Latest / Behind The Knife: The Surgery Podcast / Journal Review in Endocrine Surgery: Updates of the 2025 American Thyroid Association Guidelines for Differentiated Thyroid Cancer
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- BTK - UW Endocrine Surgery - March 2026 - Journal Review === Speaker: [00:00:00] Hi everyone. Welcome to another discussion with the University of Wisconsin Endocrine Surgery Team. And today we're gonna talk about what is new in the 2025 American Thyroid Association guidelines. So today we have myself, Amanda Doubleday. I am a fellowship trained endocrine surgeon, affiliated with UW Health, practicing both in Waukesha and Madison, Wisconsin. We have Dr. Alex Chu, also a fellowship trained endocrin surgeon at UW Health, practicing full-time in Madison, Wisconsin. Alex, thanks for being here. Speaker 2: Thanks for having me. Speaker: Dr. Simon Holbeck, also a fellowship trained endocrine surgeon affiliated with UW Health, practicing in both Northern Illinois and Madison, Wisconsin. Simon, thanks for being here. Speaker 3: Thanks, Amanda. Speaker: And finally, for our, our senior expert surgeon, Dr. Rebecca Sip. She's a professor of surgery and division Chief of Endocrine Surgery at the University of Wisconsin Madison. [00:01:00] She's our most recent past president of the American Association of Endocrine Surgeons. She's an internationally recognized leader in the field of endocrine surgery with other over 250 publications. So thank you so much, Dr. Sybil, for being here. Speaker 4: Always happy to be here to support. Speaker: Okay, so I'm gonna jump into it so we have no disclosures related to this topic. Today we're gonna focus on the clinical implications from the updates from the paper titled 2025 American Thyroid Association Management Guidelines for Adult Patients With Differentiated Thyroid Cancer. This was pub published in thyroid in August of 2025. So this new set of guidelines has omitted the discussion about thyroid nodules and primarily focuses on differentiated thyroid cancer, which would include papillary, follicular, and oncotic. Speaker 2: Yeah, so they actually split up the guidelines into two sections this time, and from what I've heard, we should expect a new set of guidelines [00:02:00] specifically focus on thyroid nodules coming out later this year. Speaker: Okay, great. Thanks Alex. Good to know. So we will all be on the lookout for that. So in terms of the new 2025 guidelines, you know, there's, there's been some changes and we've discussed that sort of an overlying theme seems Tovo focus on. General deescalation of aggressive treatment such that perhaps maybe we can accept that less surgery is appropriate. This may include active surveillance. Um, there's kind of a new discussion about less invasive percutaneous techniques, um, and more lobectomies versus total thyroidectomies. Uh, it does seem like there's also been a shift towards less utilization of central lymph node dissection, which actually Dr. Sipple and the UW team have already highlighted in a hallmark paper from 2020, um, which they at that time concluded there was no real benefit to prophylactic central lymph node dissection in clinically node negative papillary thyroid cancer. [00:03:00] And now furthermore, in the 2025 guidelines. If you are to address the central neck, it would be, um, now considered level six through seven. However, there's probably a lot of us that are already doing that. So then finally, um, deescalation of, of therapy along with follow-up therapy is, um, really discussing how to assess response to therapy early. And so this may allow us to deescalate adjunct therapy such as radioactive iodine or even long-term surveillance. So Speaker 4: today Speaker: we're gonna, yeah. I Speaker 4: think another approach too, Amanda, just with these guidelines is I feel like it's been a little bit more patient centered too. I think there's a lot of discussion about shared decision making. You know, I think they've recognized that most patients with thyroid cancer do really well. And you know, for most patients it's not gonna limit their life, but it can have impacts on quality of life. And so really engaging the patient in the discussion about their treatment options and decision making. And also recognizing that the burden of [00:04:00] long-term follow-up can be significant. So recognizing how we can best support patients in the survivorship phase of their cancer treatment. So I think those are all really positive changes with these new guidelines. Speaker: Yeah, that's a great point. And I think that's something that we all learned in Fellowship to kind of highlight in our discussions with patients is that shared decision making process. So, um, all right, so let's, let's present a case and then we'll talk about the different discussions and highlight some of the changes in the new guidelines. So we'll start with a 55-year-old female. Fairly straightforward thyroid cancer case. She, let's say, has a 1.8 centimeter right thyroid nodule. The left lobe of the thyroid's normal. She has no clinical lymph node concern. She's euthyroid and otherwise asymptomatic. She gets a biopsy. The cytology from FNA shows Bethesda six confirmed papillary thyroid cancer. So she's in your office. First question is, how, how bad is this? You know? And, and my response would be to try to answer this, [00:05:00] um, with a discussion about risk stratification. And we used to discuss differentiated thyroid, differentiated thyroid cancer in one of three categories. But now with the new guidelines, it's um, we wanna really consider this in one of four categories. Low risk of recurrence, low, intermediate, high, intermediate, and high. So for Dr. Sippel, I would, I guess I would wonder how you, how do you interpret this and can you explain how you would talk to these, talk to your patient about these categories? Speaker 4: Yeah, I mean I think for every patient, you know, not all thyroid cancers are the same and there's really a spectrum of disease from the really low grade, slow growing, which we probably could do nothing and they'd probably be fine. Um, versus those that are much more aggressive. So I think there's a spectrum, and I think what we're really trying to identify for patients is where do they fall on? Spectrum to know like how aggressive should we be with the treatment upfront and how aggressive should we be in the follow up? So I think, [00:06:00] you know, one of the nice things was is I think when it's a really low grade, slow growing, we kind of all know that and recognize that we can kind of be a minimalist with treatment. And when it's really high grade and aggressive, we need to be aggressive. But I think the intermediate was kind of the, the area that there was a lot. A lot of variability. So in the new guidelines, they really divided it into the low intermediate and the intermediate high, uh, with really looking at the risk of recurrence being for the low intermediate between 10 to 15 and the intermediate to high being the 15 to 30%. And I think as we think about that, that's really information we're probably gonna know postoperatively, not necessarily always pre-op. Um, but it really. I think can probably be used to factor into the decision about when to give radioactive iodine. You know, I think we, we, we know it shouldn't be given for the low risk, and it should probably always be given for the high risk. It's that, you know, the, uh, the in, in intermediate group that we just don't always know. And so I think if you're gonna sort of on the decision making, those high intermediate maybe are the ones that maybe there [00:07:00] is more of a benefit to radioactive iodine that you might wanna consider giving it. But in the low intermediate, probably most of those patients aren't gonna probably benefit. And so especially if there other risk stratification puts them, you know, with a good response to therapy, they probably don't need additional treatment. Speaker: Okay, great. Yeah, and I would say for, for our listeners, I found this helpful that you can refer to figure two from the paper for a more kind of detailed definition of those categories within the different types of thyroid cancer. Um, so yeah, I found that helpful. Um, great. Okay. So for surgical treatment then, um, we talked about, based on previous guidelines, how we would recommend a lobectomy for papillary thyroid cancer less than a centimeter. And now in 2025, we're saying that a lobectomy is actually appropriate for any PTC or papillary thyroid cancer less than two centimeters. So, and there's variation in that depending on your shared patient decision making. Right. But I would, so [00:08:00] for this patient, I would offer a right lobectomy. Dr. Sybil, do you agree? Speaker 4: Yeah, I think absolutely. I think, you know, this is probably the biggest shift if I think about sort of where practice was at when I started 20 years ago to where it is now. And I think early in my practice, pretty much everybody got a total thyroidectomy and radioactive iodine. And I think we have really sort of shifted away from that. So I think up to two centimeters absolutely appropriate to consider a lobectomy. And I would say that many patients, even up to four centimeters, were considering a lobectomy. I would say that even those greater than four centimeters, you know, if they have a kind of a low grade neoplastic, uh, lesion, I think even those patients probably are okay with a lobectomy. So I think it's really the disease biology that factors into it more so than the strict size of the tumor. I would say that the decision about a low burst is a total, is a really nuanced discussion. I think, uh, one of my past fellows teased me once and said it took me longer to. Explain to somebody about the [00:09:00] decision to take out a lobe than it did to do the operation. Uh, and he's probably right, right? Because it's a really complicated discussion. But I would say that like if the contralateral lobe is normal and there's no lymphadenopathy, I think a lobectomy is totally appropriate. It's gonna lower the surgical risk, it's gonna potentially avoid the need for lifelong thyroid hormone replacement for many of the patients. And and I do think that there's this concept of people getting this. Theia post-op where they just don't feel normal on thyroid hormone replacement. And I think even if they require thyroid hormone replacement, if they have a little bit of native thyroid tissue, they just tend to feel better. So I think patients do better by just having some of that natural thyroid tissue. But I think. If they're already on thyroid hormone replacement, if there's a bunch of nodules on the other side of the thyroid, if they have a history of radiation exposure, if they have a family history, those are all things that might make me favor to say, maybe you're not gonna be best served with a lobectomy, because we're gonna still be worried about the other side, and there's gonna [00:10:00] be a lot of. Ongoing surveillance and question marks. So I think the patients just have to understand the pros and cons of the two options and really make the best decision. Uh, I think we always say you can always take out more, but you can never take out less. So I think anytime a patient is sort of. Kind of not certain. I would always favor doing just a lobe because you can always go back and take out the other side, but you can't put it back. So I think, you know, too often people panic with a cancer diagnosis. They wanna be really aggressive and then they have regret. And so I think what we wanna do is avoid decision, regret and sort of let people kind of do less at first. They can always choose to do more, but to not over commit at the first operation. Speaker 2: Can I just say I think one interesting point is in the previous guidelines for a lesion less than two centimeters, lobectomy was an acceptable option and should be considered. But on these new guidelines, that's to say you should do a lobectomy for [00:11:00] less than two centimeters. Kind of putting that emphasis. 'cause I think there was a lot of data showing that people are still doing total thyroidectomies even after the last guidelines for these small. Thyroid cancers when patients would probably be oncologically sufficient with just the LO and getting more complications. This is really putting that emphasis on deescalation and saying less incinerators. You should probably really think about a lo unless you have other reasons to be more aggressive with a total. Speaker: Yeah, that's, yeah. All excellent points. All right. Yeah, and, and again, that whole shared decision making is really a factor. 'cause you have some patients who you've proven the other side has the nodule that's benign, but they're like, Nope, I want it out. Or, you know, what, whatever's important to that patient. So, all right. So let's say we do a right thyroid lobectomy for this patient. She has no complications in the hands of a high volume surgeon. She is euthyroid six weeks after surgery. And so in terms of a cancer case. You know, typically I've been getting routine [00:12:00] thyroglobulin levels. Preoperatively I'll get it if I suspect a cancer, but then definitely post-op and then continue surveillance with those thyroglobulin or TG levels. Neck ultrasound and then utilizing TSH suppression. So just kind of wanted to touch on that 'cause that is a change as well. Um, the new guidelines say we can assess response to therapy within three months, um, and that a standard TG level should be done after a lobe or a total in six to 12 months, but that you only really only need one level after a lobe. If it's found to be within what you would expect. And then further, TSH suppression targets now are much broader. Um, they used to be pretty strict with certain intervals, more aggressive TSH suppression less than 0.1 or 0.1 if 0.5 or less than two for low risk cancers. But now they're really saying that if it's, um. If the recommendation for a, for a, a patient who's had a low risk of recurrence, that it should just, the TSH should really be within [00:13:00] the normal range. So Dr. Sybil, what kind of surveillance do you guys do at your practice at uw and, and will that change with these new guidelines? Speaker 4: Yeah, so I think this is one of the changes that I was really happy to see, and it, it actually mirrors what we've been doing at UW for the last 10 years. You know, I think the, the previous guideline talked about sort of assessing your disease response to initial therapy at one year, checking the thyroglobulin and sort of reassessing sort of the disease biology. Uh, but now they're saying that really should be done at that three month interval. And that's what we've been doing is checking a postoperative thro globulin level at six weeks. And I think at that early time point you can really sort of reassess. Was the appropriate extent of surgery done? And how did the patient respond? Because I would say there's a lot of patients who, with surgery alone, can get an undetectable thyroglobulin level. And so I would say as much as we focus on disease biology and the pathology report and whether or not they have high risk features, if somebody had a larger [00:14:00] tumor or a high risk features. Their post-op, the globulin is already undetectable. Prior to radioactive iodine, I think you could really argue what is the benefit of radioactive iodine. We've already gotten to the optimal outcome with surgery alone, and maybe some of those patients don't need it. So I think having it at that early time point really is just another piece of information to sort of. Put into your conversation about the pros and cons of radioactive iodine. Um, and so I think it's a really great change. I would say that in addition to checking the thyroglobulin level at six weeks, we always check it again at six months. Just 'cause sometimes people will have a little bit delayed clearance and it won't have fully normalized by six weeks. So that's why we wait, check it again at six months. We do the same for a lobe. And you know, I, I think we're still trying to understand what the value of thyroid globulin levels are in thyroid lobes. I think the, the, the initial levels to make sure it's not way out of the realm of what we would expect. Somebody just had a lobectomy. Um, you know, it's gonna be [00:15:00] elevated, but I don't want it to be a hundred or 200. I'd expect it to me be maybe in the 10 to 15 range kind of equivalent to somebody who has half of a thyroid. Um, and then we check it again at six months just to document that it's stability. I think after that point, if it's in the normal range or what we would. Spec it probably doesn't need to be checked again after that, um, because it is gonna potentially fluctuate over time. We always get a baseline ultrasound at six months. That's usually the first time I think, getting an ultrasound prior to six months. There's a lot of postoperative changes and it's not always as reliable. Um, so I think, you know, six months is the first time for, for the neck ultrasound. The thyroid replacement guideline changes, I think are, are, are great. I would say. I think what it's recognized is that TSH suppression. Probably wasn't providing a huge advantage for a lot of patients and, and was leading to cardiovascular risk as well as osteoporosis. And so there were probably more harm than good for a lot of those patients. [00:16:00] And so really the new guidelines are for that. Most patients, they can just be maintained in the normal range. So probably the greatest benefit is for all these patients who had a lobectomy. You know, with the previous guidelines we had to keep their TSH low and nobody could do that after just a lobe. So what ended up happening is almost everybody who had a lobectomy ended up on full thyroid hormone replacement. And I think now with the goal being just in the normal range, hopefully a lot of those people who chose a lobectomy could avoid going on thyroid hormone replacement, which would be great. I think we're a little bit more flexible with the lobes as far as letting the TSH, so we, they can avoid going on thyroid hormone replacement, but I think if somebody's already on thyroid hormone replacement after a total thyroidectomy, then I would say my goal is the normal range. But I would say I usually try to keep it in the one to two range just 'cause I think people tend to feel better with a TSH. At the lower end of normal. I don't think most people feel great if their TSH is three and a half or four, so [00:17:00] it might be in the normal range, but I think most people just don't feel great with the TSH in that range. Speaker 3: I think that A TSH goal change is like a subtle but meaningful change in these guidelines that again, like, you know, I don't know what everyone quotes, uh, replacement, you know, uh, percentages after lobectomy, but you know, most of the papers say 30 to 40%, but when it comes back as a cancer, we all know, I mean, there's research to support this as well, that that rate approach is at least 50%. And so, you know, someone decided on a lobectomy and then it comes back as a cancer, whether it was expected or not. And then more often than not, it seems like you're giving them at least some thyroid hormone replacement. And, um, you know, there's some impacts both like financially and just, you know, on the, on the patient's body like you're mentioning with osteoporosis over time. And it's nice to be able to say, if you get a lobectomy, it really is that like 30% chance that you're gonna need to be on thyroid hormone replacement. So I, I like that and hope to incorporate that in my practice. Speaker: Yeah, that's a great [00:18:00] point. So, so that being said, then we talk about, you know, annual ultrasounds. If someone had a, has had a total thyroidectomy, and then if someone's had a lobectomy uh. We wanna ultrasound that contralateral side and you can do it every one to three years. But then the new guidelines really talk about how maybe at five to eight years, if they've had a great response and there's no concern for any further structural disease, that maybe we can stop following these. Um, so that's also kind of nice to have a time point. 'cause I've always, um. Had patients ask me, when's the end point? And it's always like, hmm, it's not, you know, it hasn't been that clear. Um, so, and I just wanna point out too, at least, you know, my practice may be a little different than someone else's at a more of a community center or a academic center where endocrinology oftentimes will get involved as well. So a lot of times I'll have a discussion with my endocrinologist about these numbers. Um, so the surgeon may be more or less involved, you know, just depending on your institution. Speaker 4: Yeah, I think you're right though. This has been a big positive change is sort of having an endpoint for [00:19:00] follow up. Um, and I think the idea that you could stop doing ultrasounds after five to eight years if, if they've had a good response and nothing is worrisome. Um, and then also just stopping biochemical follow up after, you know, the 10 to 15 year mark. I think it's nice to know that we can, we can never save. You're cured, but we can say if you've got a good response at that time point, that the likelihood of recurrence is so low that the risks of us finding things and leading to unnecessary interventions is probably much greater than the benefits of ongoing surveillance at that point. Speaker: Yeah. Great. Okay, so I'm gonna direct my next question to Dr. Chu because he has had some experience in our UW team now with some of the percutaneous approaches. So I'd like to get your opinion. So let's say, let's change the scenario a little bit. Let's say that we have this patient come to your office and she has a 0.7 centimeter tumor and it has been biopsied [00:20:00] and it comes back PTC, what, so this would be considered a micro PTC. Right? It's so, it's less than one centimeter. So we consider that micro. And a lot of times these tumors wouldn't get biopsied. But if it had, and it came back as PTC, um, Dr. Shu, what would some of the other treatment options be that we could offer this patient? Speaker 2: Sure. So management of these micro PTCs, I think marks a pretty big change from the last set of guidelines. Prior guidelines would say, wouldn't recommend a lobectomy for these small cancers that were found. But kind of staying with our theme of deescalation of care, these current guidelines now say, uh, and offer active surveillance or percutaneous ablation for these small papillary thyroid cancers. And of course, this is all, you know, within the realm of shared decision making with your patient and find out. Options are best for them, but getting the specifics according to these guidelines. So active surveillance, what they're kind of defining says will be repeat ultrasound [00:21:00] of this thyroid cancer every six months for at least the first one to two years, and then yearly afterwards. Unlike following post-treatment cancers, they don't really have enough evidence yet to say how long we need to follow these for. And I think a lot of it will depend on the specifics of your patient and their kind of goals of care. Importantly, they do put down a growth measurement of three millimeters as a marker of when you should really start considering intervention. And the other side of this is the introduction of percutaneous ablation for these small cancers. And for those of you who have not been exposed to percutaneous thyroid ablation, it's very similar to ablations performed in other parts of the body. Uh, the most common uh, modality use is radiofrequency ablation. Also people are doing microwave and laser ablations to good effect. There've been a large number of studies mostly out of Asia, uh, that show the recurrence rates for cancer after ablation have been quite excellent. So this has been, uh, offered as an option. Now as Amanda was [00:22:00] mentioning, it is generally pretty rare a patient has a preoperative diagnosis of a micro PTC because most nodules, less than one centimeter aren't getting biopsied. I do think this is something interesting to keep an eye on. Uh, as this gen general trend of deescalation increases, there's more and more studies being conducted on active surveillance and ablation for larger cancers. And so it'll be interesting to see what the data looks like in time for the next set of guidelines. If this options, if these options become, uh, expanded for larger thyroid cancer. Speaker 4: I think a couple things about that that I just wanted to highlight was the ultrasound surveillance. You know, I think one of the challenges is I think most radiologists can look at a thyroid nodule and measure for changes, but I would say lymph node assessment on ultrasound is highly variable. So when you're doing active surveillance, I think it is something to just sort of recognize that. They should be looking at the lateral in the central neck and just making sure you're getting appropriate images and, and that someone knows how to look for suspicious lymph nodes because they do think it's not just the growth [00:23:00] of the primary, but we all have seen small thyroid cancers that can then develop nodal disease. The other thing I just wanted to ask Alex about was the ultrasound follow up. If somebody is doing an RFA for thyroid cancer, like how good is ultrasound surveillance of that post RFA? Speaker 2: It can be tricky 'cause it's gonna look really funky afterwards. And then this may be a bit more of an issue for when you have a bigger nodule that you feel pretty good as benign. And you've, you've, you've RF aed, um, that said, a lot of folks with these micro PTCs, they're actually gonna get total nodule disappearance after ablation. And that's kind of the ultimate effect. But that probably only happens about half the time. Otherwise, you're just gonna follow these nodules. I, they have not set guidelines on how big or changes. I think it's just gonna be within your clinical suspicion of, of something you buy up or ablated is gonna start growing again. Speaker 3: [00:24:00] I, I've definitely seen, uh, some people talk at conferences where they start with like a tres two or three, you know, three centimeter nodule. They do an ablation and then a subsequent ultrasound says TRES five nodule, you know, that maybe has shrunk in size, but 'cause then like you go down the pathway of it, radiologist calls it as a higher tres rating. And then. When you get a repeat biopsy, if that were to happen now, it's a very confusing biopsy for the cytologist to review. So you definitely kind of open up a can of worms in this situation to where once someone's in the sort of ablation arm, like the only other option is repeat ablation or lobectomy. But the continued surveillance becomes very confusing. You know, even for benign nodules. Speaker 4: Yeah, it can be a real challenge. Speaker: All right. Excellent points. Thank you everyone. Um, so I think we'll switch gears now. At this point, I'll give the floor to Simon, um, Dr. Hallock to discuss maybe a second case [00:25:00] that's a little higher risk. Speaker 3: Okay. Let's see. For our next case, we're gonna change this up a little bit. I'm gonna direct this towards, uh, Becky Sippel. All right. Your patient is a 56-year-old male with a four centimeter right thyroid nodule that had a recent finding aspiration concerning four papillary thyroid cancer. The preoperative ultrasound. Had revealed poorly defined margins concerning for extra thyroidal extension anteriorly into the strap muscles. Preoperatively, uh, there's a discussion about extended surgery and total thyroidectomy you know, is favored due to the high risk features. Preoperative lymph node mapping reveals level six or, you know, central lymph nodes on the right. Dr. Sipple, what procedure would you consent this patient for? Speaker 4: Yeah, so I think this is where sort of ultrasound can be really used to help restratify things. You know, I would say there is a biopsy that's a PTC that is, um, kind of a, just a cellular hypervascular nodule that looks well contained and has clean margins. It's [00:26:00] probably gonna be a low grade follicular. You know, pattern follicular, variant de papillary, and those, I, I think just a lobe is probably appropriate, but when they have extra thyroidal extension or poorly defined margins, or it is just sort of more infiltrative, those are tumors that are just. Gonna be more challenging to manage in patients that are probably gonna benefit from radioactive iodine. So that patient is gonna benefit from a total thyroidectomy upfront. Uh, and then if there's a suspicion of lymph node disease I don't necessarily prove it on biopsy in the central neck. If those lymph nodes look concerning in the central neck, I'm gonna do a central neck dissection. I think it's. You know, especially in the setting of cancer, if they look abnormal pre-op, they're gonna look abnormal post-op. So I think really looking at that central neck on ultrasound, and if there's any question doing a central neck dissection. Um, so while I'm not a fan of prophylactic central neck dissections with a, you know, a clean ultrasound, if there's a. Suspicious lymph nodes in the central neck, they [00:27:00] should get a formal central neck dissection, and that includes both level six and seven. Um, you don't ever wanna just berry pick or take out a few obvious nodes. You really wanna dissect out the recurrent nerve and take all the fibro fatty tissue, anterior, posterior, down to the level of the denominate on that side, and really make sure there's nothing left. Speaker 3: Alright, uh, so you perform a total thyroidectomy with right central neck dissection and final pathology reveals a four centimeter tall cell variant of papillary thyroid cancer of the right lobe with extra thyroidal extension and four of 10, uh, lymph nodes in the right central neck are found to be positive. And the left, uh, lo of the thyroid is normal. So, Dr. Sipple, when you get a postoperative TSH and thyroid globulin, uh, according to these, uh, new 2025 guidelines. Speaker 4: So I would say that, um, you know, whether it's low risk or high risk, our protocol is to get both of those at six weeks. And I think [00:28:00] this is high risk pathology. So this is a patient who's gonna benefit from radioactive iodine treatment. Um, but I think that th globulin level at the six to eight week mark really can sort of make sure that that's the right next step. So I would expect a post-op TG in this patient to be like 0.5 or lower. Like it should be pretty. Pretty low. If for some reason our threshold is if it's above two, that's a red flag, like a, a post-op thyroglobulin above two means we maybe didn't get it all, so prior to going down the road of radioactive iodine treatment and prep, those are patients that we pause and we get some additional imaging. We might get a neck ultrasound or potentially a CT scan. Make sure that there wasn't disease in the lateral neck that wasn't appreciated. We really wanna make sure that the patient is optimally surgically debulk before you would consider radioactive ine treatment. So I think a th globulin level, uh, at two, uh, of two is sort of our threshold. So I think that [00:29:00] that's one of the changes with the guidelines of checking that early really can help to, to maximize decision making and avoid. Treatment with radioactive iodine for disease that needed to be removed surgically. Nothing to me is more frustrating to see a post-op radioactive iodine scan with lateral neck lymph nodes that light up like those should have been removed surgically. We're not gonna ablate 'em with radioactive iodine. And so I think the more we can know that before we treat the better. Speaker 3: Yeah, I think that, uh, new thyroid globulin guideline is gonna be a little controversial, so I look forward to seeing what, uh. Uh, guideline adherence looks like sort of, you know, in that situation. So I think it's fair to say that you would refer this patient on for radioactive. I then. Speaker 4: Yeah, I think I would. And you know, like I said, as surgeons we may not always be the ones making the final decision, but I do think our patients look to us, so we're reviewing the pathology with them. We can talk to them about their risk stratification based on the pathology. And then we have another follow-up [00:30:00] at six weeks when that post-op thorough globulin comes back so that we can incorporate that in our decision making. And we will usually give recommendations to patients based on this. I think you're at high risk. I would recommend the radioactive iodine or I would not recommend it. Um, and if they're in the intermediate, you know. I also say that they don't have to make the decision right away, so it is okay for those patients in that intermediate who are sort of waffling on the decision. Those ones all say, come back at six months. Let's get that first ultrasound. Let's make sure there's nothing that looks suspicious. Let's recheck the thoro globulin and then we can have the discussion. I, I think the decision about radioactive iodine doesn't have to be made immediately, and it's okay to wait six months and reassess things and make that final decision. Because I think ultimately the decision about radioactive iodine is really twofold. It's either gonna be adjuvant therapy to sort of treat sort of, you know, known residual disease or metastatic disease, or it's, it's an ablation. And I would say that [00:31:00] sometimes the ablation is just to destroy normal thyroid tissue. Uh, but sometimes it's to destroy microscopic lymph node disease. And so I think if the TG is still detectable after surgery, you don't really know which of those it is. But for some people that peace of mind of getting that tho goin level undetectable is worth it. And so I think it's okay to sort of have that conversation about really what are our goals of doing this treatment and then what are the risks and benefits of it so the patient can ultimately make the right decision for them going forward. Speaker 3: So for this patient specifically, after they receive their radioactive iodine, their, uh, ultrasound lymph, no mapping is unremarkable. TG is 0.1. So undetectable. So I assume that would be your thyroid globulin goal for anyone After total thyroidectomy, what would be your TSH goal and um, you know, sort of where would you go from there with this patient? Speaker 4: Yeah, so I would say that, um, you know, in the 2015 guidelines, the goal would've been to keep the, the patient suppressed to, you know, I would say the [00:32:00] new guidelines have really backed off on that, recognizing that there isn't the huge benefit. I would say that, you know, while it is in the normal range, I would say I would. Typically wanna keep it in the lower end of the normal range. So I would say if they have known residual disease, so if their TG is still EL elevated or you're, you have known nodal disease that hasn't been resected, then you probably do want to sort of keep it slightly suppressed. But I would say then the absence of known disease, I think we can back off and just try to keep things at the low end of the normal range. Speaker 3: Alright, let's end with some quick hits for everyone. The 2025 American Thyroid Association Guidelines for differentiated Thyroid Cancer, largely advocates for a deescalation in care and an earlier assessment of response to therapy. Uh, second, there's a strong recommendation for thyroid lobectomy for any differentiated thyroid cancer now up to two centimeters and it's open for consideration for any tumor up to four centimeters. As long as there are no. [00:33:00] High risk features including, uh, lymph, no metastasis, extra thyroidal extension, and all the other classic high risk features. And then last but not least, there is no longer a recommendation to suppress the TSH in a patient who is deemed surgically, uh, complete with good oncologic response, dominate the day.