Care for patients with thyroid nodules is complex and multidisciplinary. Has been shown to vary significantly between institutions and providers. Goal was to reduce unwarranted variation and improve quality of care

1. AHNS Endocrine Surgery Section
Guidelines
https://endocrine.ahns.info
North American Quality Statements and
Evidence Based Multidisciplinary Workflow
Algorithms for the Evaluation and
Management of Thyroid Nodules
Meltzer CJ, Irish J, Odell M, Wiseman SM, Haymart MR, Shin J,
Monteiro E, Ferris RL, Wong RJ, Tuttle RM, Morris JC, Haugen BR,
Morris LGT, McIver B, Busady NL, Mechanick JI, Harrell RM,
Shonka DC, Scharpf J, Dwojak S, Urken M, Davies L, Thompson GB,
Angelos P, Randolph GW

2. AHNS Endocrine Surgery Section - https://endocrine.ahns.info

3. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Care for patients with thyroid nodules is complex and
multidisciplinary
• Has been shown to vary significantly between
institutions and providers
• Goal was to reduce unwarranted variation and improve
quality of care
Background

4. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Consensus Author Panel
• National, multidisciplinary effort
• Members of AHNS Endocrine Surgery Section, endocrine
surgeons, head & neck surgeons, endocrinologists
• Modified Delphi approach
• Source Documents
• Workflow algorithm from Kaiser Permanente Northern
California
• Workflow algorithm from Cancer Care of Ontario
Consensus Development

5. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Rigorous method to achieve consensus
• Consensus achieved in 2 rounds
• Likert scale ranging from 1 (strongly disagree) to 9 (strongly
agree) used
• RAND/UCLA Appropriateness method used to quantify
findings
• Consensus criteria required a median of > 7.0 to agree
• Disagreement index (DI) calculated at >1.0 indicated
disagreement
Consensus Process

6. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE PREOPERATIVE WORKUP
EUTHYROID
NODULE
Tracking
Metric 1
Obtain US ofthyroid
and all anterior and
lateral neck
structures
(ATA A8/REC 6)*
Risk stratification of
US using ATA
or ACR TIRADS
Tracking
Metric 2
No nodule or
nodules smaller
than FNA sizecut-off
ATA Benign
or TIRADS **1
TIRADS 2
ATA Very low
suspicion
TIRADS 3
ATA Intermediate
Suspicion
Observe
(ATA A8/REC 8E)
Tracking
Metric 3
FNA 2 cm
(ATA A9/REC 8D)
FNA 2.5 cm FNA 1.5 cm
(ATA A9/REC 8C)
FNA 1 cm
(ATA A9/REC 8B)
FNA 1 cm
(ATA A9 /REC 8A)
Utilization of Bethesda System for Reporting Thyroid Cytopathology
(ATA A11/REC 9)
Bethesda I
Nondiagnostic
Repeat FNA
biopsy in 3 mos
(ATA A12/REC 10A)
US very low risk
nodules, consider
US in 2 yrs
(ATA A24/REC 23C)
Bethesda V-VI
Suspicious for
malignancy or
malignant
Bethesda III
AUS/FLUS
If Bethesda I again,
consider
observation vs.
diagnostic
lobectomy
(ATA 12/REC 10B/C)
IfBethesda II-VI,
follow the
appropriate path
Bethesda II
Benign
If FNA is repeated
and again found to
bebenign, no
further surveillance
is indicated
(ATA A25/REC 23D)
US low to intermediate
risk nodules or TIRADS
3, consider repeat US
in 12-24 mos
(ATA A24/REC 23 B)
If evidence of growth
2 mmin 2
dimensions or 50%
change in volume or
suspicious US findings,
repeat FNA
(ATA A24/REC 23B)
Bethesda IV
Follicular neoplasm
or suspicious for a
follicular neoplasm
US high risk nodules or
TIRADS 4-5, consider
repeat US or FNAin
6-12 mos
(ATA A24/REC 23A)
If repeat FNA is benign,
no further surveillance
is indicated
(ATA A25/REC 23D)
If repeat US still
appears high risk,
consider repeat US at
2-3 yrs and less often if
stable
Repeat FNAbiopsy
in 3 mos or
surveillance or
surgery
Consider molecular
testing or
surveillance or
surgery
(ATA A17/REC 15)
Order perioperative
serum calcium test
for alland serum
calcitonin for known
or suspected
medullary CA
RoutineTSH
suppression NOT
recommended
(ATA A27/REC 25)
Repeat FNA
yields AUS/
FLUS
Tracking
Metric 5
If initial US did not
include lateral neck, then
repeat US of central and
lateral neck with FNA of
any suspicious nodes
> 8-10 mmin smallest
diameter
(ATA B4/REC 32)
Obtain cross-sectional
imaging with contrast or
MRI if there are
abnormal nodes at the
limits ofthe sonogram,
extensive nodaldisease
or the primary tumor is
very large or invasive
(ATA 85/REC 33)
Surgery consult with
high volume surgeon
(ATA A14/REC 12)
Tracking
Metric 6
PATHOLOGY
MEDICAL IMAGING
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Moderate quality evidence
WEAK RECOMMENDATION– Low quality evidence
 AUS – Atypia of unknown
significance
 FLUS – Follicular lesion of
undetermined significance
 CT – Computed tomography
 MRI – Magnetic resonance
imaging
 US – Ultrasound
 FNA – Fine-needle aspiration
NOTE: There are slightly
different management
recommendations from
the ATA and ACR:
*2015 ATA Management
Guidelines for Adult Patients
with Thyroid Nodules and
Differentiated Cancer
**ACR Thyroid Imaging,
Reporting, and Data System
(TIRADS): White Paper of the
ACR TIRADS Committee
Tracking
Metric 4
IMAGING/
ENDOCRINOLOGY
ATA Low suspicion
or TIRADS 4
ATA High suspicion
or TIRADS 5

7. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE PREOPERATIVE WORKUP
EUTHYROID
NODULE
Tracking
Metric 1
Obtain US ofthyroid
and all anterior and
lateral neck
structures
(ATA A8/REC 6)*
Risk stratification of
US using ATA
or ACR TIRADS
Tracking
Metric 2
No nodule or
nodules smaller
than FNA sizecut-off
ATA Benign
or TIRADS **1
TIRADS 2
ATA Very low
suspicion
TIRADS 3
ATA Intermediate
Suspicion
Observe
(ATA A8/REC 8E)
Tracking
Metric 3
FNA 2 cm
(ATA A9/REC 8D)
FNA 2.5 cm FNA 1.5 cm
(ATA A9/REC 8C)
FNA 1 cm
(ATA A9/REC 8B)
FNA 1 cm
(ATA A9 /REC 8A)
Utilization of Bethesda System for Reporting Thyroid Cytopathology
(ATA A11/REC 9)
Bethesda I
Nondiagnostic
Repeat FNA
biopsy in 3 mos
(ATA A12/REC 10A)
US very low risk
nodules, consider
US in 2 yrs
(ATA A24/REC 23C)
Bethesda V-VI
Suspicious for
malignancy or
malignant
Bethesda III
AUS/FLUS
If Bethesda I again,
consider
observation vs.
diagnostic
lobectomy
(ATA 12/REC 10B/C)
IfBethesda II-VI,
follow the
appropriate path
Bethesda II
Benign
If FNA is repeated
and again found to
bebenign, no
further surveillance
is indicated
(ATA A25/REC 23D)
US low to intermediate
risk nodules or TIRADS
3, consider repeat US
in 12-24 mos
(ATA A24/REC 23 B)
If evidence of growth
2 mmin 2
dimensions or 50%
change in volume or
suspicious US findings,
repeat FNA
(ATA A24/REC 23B)
Bethesda IV
Follicular neoplasm
or suspicious for a
follicular neoplasm
US high risk nodules or
TIRADS 4-5, consider
repeat US or FNAin
6-12 mos
(ATA A24/REC 23A)
If repeat FNA is benign,
no further surveillance
is indicated
(ATA A25/REC 23D)
If repeat US still
appears high risk,
consider repeat US at
2-3 yrs and less often if
stable
Repeat FNAbiopsy
in 3 mos or
surveillance or
surgery
Consider molecular
testing or
surveillance or
surgery
(ATA A17/REC 15)
Order perioperative
serum calcium test
for alland serum
calcitonin for known
or suspected
medullary CA
RoutineTSH
suppression NOT
recommended
(ATA A27/REC 25)
Repeat FNA
yields AUS/
FLUS
Tracking
Metric 5
If initial US did not
include lateral neck, then
repeat US of central and
lateral neck with FNA of
any suspicious nodes
> 8-10 mmin smallest
diameter
(ATA B4/REC 32)
Obtain cross-sectional
imaging with contrast or
MRI if there are
abnormal nodes at the
limits ofthe sonogram,
extensive nodaldisease
or the primary tumor is
very large or invasive
(ATA 85/REC 33)
Surgery consult with
high volume surgeon
(ATA A14/REC 12)
Tracking
Metric 6
PATHOLOGY
MEDICAL IMAGING
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Moderate quality evidence
WEAK RECOMMENDATION– Low quality evidence
 AUS – Atypia of unknown
significance
 FLUS – Follicular lesion of
undetermined significance
 CT – Computed tomography
 MRI – Magnetic resonance
imaging
 US – Ultrasound
 FNA – Fine-needle aspiration
NOTE: There are slightly
different management
recommendations from
the ATA and ACR:
*2015 ATA Management
Guidelines for Adult Patients
with Thyroid Nodules and
Differentiated Cancer
**ACR Thyroid Imaging,
Reporting, and Data System
(TIRADS): White Paper of the
ACR TIRADS Committee
Tracking
Metric 4
IMAGING/
ENDOCRINOLOGY
ATA Low suspicion
or TIRADS 4
ATA High suspicion
or TIRADS 5

8. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
EUTHYROID
NODULE
Tracking
Metric 1
Obtain US ofthyroid
and all anterior and
lateral neck
structures
(ATA A8/REC 6)*
Risk stratification of
US usingATA
or ACR TIRADS
Tracking
Metric 2
No nodule or
nodules smaller
than FNA sizecut-off
ATA Benign
or TIRADS **1
TIRADS 2
ATA Very low
suspicion
TIRADS 3
ATA Intermediate
Suspicion
Observe
(ATA A8/REC 8E)
Tracking
Metric 3
FNA 2 cm
(ATA A9/REC 8D)
FNA 2.5 cm FNA 1.5 cm
(ATA A9/REC 8C)
FNA 1 cm
(ATA A9/REC 8B)
FNA 1 cm
(ATA A9 /REC 8A)
Utilization of Bethesda System for Reporting Thyroid Cytopathology
(ATA A11/REC 9)
PATHOLOGY
MEDICAL IMAGING
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION– Moderate quality evidence
WEAK RECOMMENDATION– Low quality evidence
Tracking
Metric 4
IMAGING/
ENDOCRINOLOGY
ATA Low suspicion
or TIRADS 4
ATA High suspicion
or TIRADS 5

9. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE PREOPERATIVE WORKUP
EUTHYROID
NODULE
Tracking
Metric 1
Obtain US ofthyroid
and all anterior and
lateral neck
structures
(ATA A8/REC 6)*
Risk stratification of
US using ATA
or ACR TIRADS
Tracking
Metric 2
No nodule or
nodules smaller
than FNA sizecut-off
ATA Benign
or TIRADS **1
TIRADS 2
ATA Very low
suspicion
TIRADS 3
ATA Intermediate
Suspicion
Observe
(ATA A8/REC 8E)
Tracking
Metric 3
FNA 2 cm
(ATA A9/REC 8D)
FNA 2.5 cm FNA 1.5 cm
(ATA A9/REC 8C)
FNA 1 cm
(ATA A9/REC 8B)
FNA 1 cm
(ATA A9 /REC 8A)
Utilization of Bethesda System for Reporting Thyroid Cytopathology
(ATA A11/REC 9)
Bethesda I
Nondiagnostic
Repeat FNA
biopsy in 3 mos
(ATA A12/REC 10A)
US very low risk
nodules, consider
US in 2 yrs
(ATA A24/REC 23C)
Bethesda V-VI
Suspicious for
malignancy or
malignant
Bethesda III
AUS/FLUS
If Bethesda I again,
consider
observation vs.
diagnostic
lobectomy
(ATA 12/REC 10B/C)
IfBethesda II-VI,
follow the
appropriate path
Bethesda II
Benign
If FNA is repeated
and again found to
bebenign, no
further surveillance
is indicated
(ATA A25/REC 23D)
US low to intermediate
risk nodules or TIRADS
3, consider repeat US
in 12-24 mos
(ATA A24/REC 23 B)
If evidence of growth
2 mmin 2
dimensions or 50%
change in volume or
suspicious US findings,
repeat FNA
(ATA A24/REC 23B)
Bethesda IV
Follicular neoplasm
or suspicious for a
follicular neoplasm
US high risk nodules or
TIRADS 4-5, consider
repeat US or FNAin
6-12 mos
(ATA A24/REC 23A)
If repeat FNA is benign,
no further surveillance
is indicated
(ATA A25/REC 23D)
If repeat US still
appears high risk,
consider repeat US at
2-3 yrs and less often if
stable
Repeat FNAbiopsy
in 3 mos or
surveillance or
surgery
Consider molecular
testing or
surveillance or
surgery
(ATA A17/REC 15)
Order perioperative
serum calcium test
for alland serum
calcitonin for known
or suspected
medullary CA
RoutineTSH
suppression NOT
recommended
(ATA A27/REC 25)
Repeat FNA
yields AUS/
FLUS
Tracking
Metric 5
If initial US did not
include lateral neck, then
repeat US of central and
lateral neck with FNA of
any suspicious nodes
> 8-10 mmin smallest
diameter
(ATA B4/REC 32)
Obtain cross-sectional
imaging with contrast or
MRI if there are
abnormal nodes at the
limits ofthe sonogram,
extensive nodaldisease
or the primary tumor is
very large or invasive
(ATA 85/REC 33)
Surgery consult with
high volume surgeon
(ATA A14/REC 12)
Tracking
Metric 6
PATHOLOGY
MEDICAL IMAGING
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Moderate quality evidence
WEAK RECOMMENDATION– Low quality evidence
 AUS – Atypia of unknown
significance
 FLUS – Follicular lesion of
undetermined significance
 CT – Computed tomography
 MRI – Magnetic resonance
imaging
 US – Ultrasound
 FNA – Fine-needle aspiration
NOTE: There are slightly
different management
recommendations from
the ATA and ACR:
*2015 ATA Management
Guidelines for Adult Patients
with Thyroid Nodules and
Differentiated Cancer
**ACR Thyroid Imaging,
Reporting, and Data System
(TIRADS): White Paper of the
ACR TIRADS Committee
Tracking
Metric 4
IMAGING/
ENDOCRINOLOGY
ATA Low suspicion
or TIRADS 4
ATA High suspicion
or TIRADS 5

10. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Bethesda I
Nondiagnostic
RepeatFNA
biopsy in 3mos
(ATA A12/REC10A)
USverylowrisk
nodules,consider
USin 2yrs
(ATA A24/REC23C)
Bethesda V-VI
Suspiciousfor
malignancy or
malignant
Bethesda III
AUS/FLUS
IfBethesdaIagain,
consider
observationvs.
diagnostic
lobectomy
(ATA 12/REC10B/C)
IfBethesdaII-VI,
followthe
appropriatepath
Bethesda II
Benign
IfFNA is repeated
andagainfoundto
bebenign,no
furthersurveillance
is indicated
(ATA A25/REC23D)
USlowtointermediate
risk nodulesorTIRADS
3,considerrepeatUS
in 12-24 mos
(ATA A24/REC23 B)
Ifevidenceof growth
2mmin2
dimensions or 50%
changeinvolumeor
suspicious USfindings,
repeatFNA
(ATA A24/REC23B)
Bethesda IV
Follicularneoplasm
orsuspicious for a
follicularneoplasm
UShighrisknodules or
TIRADS 4-5,consider
repeatUSorFNAin
6-12 mos
(ATA A24/REC23A)
IfrepeatFNA is benign,
nofurthersurveillance
is indicated
(ATA A25/REC23D)
IfrepeatUS still
appears highrisk,
considerrepeatUS at
2-3yrsandlessoftenif
stable
RepeatFNAbiopsy
in 3mos or
surveillanceor
surgery
Consider molecular
testingor
surveillanceor
surgery
(ATA A17/REC15)
Orderperioperative
serumcalciumtest
forallandserum
calcitoninforknown
orsuspected
medullaryCA
RoutineTSH
suppressionNOT
recommended
(ATA A27/REC25)
RepeatFNA
yieldsAUS/
FLUS
Tracking
Metric 5
IfinitialUSdidnot
includelateralneck,then
repeatUSofcentraland
lateralneckwithFNA of
anysuspicious nodes
>8-10 mminsmallest
diameter
(ATA B4/REC32)
Obtaincross-sectional
imaging withcontrastor
MRIif thereare
abnormalnodes atthe
limits ofthesonogram,
extensivenodaldisease
ortheprimarytumoris
verylargeorinvasive
(ATA85/REC33)
Surgery consultwith
highvolumesurgeon
(ATA A14/REC12)
Tracking
Metric 6

11. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 1-6

12. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT
Consider total
thyroidectomy
(ATA A21/REC 20)
Surgeon:
 Provides informed consent (ATA B11/REC 39)
 Confirms plan with/or notifies endocrinologist ifpatient
opts for a different procedure other than theoriginal
recommendation
 Performs pre-op voice or vocalfold assessment
Document quality of
voice or laryngeal
examination
(ATA B12/REC 40)
Laryngeal examination
(ATA B12/REC 41)
Tracking
Metric 7
General considerations at
time of surgery
Visualize all important anatomy including:
NOT recommended unless specific
indications:
 Drains or perioperative antibiotics
 Frozen section is generally NOT
indicated
Large substernal goiters should be doneat
centers with thoracic backup
Notify pathologist of evidence of gross
extrathyroidal extension into strap muscles
Prophylactic central compartment
neck dissection
(ATA B8/REC 36B)
Pathology Results
If malignant, should include:
 Histologic type
 Margins
 Vascular invasion
 Number ofnodes examined
and involved
 Extrathyroidal spread
 Extranodal spread
(ATA B15/REC 46)
Central compartment neck
dissection
(ATA B8/REC 36A, 37)
Lateral neck dissection
(ATA B8/REC 37)
CNo
CN+
N+
Identification of recurrent
laryngeal nerve(s)
(ATA B13/REC 42A)
Preservation of parathyroid glands
(ATA B13/REC 43)No previous neck
surgery or normal voice
Previous neck or chest
surgery or any voice
issue
Well-differentiated thyroid
carcinoma
Microscopic papillary thyroid
Benign
High risk tumors
Surveillance
Refer to
tumor board
Pathology results
sent to endocrinologist
(ATA B14/REC 45)
Neck dissection
options to
consider for
confirmed
cancer
undergoing total
thyroidectomy
Thyroid lobectomy may be sufficient initial
treatment for low risk papillary and
follicular carcinomas without central
compartment dissection
(ATA B7/REC35B, 35C)
(ATA B8/REC 36C)
Totalthyroidectomy already completed or
proceed with totalor completion or near
total thyroidectomy based on pathology,
RAI planning, or patient preferenceand
consider neck dissection options
(ATA 21/REC 20)
(ATA B7/REC 35A)
(ATA B8/REC 36C)
(ATA B9/REC 38A))
< 4 cm. and based
on clinical, US, and
patient preference
4 cm. or presence
of contralateral
nodules or AUS/FN
with possible
molecular results
Surgical consult for patient
with Bethesda III-VI
thyroid nodule
Consider lobectomy
(ATA A21/REC 19)
Go to Postoperative Management
(Figure 3)
PATHOLOGY
SURGERY
STRONG RECOMMENDATION– High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Low quality evidence
T1 or T2/ CNo T3 or T4
ENDOCRINOLOGY
Tracking Metric 8

13. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT
Consider total
thyroidectomy
(ATA A21/REC 20)
Surgeon:
 Provides informed consent (ATA B11/REC 39)
 Confirms plan with/or notifies endocrinologist ifpatient
opts for a different procedure other than theoriginal
recommendation
 Performs pre-op voice or vocalfold assessment
Document quality of
voice or laryngeal
examination
(ATA B12/REC 40)
Laryngeal examination
(ATA B12/REC 41)
Tracking
Metric 7
General considerations at
time of surgery
Visualize all important anatomy including:
NOT recommended unless specific
indications:
 Drains or perioperative antibiotics
 Frozen section is generally NOT
indicated
Large substernal goiters should be doneat
centers with thoracic backup
Notify pathologist of evidence of gross
extrathyroidal extension into strap muscles
Prophylactic central compartment
neck dissection
(ATA B8/REC 36B)
Pathology Results
If malignant, should include:
 Histologic type
 Margins
 Vascular invasion
 Number ofnodes examined
and involved
 Extrathyroidal spread
 Extranodal spread
(ATA B15/REC 46)
Central compartment neck
dissection
(ATA B8/REC 36A, 37)
Lateral neck dissection
(ATA B8/REC 37)
CNo
CN+
N+
Identification of recurrent
laryngeal nerve(s)
(ATA B13/REC 42A)
Preservation of parathyroid glands
(ATA B13/REC 43)No previous neck
surgery or normal voice
Previous neck or chest
surgery or any voice
issue
Well-differentiated thyroid
carcinoma
Microscopic papillary thyroid
Benign
High risk tumors
Surveillance
Refer to
tumor board
Pathology results
sent to endocrinologist
(ATA B14/REC 45)
Neck dissection
options to
consider for
confirmed
cancer
undergoing total
thyroidectomy
Thyroid lobectomy may be sufficient initial
treatment for low risk papillary and
follicular carcinomas without central
compartment dissection
(ATA B7/REC35B, 35C)
(ATA B8/REC 36C)
Totalthyroidectomy already completed or
proceed with totalor completion or near
total thyroidectomy based on pathology,
RAI planning, or patient preferenceand
consider neck dissection options
(ATA 21/REC 20)
(ATA B7/REC 35A)
(ATA B8/REC 36C)
(ATA B9/REC 38A))
< 4 cm. and based
on clinical, US, and
patient preference
4 cm. or presence
of contralateral
nodules or AUS/FN
with possible
molecular results
Surgical consult for patient
with Bethesda III-VI
thyroid nodule
Consider lobectomy
(ATA A21/REC 19)
Go to Postoperative Management
(Figure 3)
PATHOLOGY
SURGERY
STRONG RECOMMENDATION– High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Low quality evidence
T1 or T2/ CNo T3 or T4
ENDOCRINOLOGY
Tracking Metric 8

14. AHNS Endocrine Surgery Section - https://endocrine.ahns.info

15. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT
Consider total
thyroidectomy
(ATA A21/REC 20)
Surgeon:
 Provides informed consent (ATA B11/REC 39)
 Confirms plan with/or notifies endocrinologist ifpatient
opts for a different procedure other than theoriginal
recommendation
 Performs pre-op voice or vocalfold assessment
Document quality of
voice or laryngeal
examination
(ATA B12/REC 40)
Laryngeal examination
(ATA B12/REC 41)
Tracking
Metric 7
General considerations at
time of surgery
Visualize all important anatomy including:
NOT recommended unless specific
indications:
 Drains or perioperative antibiotics
 Frozen section is generally NOT
indicated
Large substernal goiters should be doneat
centers with thoracic backup
Notify pathologist of evidence of gross
extrathyroidal extension into strap muscles
Prophylactic central compartment
neck dissection
(ATA B8/REC 36B)
Pathology Results
If malignant, should include:
 Histologic type
 Margins
 Vascular invasion
 Number ofnodes examined
and involved
 Extrathyroidal spread
 Extranodal spread
(ATA B15/REC 46)
Central compartment neck
dissection
(ATA B8/REC 36A, 37)
Lateral neck dissection
(ATA B8/REC 37)
CNo
CN+
N+
Identification of recurrent
laryngeal nerve(s)
(ATA B13/REC 42A)
Preservation of parathyroid glands
(ATA B13/REC 43)No previous neck
surgery or normal voice
Previous neck or chest
surgery or any voice
issue
Well-differentiated thyroid
carcinoma
Microscopic papillary thyroid
Benign
High risk tumors
Surveillance
Refer to
tumor board
Pathology results
sent to endocrinologist
(ATA B14/REC 45)
Neck dissection
options to
consider for
confirmed
cancer
undergoing total
thyroidectomy
Thyroid lobectomy may be sufficient initial
treatment for low risk papillary and
follicular carcinomas without central
compartment dissection
(ATA B7/REC35B, 35C)
(ATA B8/REC 36C)
Totalthyroidectomy already completed or
proceed with totalor completion or near
total thyroidectomy based on pathology,
RAI planning, or patient preferenceand
consider neck dissection options
(ATA 21/REC 20)
(ATA B7/REC 35A)
(ATA B8/REC 36C)
(ATA B9/REC 38A))
< 4 cm. and based
on clinical, US, and
patient preference
4 cm. or presence
of contralateral
nodules or AUS/FN
with possible
molecular results
Surgical consult for patient
with Bethesda III-VI
thyroid nodule
Consider lobectomy
(ATA A21/REC 19)
Go to Postoperative Management
(Figure 3)
PATHOLOGY
SURGERY
STRONG RECOMMENDATION– High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Low quality evidence
T1 or T2/ CNo T3 or T4
ENDOCRINOLOGY
Tracking Metric 8

16. AHNS Endocrine Surgery Section - https://endocrine.ahns.info

17. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT
Consider total
thyroidectomy
(ATA A21/REC 20)
Surgeon:
 Provides informed consent (ATA B11/REC 39)
 Confirms plan with/or notifies endocrinologist ifpatient
opts for a different procedure other than theoriginal
recommendation
 Performs pre-op voice or vocalfold assessment
Document quality of
voice or laryngeal
examination
(ATA B12/REC 40)
Laryngeal examination
(ATA B12/REC 41)
Tracking
Metric 7
General considerations at
time of surgery
Visualize all important anatomy including:
NOT recommended unless specific
indications:
 Drains or perioperative antibiotics
 Frozen section is generally NOT
indicated
Large substernal goiters should be doneat
centers with thoracic backup
Notify pathologist of evidence of gross
extrathyroidal extension into strap muscles
Prophylactic central compartment
neck dissection
(ATA B8/REC 36B)
Pathology Results
If malignant, should include:
 Histologic type
 Margins
 Vascular invasion
 Number ofnodes examined
and involved
 Extrathyroidal spread
 Extranodal spread
(ATA B15/REC 46)
Central compartment neck
dissection
(ATA B8/REC 36A, 37)
Lateral neck dissection
(ATA B8/REC 37)
CNo
CN+
N+
Identification of recurrent
laryngeal nerve(s)
(ATA B13/REC 42A)
Preservation of parathyroid glands
(ATA B13/REC 43)No previous neck
surgery or normal voice
Previous neck or chest
surgery or any voice
issue
Well-differentiated thyroid
carcinoma
Microscopic papillary thyroid
Benign
High risk tumors
Surveillance
Refer to
tumor board
Pathology results
sent to endocrinologist
(ATA B14/REC 45)
Neck dissection
options to
consider for
confirmed
cancer
undergoing total
thyroidectomy
Thyroid lobectomy may be sufficient initial
treatment for low risk papillary and
follicular carcinomas without central
compartment dissection
(ATA B7/REC35B, 35C)
(ATA B8/REC 36C)
Totalthyroidectomy already completed or
proceed with totalor completion or near
total thyroidectomy based on pathology,
RAI planning, or patient preferenceand
consider neck dissection options
(ATA 21/REC 20)
(ATA B7/REC 35A)
(ATA B8/REC 36C)
(ATA B9/REC 38A))
< 4 cm. and based
on clinical, US, and
patient preference
4 cm. or presence
of contralateral
nodules or AUS/FN
with possible
molecular results
Surgical consult for patient
with Bethesda III-VI
thyroid nodule
Consider lobectomy
(ATA A21/REC 19)
Go to Postoperative Management
(Figure 3)
PATHOLOGY
SURGERY
STRONG RECOMMENDATION– High quality evidence
STRONG RECOMMENDATION – Moderate quality evidence
STRONG RECOMMENDATION – Low quality evidence
WEAK RECOMMENDATION – Low quality evidence
T1 or T2/ CNo T3 or T4
ENDOCRINOLOGY
Tracking Metric 8

18. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Pathology Results
If malignant, should include:
 Histologic type
 Margins
 Vascular invasion
 Number of nodes examined
and involved
 Extrathyroidal spread
 Extranodal spread
(ATA B15/REC 46)
Well-differentiated thyroid
carcinoma
Microscopic papillary thyroid
Benign
High risk tumors
Surveillance
Refer to
tumor board
Pathology results
sent to endocrinologist
(ATA B14/REC 45)
Thyroid lobectomy may be sufficient initial
treatment for low risk papillary and
follicular carcinomas without central
compartment dissection
(ATA B7/REC35B, 35C)
(ATA B8/REC 36C)
Total thyroidectomy already completed or
proceed with total or completion or near
total thyroidectomy based on pathology,
RAI planning, or patient preference and
consider neck dissection options
(ATA 21/REC 20)
(ATA B7/REC 35A)
(ATA B8/REC 36C)
(ATA B9/REC 38A))
T1 or T2/ CNo T3 or T4

19. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 7-8

20. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – Moderate quality evidence
 TID – three times a day
 Tg – thyroglobulin
 PTH – parathyroid hormone
 TSH – thyroid-stimulating hormone
 BID – two times a day
Post-op
thyroidectomy
Tracking
Metric 16
Order post-op thyroid
hormonereplacement for
patients following total or
completion thyroidectomy
Order post-op TSH/Tg levels
(ATA C5/REC 62)
Updatestaging
(ATA B17/REC 47)
Empiric therapy
Calcium 1000-1200 mg TID
+/- calcitriol 0.25-0.5 µg BID
PTH-guided management
PTH > 20
No supplementation or low dosecalcium
PTH 10-20
Give calcium 1000-1200 mg TID at
discharge
PTH < 10
Add calcitriol 0.25-0.5 µg BID to calcium at
discharge
Management options
for immediate
postoperative
potential transient
hypoparathyroidism
Documents quality
of voiceand/or
vocal fold status
within 2-8 weeks
post-op
(ATA B14/REC 44)
Tracking
Metric 11
Consider serum
calcium check on
postoperative
day 2 or 3**
Consider endocrinologist if
having difficulty with
immediatepostoperative
hypocalcemia management
and/or if ongoing
beyond 4 weeks
Tracking
Metric 15
**NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the
diagnosis postoperative or history of parathyroidectomy or thyroidectomy
Do NOT use hypocalcemia without previous laboratory-validated diagnosis
Following completion or
total thyroidectomy
Following completion
or totalthyroidectomy
ALL
patients
Tracking
Metric 9
Tracking
Metric
10
Pathology
results
Surveillance
Tracking
Metric
12, 13, 14

21. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – Moderate quality evidence
 TID – three times a day
 Tg – thyroglobulin
 PTH – parathyroid hormone
 TSH – thyroid-stimulating hormone
 BID – two times a day
Post-op
thyroidectomy
Tracking
Metric 16
Order post-op thyroid
hormonereplacement for
patients following total or
completion thyroidectomy
Order post-op TSH/Tg levels
(ATA C5/REC 62)
Updatestaging
(ATA B17/REC 47)
Empiric therapy
Calcium 1000-1200 mg TID
+/- calcitriol 0.25-0.5 µg BID
PTH-guided management
PTH > 20
No supplementation or low dosecalcium
PTH 10-20
Give calcium 1000-1200 mg TID at
discharge
PTH < 10
Add calcitriol 0.25-0.5 µg BID to calcium at
discharge
Management options
for immediate
postoperative
potential transient
hypoparathyroidism
Documents quality
of voiceand/or
vocal fold status
within 2-8 weeks
post-op
(ATA B14/REC 44)
Tracking
Metric 11
Consider serum
calcium check on
postoperative
day 2 or 3**
Consider endocrinologist if
having difficulty with
immediatepostoperative
hypocalcemia management
and/or if ongoing
beyond 4 weeks
Tracking
Metric 15
**NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the
diagnosis postoperative or history of parathyroidectomy or thyroidectomy
Do NOT use hypocalcemia without previous laboratory-validated diagnosis
Following completion or
total thyroidectomy
Following completion
or totalthyroidectomy
ALL
patients
Tracking
Metric 9
Tracking
Metric
10
Pathology
results
Surveillance
Tracking
Metric
12, 13, 14

22. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Empiric therapy
Calcium1000-1200 mgTID
+/- calcitriol 0.25-0.5 µgBID
PTH-guided management
PTH> 20
No supplementation or low dosecalcium
PTH10-20
Give calcium 1000-1200 mgTID at
discharge
PTH< 10
Add calcitriol 0.25-0.5 µgBID to calcium at
discharge
Management options
for immediate
postoperative
potential transient
hypoparathyroidism
Consider serum
calcium check on
postoperative
day2 or3**
Consider endocrinologist if
havingdifficultywith
immediatepostoperative
hypocalcemiamanagement
and/or if ongoing
beyond 4 weeks
Tracking
Metric 15

23. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT
SURGERY
ENDOCRINOLOGY
STRONG RECOMMENDATION – Moderate quality evidence
 TID – three times a day
 Tg – thyroglobulin
 PTH – parathyroid hormone
 TSH – thyroid-stimulating hormone
 BID – two times a day
Post-op
thyroidectomy
Tracking
Metric 16
Order post-op thyroid
hormonereplacement for
patients following total or
completion thyroidectomy
Order post-op TSH/Tg levels
(ATA C5/REC 62)
Updatestaging
(ATA B17/REC 47)
Empiric therapy
Calcium 1000-1200 mg TID
+/- calcitriol 0.25-0.5 µg BID
PTH-guided management
PTH > 20
No supplementation or low dosecalcium
PTH 10-20
Give calcium 1000-1200 mg TID at
discharge
PTH < 10
Add calcitriol 0.25-0.5 µg BID to calcium at
discharge
Management options
for immediate
postoperative
potential transient
hypoparathyroidism
Documents quality
of voiceand/or
vocal fold status
within 2-8 weeks
post-op
(ATA B14/REC 44)
Tracking
Metric 11
Consider serum
calcium check on
postoperative
day 2 or 3**
Consider endocrinologist if
having difficulty with
immediatepostoperative
hypocalcemia management
and/or if ongoing
beyond 4 weeks
Tracking
Metric 15
**NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the
diagnosis postoperative or history of parathyroidectomy or thyroidectomy
Do NOT use hypocalcemia without previous laboratory-validated diagnosis
Following completion or
total thyroidectomy
Following completion
or totalthyroidectomy
ALL
patients
Tracking
Metric 9
Tracking
Metric
10
Pathology
results
Surveillance
Tracking
Metric
12, 13, 14

24. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Order post-op thyroid
hormonereplacement for
patients followingtotal or
completion thyroidectomy
Order post-op TSH/Tg levels
(ATA C5/REC 62)
Updatestaging
(ATA B17/REC 47)
Followingcompletion or
total thyroidectomy
Followingcompletion
or totalthyroidectomy
ALL
patients
Tracking
Metric 9
Tracking
Metric
10
Pathology
results

25. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 9-16

26. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
1. Clinic and OR Access
2. Risk Stratification
3. Monitoring DTC Rates
4. Bethesda Classification
5. Pre-op calcium
6. Surgeon case volume
7. Antibiotic utilization
8. Pre-op voice check
Quality Metrics
9. Post-op serum TSH and Tg
10. Staging of all DTC
11. Post-op voice check
12. Mortality rates
13. Readmission rates
14. Reoperation rates
15. Permanent
hypoparathyroidism rates
16. Length of stay

27. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Monitoring access to specialist consultation and
elective surgery may help determine whether clinical
care is readily available to patients
Metric 1: Clinic and OR Access
EUTHYROID
NODULE
Tracking
Metric 1

28. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Risk stratification utilizing thyroid sonography with
survey of the cervical lymph nodes should be
performed in all patients with known or suspected
thyroid nodules
Metric 2: Sonographic Risk Stratification
Risk stratification of
US using ATA
or ACR TIRADS
Tracking
Metric 2

29. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
The institutional or system wide annual rate of
thyroidectomies performed for WDTC in a nodule with a
maximum diameter less than 1 cm should be monitored
Metric 3: Incidence of WDTC
No nodule or
nodules smaller
than FNA sizecut-off
ATA Benign
or TIRADS **1
TIRADS 2
Observe
(ATA A8/REC 8E)
Tracking
Metric 3

30. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Utilization of Bethesda classification is important for
consistent reporting of thyroid cytopathology
Metric 4: Bethesda Classification
FNA 2 cm
(ATA A9/REC 8D)
FNA 2.5 cm FNA 1.5 cm
(ATA A9/REC 8C)
FNA 1 cm
(ATA A9/REC 8B)
FNA 1 cm
(ATA A9 /REC 8A)
Utilization of Bethesda System for Reporting Thyroid Cytopathology
(ATA A11/REC 9)
Tracking
Metric 4

31. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• To avoid the potential complications associated with
reoperations, it is suggested to obtain a PTH or serum
calcium level prior to thyroid surgery
Metric 5: Pre-op Calcium and Calcitonin*
Order perioperative
serum calcium test
for all and serum
calcitonin for known
or suspected
medullary CA
Tracking
Metric 5
* For known medullary thyroid carcinoma

32. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Surgical volume is a positive indicator of more efficient
and effective care. Thyroid surgeons should perform a
minimum of at least 10 cases per year
Metric 6: Surgeon Case Volume
Surgery consult with
high volume surgeon
(ATA A14/REC 12)
Tracking
Metric 6

33. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Antibiotics are not usually recommended for clean
surgeries including thyroidectomy. Monitoring for
antibiotic usage is a way to evaluate quality of care and
appropriate utilization
Metric 7: Perioperative Antibiotic Use
Tracking Metric 7
General considerations at
time of surgery
Visualize all important anatomy including:
NOT recommended unless specific
indications:
 Drains or perioperative antibiotics
 Frozen section is generally NOT
indicated
Large substernal goiters should be done at
centers with thoracic backup
Notify pathologist of evidence of gross
extrathyroidal extension into strap muscles
Identification of recurrent
laryngeal nerve(s)
(ATA B13/REC 42A)
Preservation of parathyroid glands
(ATA B13/REC 43)

34. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• To have an understanding of true post op voice status
following thyroid surgery, a preop assessment of the
voice and possible laryngeal exam if there a voice issue
or previous neck or chest surgery is recommended
Metric 8: Preoperative Voice Assessment
Document quality of
voice or laryngeal
examination
(ATA B12/REC 40)
Laryngeal examination
(ATA B12/REC 41)
Tracking
Metric 8
No previous neck
surgery or normal voice
Previous neck or chest
surgery or any voice
issue

35. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Monitoring post-operative serum thyroglobulin levels
for patients on thyroid hormone therapy or after TSH
stimulation is helpful in assessing the persistence of
disease or thyroid remnant and predicting future
disease recurrence
Metric 9: Serum TSH and Tg/TgAb
Order post-op TSH/Tg levels
(ATA C5/REC 62)
Following completion
or totalthyroidectomy Tracking
Metric 9

36. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• The AJCC Staging and Dynamic Risk Stratification
systems for DTC bring value when predicting disease
mortality or recurrence, as well as for guiding decisions
about treatment and surveillance
Metric 10: Staging
Updatestaging
(ATA B17/REC 47)
ALL
patients
Tracking
Metric
10
Pathology
results

37. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Patients should have their vocal cord function
evaluated between 2 weeks and 2 months after thyroid
surgery
Metric 11: Postoperative Voice Assessment
Post-op
thyroidectomy
Documents quality
of voice and/or
vocal fold status
within 2-8 weeks
post-op
(ATA B14/REC 44)
Tracking
Metric 11

38. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Mortality rates should be monitored after thyroid
surgery
Metric 12: Mortality Rates

39. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Readmission rates within the first 30 days following
thyroid surgery is a potential proxy for some
complications after surgery
Metric 13: Readmission Rates

40. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Reoperation rate during the first 30 days is an indicator
for some postoperative surgical complications after
thyroid surgery (e.g. hematoma, vocal cord
medialization due to aspiration)
Metric 14: Reoperation Rates

41. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• For patients who require high dose vitamin D
supplementation at 12 months or longer following total
or completion thyroidectomy, a calcium and or PTH
level should be checked
Metric 15:
Permanent Hypoparathyroidism Rates
Consider endocrinologist if
having difficulty with
immediatepostoperative
hypocalcemia management
and/or if ongoing
beyond 4 weeks
Tracking
Metric 15

42. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• The average length of stay is a good proxy for
perioperative resource management, and allows
comparisons to be made to other surgical and medical
patients
Metric 16: Length of Stay
Post-op
thyroidectomy
Tracking
Metric 16

43. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• These workflows and quality metric provide a
simplified approach to incorporating the 2015 ATA
guidelines into the everyday management of thyroid
nodules and DTC and have the potential to improve
quality and decrease unwarranted variations in care
• For implementation, users should create
multidisciplinary teams in their local settings to review,
refine, implement, and sustain these practices
Conclusions

44. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
North American Quality Statements and
Evidence Based Multidisciplinary Workflow
Algorithms for the Evaluation and
Management of Thyroid Nodules
Meltzer CJ, Irish J, Odell M, Wiseman SM, Haymart MR,
Shin J, Monteiro E, Ferris RL, Wong RJ, Tuttle RM, Morris
JC, Haugen BR, Morris LGT, McIver B, Busady NL,
Mechanick JI, Harrell RM, Shonka DC, Scharpf J, Dwojak S,
Urken M, Davies L, Thompson GB, Angelos P, Randolph GW