[ineke]

Why the European Association of Nuclear Medicine has declined to endorse the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer

Frederik A. Verburg et al.

Een paar gedeeltes:

The reasons for declining to endorse these guidelines fall into two categories. In most cases our objections are based on
differences in the interpretation of the available evidence, especially where the role of nuclear medicine is concerned.
In spite of solid evidence on the clinical efficacy of nuclear medicine in both the diagnosticwork-up of nodular thyroid disease and the care of DTC, the 2015 ATA guidelines appear to marginalise the role of nuclear medicine in the care of nodular thyroid disease and DTC.
Some of our objections also concern the wording of some parts of the text which differ from our current viewpoint and are mostly based on a cautious, legally motivated choice of words.
Our first objection is related to the recommendations regarding the use of thyroid scintigraphy in the initial diagnostic workup of nodular thyroid disease.

In recommendations 2B and 2C it is stated:
B) If the serum TSH is subnormal, a radionuclide (preferably 123I) thyroid scan should be performed. (Strong
recommendation, Moderate-quality evidence).
C) If the serum TSH is normal or elevated, a radionuclide scan should not be performed as the initial imaging
evaluation (Strong recommendation, Moderate-quality evidence).

It is not made clear in the text why 123I is preferred over 99mTc-pertechnetate, as in hyperthyroidism usually the much
cheaper and much more ubiquitously available 99mTcpertechnetate is as diagnostically adequate as 123I, especially


A second major objection to the 2015ATA guidelines is the indication for 131I therapy in the ablative setting after total
thyroidectomy. First, Recommendation 35B states:
For patients with thyroid cancer >1 cm and <4 cm without extrathyroidal extension, and without clinical evidence
of any lymph node metastases (cN0), the initial surgical procedure can be either a bilateral procedure
(near-total or total thyroidectomy) or a unilateral procedure (lobectomy).
Thyroid lobectomy alone may be sufficient initial treatment for low-risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable 131I therapy or to enhance follow-up based upon disease features and/or patient preferences. (Strong Recommendation, Moderate-quality evidence).

While this radical departure from prior, internationally accepted and practised policy with regard to the extent of surgery in patients with a non-microcarcinoma is

Another objection from our association concerns the ATA guidelines’ wording of recommendations on the use of recombinant human TSH, which is rather more cautious than the EANM has so far been. Perhaps because of the medicolegal implications, the ATA guidelines, in spite of all the available evidence with regard to equal efficacy and superior patient quality-of-life compared to levothyroxine withdrawal [23–32], are rather hesitant about the use of recombinant human TSH for patient preparation for the initial

[laura]

hoi Ineke,

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