Will the 2025 ATA Guidelines change your daily practice?
- Carlos E Costa Almeida
- há 2 dias
- 4 min de leitura
The last ATA Guidelines for management of adult patients with differentiated thyroid cancer (DTC) were from 2015. Since then, many ideas have changed or have been supported by worldwide literature. The new 2025 ATA Guidelines are now available. Do they deliver a lot of changes? Well, concerning surgical treatment, I think they basically increase the level of evidence of some previous recommendations, and try to decrease the role of surgery in some DTCs. In the following text, I will cover a few topics important for surgeons, based on the Executive Summary of the 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer, published this month in Volume 35 of the Thyroid journal.
First of all, the 2025 ATA Guidelines introduce the recommendation of patient-based decision-making. This means there are several options of treatment which are influenced by the patient’s factors and risk-benefit assessment. They refer to this clinical decision-making process as the DATA approach: Diagnosis, risk/benefit Assessment, Treatment decisions, and response Assessment.
One of the first new recommendations is the idea of DTC patients being operated on only by the so-called high-volume surgeons (>25-50 cases/year). Is this correct? What is the basis for this recommendation? I think the idea should be surgeons with low complications and high R0 resections. The rate of acceptable complications and the rate of R0 resections following thyroid surgery for DTC should be presented as the basis of a recommendation of this kind. Quantity is not quality.
They emphasize the need for preoperative assessment of extra-thyroidal extension (ETE) and aero-digestive extension, putting the preoperative CT or MRI on the table.
Active surveillance for microcarcinomas (<1 cm – T1a) and patients with high surgical risk was already part of the game. The 2025 ATA Guidelines introduced percutaneous ablation as an option for selected patients with T1a tumors and after a shared decision (e.g., high-risk patients, risk/benefit assessment). Additionally, lobectomy has been updated to the preferred approach for tumors <2 cm without ETE or suspected lymph nodes (and without contralateral nodules). Lobectomy is also a possibility (but not presented as the preferred approach) for tumors with 2-4 cm, without ETE or contralateral nodules.
I have some comments on these ideas. Indeed, lobectomy versus total thyroidectomy for tumors < 2 cm has the same recurrence rate with fewer complications and less need for hormone supplementation. Additionally, we know that low-risk DTC is an indolent disease, and many patients are being offered over-treatment. However, follow-up is easier after thyroidectomy, and we can only accurately assess multifocality with the whole thyroid gland. It is also true that DTC is a surgical disease, and a good quality surgery treats DTC. Some authors state that the idea of surveillance and percutaneous ablation reflects the afraid American surgeons have of postoperative complications and the consequent litigation. I accept lobectomy mainly because it eliminates the risk of bilateral vocal cord paralysis in a low-risk cancer, but I refuse to accept percutaneous ablation as an option. Why? There is no histological evaluation, and the local effects of ablation in a future surgery will undoubtedly increase the risk of complications. In the end, an honest exposure of the advantages and disadvantages of all options in a multidisciplinary discussion with the patient, and a deep risk/benefit assessment are crucial for decision-making.
About central neck dissection, the 2025 ATA Guidelines recognize that it increases the risk of complications. The reason why they do not recommend prophylactic central neck dissection (pCLND) for T1-T2 tumors as it does not improve survival. For tumors > 4 cm, pCLND should only be considered (not recommended), because there is no strong evidence of any benefit. Remember that many authors do not recommend pCLND for any tumor. This is also my idea and daily practice; I do not perform pCLND.
An important update of the 2025 ATA Guidelines concerns the use of intraoperative nerve monitoring (IONM). They state that “in addition to visual identification, RLN monitoring and visual identification and monitoring of EBSLN may be performed”. They also recommend that vagal or RLN stimulation should be performed before proceeding to contralateral lobe dissection. This is very important! IONM should be used routinely as it can help surgeons find and preserve the nerve function. In my opinion, the recommendation should not be “vagal or RLN stimulation”; it should be vagal and RLN stimulation. The best way of knowing that RLN is well functioning is having a good EMG wave in the V2 (vagal stimulation after dissection). This is the way! Remember that a good R2 (RLN stimulation after dissection) does not mean good nerve functioning.
The 2025 ATA Guidelines also advise for the avoidance of routine use of drains. Well… This may be true because a drain does not avoid hemorrhage, but it is hard for me not to place a drain. It gives me a feeling of safety and the possibility of early diagnosis of postoperative hemorrhage, with all the possible advantages that come from it. I even place two drains after a total thyroidectomy. Is this too much? Probably yes. But there is a reason, or there is “my reason”. If you have two drains with 50 cc drainage in the day after, there is no concern or anxiety. But if you have one drain with 100 cc drainage in the day after, there will be concern and anxiety for doctors, nurses, and the patient. A reservoir with 100 cc has a negative impact when compared to two reservoirs with 50 cc each, I think. So, placing two drains has a psychological effect on anxiety decreasing. Should I stop doing it? Hmmmm... Many actions or recommendations are surgeon-dependent.
There are a lot more recommendations and key changes in the summary of the 2025 ATA Guidelines. You have recommendations for postoperative management, long-term management, recommendations for RAIR (radioactive iodine resistant) DTC and use of systemic therapy. Feel free to assess the link below. Read them and learn to keep yourself updated. Find out if you are going to change your practice or just get support for your decisions.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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