. 2016 Jan 1;26(1):1–133. doi: 10.1089/thy.2015.0020

Table 5.

Organization of the 2015 ATA Guidelines for Thyroid Nodules and Differentiated Thyroid Cancer

Page	Location key	Sections and subsections	Item^a
10	[A1]	THYROID NODULE GUIDELINES
10	[A2]	What is the role of thyroid cancer screening in people with familial follicular cell–derived DTC?^b	R1^b
10	[A3]	What is the appropriate laboratory and imaging evaluation for patients with clinically or incidentally discovered thyroid nodules?
10	[A4]	Serum thyrotropin measurement	R2
11	[A5]	Serum thyroglobulin measurement	R3
11	[A6]	Serum calcitonin measurement	R4
11	[A7]	[18F]Fluorodeoxyglucose positron emission tomography^b	R5^b
12	[A8]	Thyroid sonography	R6
12	[A9]	US for FNA decision-making	R7
12	[A10]	Recommendations for diagnostic FNA of a thyroid nodule based on sonographic pattern^c	R8^c F1^c, F2^c, T6^c
16	[A11]	What is the role of FNA, cytology interpretation, and molecular testing in patients with thyroid nodules?^c	R9^c, F1^c, T7^c
17	[A12]	Nondiagnostic cytology	R10
17	[A13]	Benign cytology	R11
18	[A14]	Malignant cytology	R12
19	[A15]	Indeterminate cytology (AUS/FLUS, FN, SUSP)^c
19	[A16]	What are the principles of the molecular testing of FNA samples?^b	R13–14
21	[A17]	AUS/FLUS cytology^c	R15^c
22	[A18]	Follicular neoplasm/suspicious for follicular neoplasm cytology ^c	R16^c
23	[A19]	Suspicious for malignancy cytology^c	R17^c
23	[A20]	What is the utility of ¹⁸FDG -PET scanning to predict malignant or benign disease when FNA cytology is indeterminate (AUS/FLUS, FN, SUSP)?^b	R18^b
23	[A21]	What is the appropriate operation for cytologically indeterminate thyroid nodules?^c	R19–20^c
25	[A22]	How should multinodular thyroid glands (i.e., two or more clinically relevant nodules) be evaluated for malignancy?	R21–22
25	[A23]	What are the best methods for long-term follow-up of patients with thyroid nodules?
25	[A24]	Recommendations for initial follow-up of nodules with benign FNA cytology^c	R23A–C^c
25	[A25]	Recommendation for follow-up of nodules with two benign FNA cytology results^b	R23D^b
26	[A26]	Follow-up for nodules that do not meet FNA criteria^b	R24^b
27	[A27]	What is the role of medical or surgical therapy for benign thyroid nodules?	R25–29
27	[A28]	How should thyroid nodules in pregnant women be managed?
27	[A29]	FNA for thyroid nodules discovered during pregnancy	R30
28	[A30]	Approaches to pregnant patients with malignant or indeterminate cytology	R31
28	[B1]	DIFFERENTIATED THYROID CANCER: INITIAL MANAGEMENT GUIDELINES
29	[B2]	Goals of initial therapy of DTC
29	[B3]	What is the role of preoperative staging with diagnostic imaging and laboratory tests?
29	[B4]	Neck imaging—ultrasound	R32 F3, T6, T8^b
30	[B5]	Neck imaging—CT/MRI/PET^c	R33^c
31	[B6]	Measurement of serum Tg and anti-Tg antibodies	R34
31	[B7]	Operative approach for a biopsy diagnostic for follicular cell–derived malignancy^c	R35^c
33	[B8]	Lymph node dissection	R36–37, F3
35	[B9]	Completion thyroidectomy	R38
35	[B10]	What is the appropriate perioperative approach to voice and parathyroid issues?^b
35	[B11]	Preoperative care communication^b	R39^b
35	[B12]	Preoperative voice assessment^b	R40–41^b, T9^b
36	[B13]	Intraoperative voice and parathyroid management^b	R42–43^b
37	[B14]	Postoperative care^b	R44–45^b
37	[B15]	What are the basic principles of histopathologic evaluation of thyroidectomy samples?^b	R46^b
40	[B16]	What is the role of postoperative staging systems and risk stratification in the management of DTC?
40	[B17]	Postoperative staging	R47
40	[B18]	AJCC/UICC TNM staging	T10
41	[B19]	What initial stratification system should be used to estimate the risk of persistent/recurrent disease?^c	R48^c, T11^b, T12^c
43	[B20]	Potential impact of specific clinico-pathologic features on the risk estimates in PTC^b
44	[B21]	Potential impact of BRAF^V600E and other mutations on risk of estimates in PTC^b
45	[B22]	Potential impact of postoperative serum Tg on risk estimates^b
46	[B23]	Proposed modifications to the 2009 ATA initial risk stratification system^b	T12^c
46	[B24]	Risk of recurrence as a continuum of risk^b	F4^b
46	[B25]	How should initial risk estimates be modified over time?^b	R49
47	[B26]	Proposed terminology to classify response to therapy and clinical implications^b
47	[B27]	Excellent response: no clinical, biochemical, or structural evidence of disease after initial therapy (remission, NED)^b	T13^b
50	[B28]	Biochemical incomplete response: abnormal Tg values in the absence of localizable disease^b	T13^b
51	[B29]	Structural incomplete response: persistent or newly identified loco-regional or distant metastases^b	T13^b
52	[B30]	Indeterminate response: biochemical or structural findings that cannot be classified as either benign or malignant (acceptable response)^b	T13^b
52	[B31]	Using risk stratification to guide disease surveillance and therapeutic management decisions^b
53	[B32]	Should postoperative disease status be considered in decision-making for RAI therapy for patients with DTC?	R50
53	[B33]	Utility of postoperative serum Tg in clinical decision-making
54	[B34]	Potential role of postoperative US in conjunction with postoperative serum Tg in clinical decision-making
54	[B35]	Role of postoperative radioisotope diagnostic scanning in clinical decision-making
55	[B36]	What is the role of RAI (including remnant ablation, adjuvant therapy, or therapy persistent disease) after thyroidectomy in the primary management of differentiated thyroid cancer?	R51 T14
58	[B37]	What is the role of molecular marker status in therapeutic RAI decision-making?^b	R52^b
58	[B38]	How long does thyroid hormone need to be withdrawn in preparation for RAI remnant ablation/treatment or diagnostic scanning?	R53
59	[B39]	Can rhTSH (Thyrogen) be used as an alternative to thyroxine withdrawal for remnant ablation or adjuvant therapy in patients who have undergone near-total or total thyroidectomy?	R54
60	[B40]	What activity of ¹³¹I should be used for remnant ablation or adjuvant therapy?^c	R55–56^c
63	[B41]	Is a low-iodine diet necessary before remnant ablation?	R57
63	[B42]	Should a posttherapy scan be performed following remnant ablation or adjuvant therapy?	R58
64	[B43]	Early management of DTC after initial therapy
64	[B44]	What is the appropriate degree of initial TSH suppression?	R59
65	[B45]	Is there a role for adjunctive external beam radiation or chemotherapy?
65	[B46]	External beam radiation	R60
65	[B47]	Systemic adjuvant therapy	R61
65	[C1]	DTC: LONG-TERM MANAGEMENT AND ADVANCED CANCER MANAGEMENT GUIDELINES
65	[C2]	What are the appropriate features of long-term management?
66	[C3]	What are the criteria for absence of persistent tumor (excellent response)?
66	[C4]	What are the appropriate methods for following patients after initial therapy?
66	[C5]	What is the role of serum Tg measurement in the follow-up of DTC?^c	R62–63^c
66	[C6]	Serum Tg measurement and clinical utility
68	[C7]	Anti-Tg antibodies
68	[C8]	What is the role of serum Tg measurement in patients who have not undergone RAI remnant ablation?	R64
69	[C9]	What is the role of US and other imaging techniques (RAI SPECT/CT, CT, MRI, PET-CT) during follow-up?
69	[C10]	Cervical ultrasonography	R65
69	[C11]	Diagnostic whole-body RAI scans	R66–67
70	[C12]	¹⁸FDG-PET scanning	R68
71	[C13]	CT and MRI^b	R69^b
72	[C14]	Using ongoing risk stratification (response to therapy) to guide disease long-term surveillance and therapeutic management decisions^b
72	[C15]	What is the role of TSH suppression during thyroid hormone therapy in the long-term follow-up of DTC?^c	R70^c T15^b
74	[C16]	What is the most appropriate management of DTC patients with metastatic disease?
74	[C17]	What is the optimal directed approach to patients with suspected structural neck recurrence?	R71
74	[C18]	Nodal size threshold
75	[C19]	Extent of nodal surgery
75	[C20]	Ethanol injection^b
75	[C21]	Radiofrequency or laser ablation^b
75	[C22]	Other therapeutic options^b
76	[C23]	What is the surgical management of aerodigestive invasion?	R72
76	[C24]	How should RAI therapy be considered for loco-regional or distant metastatic disease?
76	[C25]	Administered activity of ¹³¹I for loco-regional or metastatic disease^c	R73^c
77	[C26]	Use of rhTSH (Thyrogen) to prepare patients for ¹³¹I therapy for loco-regional or metastatic disease	R74–75
77	[C27]	Use of lithium in ¹³¹I therapy	R76
77	[C28]	How should distant metastatic disease to various organs be treated?
78	[C29]	Treatment of pulmonary metastases	R77–78
78	[C30]	RAI treatment of bone metastases	R79
79	[C31]	When should empiric RAI therapy be considered for Tg-positive, RAI diagnostic scan–negative patients?	R80–82
79	[C32]	What is the management of complications of RAI therapy?	R83–85
80	[C33]	How should patients who have received RAI therapy be monitored for risk of secondary malignancies?	R86
80	[C34]	What other testing should patients receiving RAI therapy undergo?	R87
80	[C35]	How should patients be counseled about RAI therapy and pregnancy, breastfeeding, and gonadal function?	R88–90
81	[C36]	How is RAI-refractory DTC classified?^b	R91^b
82	[C37]	Which patients with metastatic thyroid cancer can be followed without additional therapy?^b	R92^b
82	[C38]	What is the role for directed therapy in advanced thyroid cancer?^c	R93^c
84	[C39]	Treatment of brain metastases	R94
84	[C40]	Who should be considered for clinical trials?^b	R95^b
84	[C41]	What is the role of systemic therapy (kinase inhibitors, other selective therapies, conventional chemotherapy, bisphosphonates) in treating metastatic DTC?^c
85	[C42]	Kinase inhibitors^b	R96^b, T16^b
87	[C43]	Patients for whom first-line kinase inhibitor therapy fails^b	R97^b
87	[C44]	Management of toxicities from kinase inhibitor therapy^b	R98^b, T17^b
87	[C45]	Other novel agents^b	R99
87	[C46]	Cytotoxic chemotherapy	R100
88	[C47]	Bone-directed agents^c	R101^c
89	[D1]	DIRECTIONS FOR FUTURE RESEARCH
89	[D2]	Optimizing molecular markers for diagnosis, prognosis, and therapeutic targets
89	[D3]	Active surveillance of DTC primary tumors
90	[D4]	Improved risk stratification
90	[D5]	Improving our understanding of the risks and benefits of DTC treatments and optimal implementation/utilization
90	[D6]	Issues with measurement of Tg and anti-Tg antibodies
90	[D7]	Management of metastatic cervical adenopathy detected on US
91	[D8]	Novel therapies for systemic RAI-refractory disease
91	[D9]	Survivorship care

^{^a}

F, figure; R, recommendation; T, table.

^{^b}

New section/recommendation.

^{^c}

Substantially changed recommendation compared with 2009.

ATA, American Thyroid Association; AUS/FLUS, atypia of undetermined significance/follicular lesion of undetermined significance; CT, computed tomography; DTC, differentiated thyroid cancer; FN, follicular neoplasm; FNA, fine-needle aspiration; ¹⁸FDG-PET, [¹⁸F]fluorodeoxyglucose positron emission tomography; MRI, magnetic resonance imaging; NED, no evidence of disease; PET, positron emission tomography; RAI, radioactive iodine (radioiodine); rhTSH, recombinant human thyrotropin; SPECT/CT, single photon emission computed tomography–computed tomography; SUSP, suspicious for malignancy; Tg, thyroglobulin; TSH, thyrotropin; US, ultrasound.