Table 7. Recommendation Matrix of Existing Guidelines (Clinical Situation 2: Preoperative Evaluation of Thyroid Cancer).
| Source Guidelines | AGREE II | Recommendation | Grading of Recommendation |
|---|---|---|---|
| 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer | 72 | Preoperative neck US for cervical (central and especially lateral neck compartments) lymph nodes is recommended for all patients undergoing thyroidectomy for malignant or suspicious for malignancy cytologic or molecular findings | Strong recommendation, high-quality evidence |
| Preoperative use of cross-sectional imaging studies (CT, MRI) with IV contrast is recommended as an adjunct to US for patients with clinical suspicion for advanced disease, including invasive primary tumor, or clinically apparent multiple or bulky lymph node involvement | Strong recommendation, low-quality evidence | ||
| AACE/AME/ETA Medical Guidelines for Clinical Practice for Diagnosis and Management of Thyroid Nodules | 72 | US examination of the neck, FNA biopsy of any concomitant suspicious nodule or lymph node, and vocal cord assessment with laryngoscopy are recommended before surgery | Grade A; BEL 2 |
| In the case of suspicious US features, confirm the metastatic nature of a lymph node with measurement of Tg or calcitonin in the washout of the FNA needle | BEL 2, GRADE A | ||
| Consider the use of MRI, CT, and/or 18FDG PET/CT in selected cases with aggressive features for more accurate preoperative staging | BEL 3, GRADE B | ||
| British Thyroid Association Guidelines for the Management of Thyroid Cancer | 84 | In patients with thyroid cancer assessment of extra-thyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively | Good practice point |
| A combination of US and CT/MRI imaging is advised depending upon local expertise | Good practice point | ||
| Lymph nodes that are equivocal/suspicious on US should be assessed by FNAC. Measurement of Tg in aspirate washout fluid may aid the diagnosis of lymph node metastasis | 4, D | ||
| US Diagnosis and Imaging-based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations | 50 | US is the established primary imaging modality for the assessment of the lymph nodes in the patients with thyroid nodules and proven thyroid cancers | Not available |
| Contrast enhanced CT has a complementary role in the preoperative assessment of the extent of the primary tumors and nodal metastases | Not available | ||
| We recommend preoperative contrast enhanced CT for the patients with a suspected invasive primary tumor or cervical lymph node metastasis | |||
| ACR Appropriateness Criteria® Thyroid Disease | 69 | US thyroid; usually appropriate | Strong |
| CT neck with IV contrast; may be appropriate | Strong | ||
| CT neck without IV contrast; usually not appropriate | |||
| MRI neck without IV contrast; may be appropriate | Expert consensus | ||
| MRI without and with IV contrast; may be appropriate | |||
| Revised Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Thyroid Cancer | 33 | Preoperative neck US for cervical (central and especially lateral neck compartments) lymph nodes is recommended for all patients undergoing thyroidectomy for malignant or suspicious for malignancy cytologic or molecular findings | Not available |
| Preoperative use of CT, MRI with IV contrast is recommended as an adjunct to US for patients with clinical suspicion for advanced disease, including invasive primary tumor, or clinically apparent multiple or bulky lymph node involvement | |||
| NCCN Clinical Practice Guidelines in Oncology, Thyroid Carcinoma, Version 1. 2019 | 75 | Perform thyroid and neck US (including central and lateral compartments), if not previously done | 2A |
| Perform CT/MRI with contrast for fixed, bulky, or substernal lesions | 2A |
AACE/AME/ETA = American Association of Clinical Endocrinologists/Italian Association of Clinical Endocrinologists/European Thyroid Association, ACR = American College of Radiology, CT = computed tomography, FNA = fine-needle aspiration, FNAC = FNA cytology, IV = intravenous, MRI = magnetic resonance imaging, NCCN = National Comprehensive Cancer Network, PET = positron emission tomography, Tg = thyroglobulin, US = ultrasonography, 18FDG = 18-fluorodeoxyglucose