Assessment of the impact of 2015 American Thyroid Association guidelines in management of differentiated thyroid cancer patients

  • Sayak Choudhury
  • Archi Agrawal
  • Gouri Pantvaidya
  • Sneha Shah
  • Nilendu Purandare
  • Ameya Puranik
  • Venkatesh RangarajanEmail author
Original Article
Part of the following topical collections:
  1. Oncology – Head and Neck


The 2015 American Thyroid Association (ATA) guideline have suggested modifications in the risk stratification (RS) for differentiated thyroid cancer (DTC) patients, introduced the concept of dynamic risk stratification (DRS) and redefined the role of radioactive iodine (RAI) in treatment algorithm. The aim of this retrospective audit was to assess the practical implications of these modifications in management of DTC.


A total of 138 DTC patients were stratified according to ATA 2009 and 2015 guidelines into low (LR), intermediate (IR) and high (HR) risk groups. Change in RS and in intention of RAI use was calculated. Deviation in administered RAI dosage from the guidelines was assessed. 1-year follow-up data was audited to assess how the DRS modified the initial risk estimate.


A total of 11.6% of patients changed their RS categories in 2015 guidelines. A total of 10.1% got upstaged to HR, and 1.4% got downstaged to LR. In 2.17% of patients’ intention of RAI use changed to remnant ablation from adjuvant therapy and 65% of the LR patients won’t require any RAI therapy. A total of 26.7% of patients had received significantly more RAI dosage according to ATA 2015. At 1-year follow-up according to DRS 84% of LR, 75% of IR and 44% of HR patients showed excellent response (ER).


More patients changed RS to HR than to LR. Intention of RAI use changed in only a small number of patients. Significantly higher dosage of RAI is being administered to patients in current practice. The effect of DRS in modifying the initial RS was most prominent in IR, with most showing ER to initial therapy.


Differentiated thyroid cancer American Thyroid Association Risk stratification Radioactive iodine Dynamic risk stratification 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Statement of informed consent

This study is a retrospective study therefore there is no direct contact with the patients. Waiver of consent was obtained from institutional ethics committee.


  1. 1.
    Vaisman F, Momesso D, Bulzico DA, Pessoa CHCN, Dias F, Corbo R, et al. Spontaneous remission in thyroid cancer patients after biochemical incomplete response to initial therapy. Clin Endocrinol. 2012;77(1):132–8.CrossRefGoogle Scholar
  2. 2.
    Tuttle RM, Tala H, Shah J, Leboeuf R, Ghossein R, Gonen M, et al. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system. Thyroid. 2010;20(12):1341–9.CrossRefGoogle Scholar
  3. 3.
    Pitoia F, Bueno F, Urciuoli C, Abelleira E, Cross G, Tuttle RM. Outcomes of patients with differentiated thyroid cancer risk-stratified according to the American Thyroid Association and Latin American Thyroid Society risk of recurrence classification systems. Thyroid Off J Am Thyroid Assoc. 2013;23(11):1401–7.CrossRefGoogle Scholar
  4. 4.
    Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167–214.CrossRefGoogle Scholar
  5. 5.
    Ito Y, Fukushima M, Tomoda C, Inoue H, Kihara M, Higashiyama T, et al. Prognosis of patients with papillary thyroid carcinoma having clinically apparent metastasis to the lateral compartment. Endocr J. 2009;56(6):759–66.CrossRefGoogle Scholar
  6. 6.
    Ito Y, Jikuzono T, Higashiyama T, Asahi S, Tomoda C, Takamura Y, et al. Clinical significance of lymph node metastasis of thyroid papillary carcinoma located in one lobe. World J Surg. 2006;30(10):1821–8.CrossRefGoogle Scholar
  7. 7.
    Cranshaw IM, Carnaille B. Micrometastases in thyroid cancer. an important finding? Surg Oncol. 2008;17(3):253–8.CrossRefGoogle Scholar
  8. 8.
    Urken ML, Mechanick JI, Sarlin J, Scherl S, Wenig BM. Pathologic reporting of lymph node metastases in differentiated thyroid cancer: a call to action for the College of American Pathologists. Endocr Pathol. 2014;25(3):214–8.CrossRefGoogle Scholar
  9. 9.
    Leboulleux S, Rubino C, Baudin E, Caillou B, Hartl DM, Bidart J-M, et al. Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis. J Clin Endocrinol Metab. 2005;90(10):5723–9.CrossRefGoogle Scholar
  10. 10.
    Randolph GW, Duh Q-Y, Heller KS, LiVolsi VA, Mandel SJ, Steward DL, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid Off J Am Thyroid Assoc. 2012;22(11):1144–52.CrossRefGoogle Scholar
  11. 11.
    Liu J, Singh B, Tallini G, Carlson DL, Katabi N, Shaha A, et al. Follicular variant of papillary thyroid carcinoma: a clinicopathologic study of a problematic entity. Cancer. 2006;107(6):1255–64.CrossRefGoogle Scholar
  12. 12.
    Piana S, Frasoldati A, Di Felice E, Gardini G, Tallini G, Rosai J. Encapsulated well-differentiated follicular-patterned thyroid carcinomas do not play a significant role in the fatality rates from thyroid carcinoma. Am J Surg Pathol. 2010;34(6):868–72.CrossRefGoogle Scholar
  13. 13.
    O’Neill CJ, Vaughan L, Learoyd DL, Sidhu SB, Delbridge LW, Sywak MS. Management of follicular thyroid carcinoma should be individualised based on degree of capsular and vascular invasion. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2011;37(2):181–5.Google Scholar
  14. 14.
    Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 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. Thyroid Off J Am Thyroid Assoc. 2016;26(1):1–133.CrossRefGoogle Scholar
  15. 15.
    Verburg FA, Aktolun C, Chiti A, Frangos S, Giovanella L, Hoffmann M, et al. 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. Eur J Nucl Med Mol Imaging. 2016;43(6):1001–5.CrossRefGoogle Scholar
  16. 16.
    Tuttle RM, Ahuja S, Avram AM, Bernet VJ, Bourguet P, Daniels GH, et al. Controversies, Consensus, and collaboration in the use of 131I Therapy in differentiated thyroid cancer: a joint statement from the American Thyroid Association, the European Association of Nuclear Medicine, the Society of Nuclear Medicine and Molecular Imaging, and the European Thyroid Association. Thyroid. 2019;29(4):461–70.CrossRefGoogle Scholar
  17. 17.
    Annual congress of the European Association of Nuclear Medicine October 13–17, 2018 Düsseldorf, Germany. Eur J Nucl Med Mol Imaging. 2018;45(1):1–844.CrossRefGoogle Scholar
  18. 18.
    Sywak M, Cornford L, Roach P, Stalberg P, Sidhu S, Delbridge L. Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer. Surgery. 2006;140(6):1000–1005-1007.CrossRefGoogle Scholar
  19. 19.
    Hughes DT, White ML, Miller BS, Gauger PG, Burney RE, Doherty GM. Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer. Surgery. 2010;148(6):1100–1106-1007.CrossRefGoogle Scholar
  20. 20.
    Qubain SW, Nakano S, Baba M, Takao S, Aikou T. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma. Surgery. 2002;131(3):249–56.CrossRefGoogle Scholar
  21. 21.
    Frangos S, Iakovou IP, Marlowe RJ, Eftychiou N, Patsali L, Vanezi A, et al. Difficulties in deciding whether to ablate patients with putatively “low–intermediate-risk” differentiated thyroid carcinoma: do guidelines mainly apply in the centres that produce them? Results of a retrospective, two-centre quality assurance study. Eur J Nucl Med Mol Imaging. 2015;42(13):2045–55.CrossRefGoogle Scholar
  22. 22.
    Frangos S, Iakovou IP, Marlowe RJ, Eftychiou N, Patsali L, Vanezi A, et al. Acknowledging gray areas: 2015 vs. 2009 American Thyroid Association differentiated thyroid cancer guidelines on ablating putatively low-intermediate-risk patients. Eur J Nucl Med Mol Imaging. 2017;44(2):185–9.CrossRefGoogle Scholar
  23. 23.
    Mallick U, Harmer C, Yap B, Wadsley J, Clarke S, Moss L, et al. Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer. N Engl J Med. 2012;366(18):1674–85.CrossRefGoogle Scholar
  24. 24.
    Mäenpää HO, Heikkonen J, Vaalavirta L, Tenhunen M, Joensuu H. Low vs. high radioiodine activity to ablate the thyroid after thyroidectomy for cancer: a randomized study. PLoS One. 2008;3(4):e1885.CrossRefGoogle Scholar
  25. 25.
    Fallahi B, Beiki D, Takavar A, Fard-Esfahani A, Gilani KA, Saghari M, et al. Low versus high radioiodine dose in postoperative ablation of residual thyroid tissue in patients with differentiated thyroid carcinoma: a large randomized clinical trial. Nucl Med Commun. 2012;33(3):275–82.CrossRefGoogle Scholar
  26. 26.
    Castagna MG, Cevenini G, Theodoropoulou A, Maino F, Memmo S, Claudia C, et al. Post-surgical thyroid ablation with low or high radioiodine activities results in similar outcomes in intermediate risk differentiated thyroid cancer patients. Eur J Endocrinol. 2013;169(1):23–9.CrossRefGoogle Scholar
  27. 27.
    Sabra MM, Grewal RK, Ghossein RA, Tuttle RM. Higher administered activities of radioactive iodine are associated with less structural persistent response in older, but not younger, papillary thyroid cancer patients with lateral neck lymph node metastases. Thyroid Off J Am Thyroid Assoc. 2014;24(7):1088–95.CrossRefGoogle Scholar
  28. 28.
    Han JM, Kim WG, Kim TY, Jeon MJ, Ryu J-S, Song DE, et al. Effects of low-dose and high-dose postoperative radioiodine therapy on the clinical outcome in patients with small differentiated thyroid cancer having microscopic extrathyroidal extension. Thyroid. 2014;24(5):820–5.CrossRefGoogle Scholar
  29. 29.
    Ozkan E, Soydal C, Nak D, Kucuk NO, Kir KM. Dynamic risk stratification for predicting the recurrence in differentiated thyroid cancer. Nucl Med Commun. 2017;38(12):1055–9.CrossRefGoogle Scholar
  30. 30.
    Castagna MG, Maino F, Cipri C, Belardini V, Theodoropoulou A, Cevenini G, et al. Delayed risk stratification, to include the response to initial treatment (surgery and radioiodine ablation), has better outcome predictivity in differentiated thyroid cancer patients. Eur J Endocrinol. 2011;165(3):441–6.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Sayak Choudhury
    • 1
  • Archi Agrawal
    • 1
  • Gouri Pantvaidya
    • 2
  • Sneha Shah
    • 1
  • Nilendu Purandare
    • 1
  • Ameya Puranik
    • 1
  • Venkatesh Rangarajan
    • 1
    Email author
  1. 1.Department of Nuclear Medicine and Molecular ImagingTata Memorial Hospital, Homi Bhaba National Institute (HBNI)MumbaiIndia
  2. 2.Department of Surgical OncologyTata Memorial Hospital, Homi Bhaba National Institute (HBNI)MumbaiIndia

Personalised recommendations