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Int J Thyroidol. 2015 Nov;8(2):129-136. Korean.
Published online November 30, 2015.
Copyright © 2015. the Korean Thyroid Association. All rights reserved.
ATA Guideline in a View Point of Nuclear Medicine
Ju Won Seok
Department of Nuclear Medicine, College of Medicine, Chung-Ang University, Seoul, Korea.

Correspondence: Ju Won Seok, MD, PhD, Department of Nuclear Medicine, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu, Seoul 156-755, Korea. Tel: 82-2-6299-2897, Fax: 82-2-6299-2899, Email:
Received March 18, 2015; Revised May 18, 2015; Accepted June 15, 2015.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Since the American Thyroid Association's guidelines for the management of thyroid nodule and differentiated thyroid cancer were published in 1996 and revised in 2006 and 2009, significant scientific advances have occurred in the field. The new revised guideline for informing clinicians, patients, researchers, and health policy makers on updated published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer is recently announced. We reviewed the part which is related the nuclear medical diagnosis and treatment in the new guideline and expected it will be made the new guideline for nuclear medicine physician based on the consensus among nuclear medicine physicians and the verification through further research.

Keywords: Thyroid nodule; Differentiated thyroid cancer; Guideline; Nuclear medicine


Table 1
Clinical implications of response to therapy re-classification in differentiated thyroid cancer patients treated with total thyroidectomy and RAI remnant ablation
Click for larger image

Table 2
Characteristics according to the ATA risk stratification system and AJCC/TNM staging system that may impact post-operative RAI decision-making
Click for larger image

1. Singer PA, Cooper DS, Daniels GH, Ladenson PW, Greenspan FS, Levy EG, et al. Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. American Thyroid Association. Arch Intern Med 1996;156(19):2165–2172.
2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006;16(2):109–142.
3. Thyroid American;DS. Cooper;GM. Doherty;BR. Haugen;RT. Kloos;SL. Lee,et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1167–1214.
4. Yi KH, Park YJ, Koong SS, Kim JH, Na DG, Ryu JS, et al. Revised Korean Thyroid Association Management Guidelines for patients with thyroid nodules and thyroid cancer. J Korean Thyroid Assoc 2010;3(2):65–96.
5. Kim WB, Seok JW, Kim MH, Kim BI, Park YJ, Lee KE, et al. Korean Thyroid Association Guidelines for patients undergoing radioiodine therapy for differentiated thyroid cancers (first edition, 2012). J Korean Thyroid Assoc 2013;6(1):12–25.
6. Tuttle RM, Leboeuf R. Follow up approaches in thyroid cancer: a risk adapted paradigm. Endocrinol Metab Clin North Am 2008;37(2):419–435. ix–x.
7. Tuttle RM, Tala H, Shah J, Leboeuf R, Ghossein R, Gonen M, et al. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system. Thyroid 2010;20(12):1341–1349.
8. Vaisman F, Shaha A, Fish S, Michael Tuttle R. Initial therapy with either thyroid lobectomy or total thyroidectomy without radioactive iodine remnant ablation is associated with very low rates of structural disease recurrence in properly selected patients with differentiated thyroid cancer. Clin Endocrinol (Oxf) 2011;75(1):112–119.
9. Jonklaas J, Sarlis NJ, Litofsky D, Ain KB, Bigos ST, Brierley JD, et al. Outcomes of patients with differentiated thyroid carcinoma following initial therapy. Thyroid 2006;16(12):1229–1242.
10. Jonklaas J, Cooper DS, Ain KB, Bigos T, Brierley JD, Haugen BR, et al. Radioiodine therapy in patients with stage I differentiated thyroid cancer. Thyroid 2010;20(12):1423–1424.
11. Sacks W, Fung CH, Chang JT, Waxman A, Braunstein GD. The effectiveness of radioactive iodine for treatment of low-risk thyroid cancer: a systematic analysis of the peer-reviewed literature from 1966 to April 2008. Thyroid 2010;20(11):1235–1245.
12. Sawka AM, Brierley JD, Tsang RW, Thabane L, Rotstein L, Gafni A, et al. An updated systematic review and commentary examining the effectiveness of radioactive iodine remnant ablation in well-differentiated thyroid cancer. Endocrinol Metab Clin North Am 2008;37(2):457–480. x.
13. Ross DS, Litofsky D, Ain KB, Bigos T, Brierley JD, Cooper DS, et al. Recurrence after treatment of micropapillary thyroid cancer. Thyroid 2009;19(10):1043–1048.
14. Kim HJ, Kim NK, Choi JH, Kim SW, Jin SM, Suh S, et al. Radioactive iodine ablation does not prevent recurrences in patients with papillary thyroid microcarcinoma. Clin Endocrinol (Oxf) 2013;78(4):614–620.
15. Baudin E, Travagli JP, Ropers J, Mancusi F, Bruno-Bossio G, Caillou B, et al. Microcarcinoma of the thyroid gland: the Gustave-Roussy Institute experience. Cancer 1998;83(3):553–559.
16. Creach KM, Siegel BA, Nussenbaum B, Grigsby PW. Radioactive iodine therapy decreases recurrence in thyroid papillary microcarcinoma. ISRN Endocrinol 2012;2012:816386.
17. Lin HW, Bhattacharyya N. Survival impact of treatment options for papillary microcarcinoma of the thyroid. Laryngoscope 2009;119(10):1983–1987.
18. Kuo EJ, Roman SA, Sosa JA. Patients with follicular and Hurthle cell microcarcinomas have compromised survival: a population level study of 22,738 patients. Surgery 2013;154(6):1246–1253. discussion 1253-4.
19. Mallick U, Harmer C, Hackshaw A, Moss L. IoN Trial Management Group. Iodine or Not (IoN) for low-risk differentiated thyroid cancer: the next UK National Cancer Research Network randomised trial following HiLo. Clin Oncol (R Coll Radiol) 2012;24(3):159–161.
20. Kazaure HS, Roman SA, Sosa JA. Aggressive variants of papillary thyroid cancer: incidence, characteristics and predictors of survival among 43,738 patients. Ann Surg Oncol 2012;19(6):1874–1880.
21. Kazaure HS, Roman SA, Sosa JA. Insular thyroid cancer: a population-level analysis of patient characteristics and predictors of survival. Cancer 2012;118(13):3260–3267.
22. Chow SM, Yau S, Kwan CK, Poon PC, Law SC. Local and regional control in patients with papillary thyroid carcinoma: specific indications of external radiotherapy and radioactive iodine according to T and N categories in AJCC 6th edition. Endocr Relat Cancer 2006;13(4):1159–1172.
23. Podnos YD, Smith DD, Wagman LD, Ellenhorn JD. Survival in patients with papillary thyroid cancer is not affected by the use of radioactive isotope. J Surg Oncol 2007;96(1):3–7.
24. Lee J, Yun MJ, Nam KH, Chung WY, Soh EY, Park CS. Quality of life and effectiveness comparisons of thyroxine withdrawal, triiodothyronine withdrawal, and recombinant thyroidstimulating hormone administration for low-dose radioiodine remnant ablation of differentiated thyroid carcinoma. Thyroid 2010;20(2):173–179.
25. Robbins RJ, Driedger A, Magner J. U.S. and Canadian Thyrogen Compassionate Use Program Investigator Group. Recombinant human thyrotropin-assisted radioiodine therapy for patients with metastatic thyroid cancer who could not elevate endogenous thyrotropin or be withdrawn from thyroxine. Thyroid 2006;16(11):1121–1130.
26. Chianelli M, Todino V, Graziano FM, Panunzi C, Pace D, Guglielmi R, et al. Low-activity (2.0 GBq; 54 mCi) radioiodine post-surgical remnant ablation in thyroid cancer: comparison between hormone withdrawal and use of rhTSH in low-risk patients. Eur J Endocrinol 2009;160(3):431–436.
27. Mallick U, Harmer C, Yap B, Wadsley J, Clarke S, Moss L, et al. Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer. N Engl J Med 2012;366(18):1674–1685.
28. Pacini F, Ladenson PW, Schlumberger M, Driedger A, Luster M, Kloos RT, et al. Radioiodine ablation of thyroid remnants after preparation with recombinant human thyrotropin in differentiated thyroid carcinoma: results of an international, randomized, controlled study. J Clin Endocrinol Metab 2006;91(3):926–932.
29. Schlumberger M, Catargi B, Borget I, Deandreis D, Zerdoud S, Bridji B, et al. Strategies of radioiodine ablation in patients with low-risk thyroid cancer. N Engl J Med 2012;366(18):1663–1673.
30. Taieb D, Sebag F, Cherenko M, Baumstarck-Barrau K, Fortanier C, Farman-Ara B, et al. Quality of life changes and clinical outcomes in thyroid cancer patients undergoing radioiodine remnant ablation (RRA) with recombinant human TSH (rhTSH): a randomized controlled study. Clin Endocrinol (Oxf) 2009;71(1):115–123.
31. Emmanouilidis N, Muller JA, Jager MD, Kaaden S, Helfritz FA, Guner Z, et al. Surgery and radioablation therapy combined: introducing a 1-week-condensed procedure bonding total thyroidectomy and radioablation therapy with recombinant human TSH. Eur J Endocrinol 2009;161(5):763–769.
32. Tu J, Wang S, Huo Z, Lin Y, Li X, Wang S. Recombinant human thyrotropin-aided versus thyroid hormone withdrawalaided radioiodine treatment for differentiated thyroid cancer after total thyroidectomy: a meta-analysis. Radiother Oncol 2014;110(1):25–30.
33. Elisei R, Schlumberger M, Driedger A, Reiners C, Kloos RT, Sherman SI, et al. Follow-up of low-risk differentiated thyroid cancer patients who underwent radioiodine ablation of postsurgical thyroid remnants after either recombinant human thyrotropin or thyroid hormone withdrawal. J Clin Endocrinol Metab 2009;94(11):4171–4179.
34. Emmanouilidis N, Schrem H, Winkler M, Klempnauer J, Scheumann GF. Long-term results after treatment of very low-, low-, and high-risk thyroid cancers in a combined setting of thyroidectomy and radio ablation therapy in euthyroidism. Int J Endocrinol 2013;2013:769473.
35. Hugo J, Robenshtok E, Grewal R, Larson S, Tuttle RM. Recombinant human thyroid stimulating hormone-assisted radioactive iodine remnant ablation in thyroid cancer patients at intermediate to high risk of recurrence. Thyroid 2012;22(10):1007–1015.
36. Rosario PW, Mineiro Filho AF, Lacerda RX, Calsolari MR. Long-term follow-up of at least five years after recombinant human thyrotropin compared to levothyroxine withdrawal for thyroid remnant ablation with radioactive iodine. Thyroid 2012;22(3):332–333.
37. Pitoia F, Marlowe RJ, Abelleira E, Faure EN, Bueno F, Schwarzstein D, et al. Radioiodine thyroid remnant ablation after recombinant human thyrotropin or thyroid hormone withdrawal in patients with high-risk differentiated thyroid cancer. J Thyroid Res 2012;2012:481568.
38. Bartenstein P, Calabuig EC, Maini CL, Mazzarotto R, Muros de, Petrich T, et al. High-risk patients with differentiated thyroid cancer T4 primary tumors achieve remnant ablation equally well using rhTSH or thyroid hormone withdrawal. Thyroid 2014;24(3):480–487.
39. Tala H, Robbins R, Fagin JA, Larson SM, Tuttle RM. Five-year survival is similar in thyroid cancer patients with distant metastases prepared for radioactive iodine therapy with either thyroid hormone withdrawal or recombinant human TSH. J Clin Endocrinol Metab 2011;96(7):2105–2111.
40. Klubo-Gwiezdzinska J, Burman KD, Van Nostrand D, Mete M, Jonklaas J, Wartofsky L. Radioiodine treatment of metastatic thyroid cancer: relative efficacy and side effect profile of preparation by thyroid hormone withdrawal versus recombinant human thyrotropin. Thyroid 2012;22(3):310–317.
41. Maenpaa HO, Heikkonen J, Vaalavirta L, Tenhunen M, Joensuu H. Low vs. high radioiodine activity to ablate the thyroid after thyroidectomy for cancer: a randomized study. PLoS One 2008;3(4):e1885.
42. Pilli T, Brianzoni E, Capoccetti F, Castagna MG, Fattori S, Poggiu A, et al. A comparison of 1850 (50 mCi) and 3700 MBq (100 mCi) 131-iodine administered doses for recombinant thyrotropin-stimulated postoperative thyroid remnant ablation in differentiated thyroid cancer. J Clin Endocrinol Metab 2007;92(9):3542–3546.
43. Zaman M, Toor R, Kamal S, Maqbool M, Habib S, Niaz K. A randomized clinical trial comparing 50mCi and 100mCi of iodine-131 for ablation of differentiated thyroid cancers. J Pak Med Assoc 2006;56(8):353–356.
44. Kukulska A, Krajewska J, Gawkowska-Suwinska M, Puch Z, Paliczka-Cieslik E, Roskosz J, et al. Radioiodine thyroid remnant ablation in patients with differentiated thyroid carcinoma (DTC): prospective comparison of long-term outcomes of treatment with 30, 60 and 100 mCi. Thyroid Res 2010;3(1):9.
45. Fang Y, Ding Y, Guo Q, Xing J, Long Y, Zong Z. Radioiodine therapy for patients with differentiated thyroid cancer after thyroidectomy: direct comparison and network metaanalyses. J Endocrinol Invest 2013;36(10):896–902.
46. Ma C, Tang L, Fu H, Li J, Wang H. rhTSH-aided lowactivity versus high-activity regimens of radioiodine in residual ablation for differentiated thyroid cancer: a meta-analysis. Nucl Med Commun 2013;34(12):1150–1156.
47. Cheng W, Ma C, Fu H, Li J, Chen S, Wu S, et al. Lowor high-dose radioiodine remnant ablation for differentiated thyroid carcinoma: a meta-analysis. J Clin Endocrinol Metab 2013;98(4):1353–1360.
48. Valachis A, Nearchou A. High versus low radioiodine activity in patients with differentiated thyroid cancer: a meta-analysis. Acta Oncol 2013;52(6):1055–1061.
49. Castagna MG, Cevenini G, Theodoropoulou A, Maino F, Memmo S, Claudia C, et al. Post-surgical thyroid ablation with low or high radioiodine activities results in similar outcomes in intermediate risk differentiated thyroid cancer patients. Eur J Endocrinol 2013;169(1):23–29.
50. Han JM, Kim WG, Kim TY, Jeon MJ, Ryu JS, Song DE, et al. Effects of low-dose and high-dose postoperative radioiodine therapy on the clinical outcome in patients with small differentiated thyroid cancer having microscopic extrathyroidal extension. Thyroid 2014;24(5):820–825.
51. Kruijff S, Aniss AM, Chen P, Sidhu SB, Delbridge LW, Robinson B, et al. Decreasing the dose of radioiodine for remnant ablation does not increase structural recurrence rates in papillary thyroid carcinoma. Surgery 2013;154(6):1337–1344. discussion 1344-5.
52. Sabra MM, Grewal RK, Ghossein RA, Tuttle RM. Higher administered activities of radioactive iodine are associated with less structural persistent response in older, but not younger, papillary thyroid cancer patients with lateral neck lymph node metastases. Thyroid 2014;24(7):1088–1095.
53. Schlumberger M, Lacroix L, Russo D, Filetti S, Bidart JM. Defects in iodide metabolism in thyroid cancer and implications for the follow-up and treatment of patients. Nat Clin Pract Endocrinol Metab 2007;3(3):260–269.
54. Kulkarni K, Van Nostrand D, Atkins F, Aiken M, Burman K, Wartofsky L. The relative frequency in which empiric dosages of radioiodine would potentially overtreat or undertreat patients who have metastatic well-differentiated thyroid cancer. Thyroid 2006;16(10):1019–1023.
55. Tuttle RM, Leboeuf R, Robbins RJ, Qualey R, Pentlow K, Larson SM, et al. Empiric radioactive iodine dosing regimens frequently exceed maximum tolerated activity levels in elderly patients with thyroid cancer. J Nucl Med 2006;47(10):1587–1591.
56. Hebestreit H, Biko J, Drozd V, Demidchik Y, Burkhardt A, Trusen A, et al. Pulmonary fibrosis in youth treated with radioiodine for juvenile thyroid cancer and lung metastases after Chernobyl. Eur J Nucl Med Mol Imaging 2011;38(9):1683–1690.
57. Ilgan S, Karacalioglu AO, Pabuscu Y, Atac GK, Arslan N, Ozturk E, et al. Iodine-131 treatment and high-resolution CT: results in patients with lung metastases from differentiated thyroid carcinoma. Eur J Nucl Med Mol Imaging 2004;31(6):825–830.
58. Hod N, Hagag P, Baumer M, Sandbank J, Horne T. Differentiated thyroid carcinoma in children and young adults: evaluation of response to treatment. Clin Nucl Med 2005;30(6):387–390.
59. Schlumberger M, Challeton C, De Vathaire F, Travagli JP, Gardet P, Lumbroso JD, et al. Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma. J Nucl Med 1996;37(4):598–605.
60. Schlumberger M, Brose M, Elisei R, Leboulleux S, Luster M, Pitoia F, et al. Definition and management of radioactive iodine-refractory differentiated thyroid cancer. Lancet Diabetes Endocrinol 2014;2(5):356–358.
61. Deandreis D, Al Ghuzlan A, Auperin A, Vielh P, Caillou B, Chami L, et al. Is (18)F-fluorodeoxyglucose-PET/CT useful for the presurgical characterization of thyroid nodules with indeterminate fine needle aspiration cytology? Thyroid 2012;22(2):165–172.
62. Vriens D, de Wilt JH, van der Wilt GJ, Netea-Maier RT, Oyen WJ, de Geus-Oei LF. The role of [18F]-2-fluoro-2-deoxy-d-glucose-positron emission tomography in thyroid nodules with indeterminate fine-needle aspiration biopsy: systematic review and meta-analysis of the literature. Cancer 2011;117(20):4582–4594.
63. Wang N, Zhai H, Lu Y. Is fluorine-18 fluorodeoxyglucose positron emission tomography useful for the thyroid nodules with indeterminate fine needle aspiration biopsy? A meta-analysis of the literature. J Otolaryngol Head Neck Surg 2013;42:38.
64. Soelberg KK, Bonnema SJ, Brix TH, Hegedus L. Risk of malignancy in thyroid incidentalomas detected by 18F-fluorodeoxyglucose positron emission tomography: a systematic review. Thyroid 2012;22(9):918–925.
65. Chen W, Parsons M, Torigian DA, Zhuang H, Alavi A. Evaluation of thyroid FDG uptake incidentally identified on FDG-PET/CT imaging. Nucl Med Commun 2009;30(3):240–244.
66. Nishimori H, Tabah R, Hickeson M, How J. Incidental thyroid "PETomas": clinical significance and novel description of the self-resolving variant of focal FDG-PET thyroid uptake. Can J Surg 2011;54(2):83–88.
67. Robbins RJ, Wan Q, Grewal RK, Reibke R, Gonen M, Strauss HW, et al. Real-time prognosis for metastatic thyroid carcinoma based on 2-[18F]fluoro-2-deoxy-D-glucose-positron emission tomography scanning. J Clin Endocrinol Metab 2006;91(2):498–505.
68. Deandreis D, Al Ghuzlan A, Leboulleux S, Lacroix L, Garsi JP, Talbot M, et al. Do histological, immunohistochemical, and metabolic (radioiodine and fluorodeoxyglucose uptakes) patterns of metastatic thyroid cancer correlate with patient outcome? Endocr Relat Cancer 2011;18(1):159–169.
69. Ciappuccini R, Heutte N, Trzepla G, Rame JP, Vaur D, Aide N, et al. Postablation (131)I scintigraphy with neck and thorax SPECT-CT and stimulated serum thyroglobulin level predict the outcome of patients with differentiated thyroid cancer. Eur J Endocrinol 2011;164(6):961–969.
70. Salvatori M, Perotti G, Villani MF, Mazza R, Maussier ML, Indovina L, et al. Determining the appropriate time of execution of an I-131 post-therapy whole-body scan: comparison between early and late imaging. Nucl Med Commun 2013;34(9):900–908.
71. Kohlfuerst S, Igerc I, Lobnig M, Gallowitsch HJ, Gomez-Segovia I, Matschnig S, et al. Posttherapeutic (131)I SPECTCT offers high diagnostic accuracy when the findings on conventional planar imaging are inconclusive and allows a tailored patient treatment regimen. Eur J Nucl Med Mol Imaging 2009;36(6):886–893.
72. Chen L, Luo Q, Shen Y, Yu Y, Yuan Z, Lu H, et al. Incremental value of 131I SPECT/CT in the management of patients with differentiated thyroid carcinoma. J Nucl Med 2008;49(12):1952–1957.
73. Schmidt D, Linke R, Uder M, Kuwert T. Five months' follow-up of patients with and without iodine-positive lymph node metastases of thyroid carcinoma as disclosed by (131) I-SPECT/CT at the first radioablation. Eur J Nucl Med Mol Imaging 2010;37(4):699–705.
74. Maruoka Y, Abe K, Baba S, Isoda T, Sawamoto H, Tanabe Y, et al. Incremental diagnostic value of SPECT/CT with 131I scintigraphy after radioiodine therapy in patients with welldifferentiated thyroid carcinoma. Radiology 2012;265(3):902–909.
75. Grewal RK, Tuttle RM, Fox J, Borkar S, Chou JF, Gonen M, et al. The effect of posttherapy 131I SPECT/CT on risk classification and management of patients with differentiated thyroid cancer. J Nucl Med 2010;51(9):1361–1367.
76. Aide N, Heutte N, Rame JP, Rousseau E, Loiseau C, Henry-Amar M, et al. Clinical relevance of single-photon emission computed tomography/computed tomography of the neck and thorax in postablation (131)I scintigraphy for thyroid cancer. J Clin Endocrinol Metab 2009;94(6):2075–2084.
77. Schmidt D, Szikszai A, Linke R, Bautz W, Kuwert T. Impact of 131I SPECT/spiral CT on nodal staging of differentiated thyroid carcinoma at the first radioablation. J Nucl Med 2009;50(1):18–23.
78. Jeong SY, Lee SW, Kim HW, Song BI, Ahn BC, Lee J. Clinical applications of SPECT/CT after first I-131 ablation in patients with differentiated thyroid cancer. Clin Endocrinol (Oxf) 2014;81(3):445–451.
79. Tharp K, Israel O, Hausmann J, Bettman L, Martin WH, Daitzchman M, et al. Impact of 131I-SPECT/CT images obtained with an integrated system in the follow-up of patients with thyroid carcinoma. Eur J Nucl Med Mol Imaging 2004;31(10):1435–1442.