Ashok Shaha, MD, (left) listens to Mark D. Coltrera, MD, discuss his concerns about American Thyroid Association Guidelines.

The American Thyroid Association (ATA) Guidelines for differentiated thyroid cancer caused a lot of hand-wringing and consternation September 14 as an expert panel tried to agree on their usefulness.

Moderated by Robert L. Witt, MD, "The American Thyroid Association Guidelines: Do We All Agree?" featured panelists Marc Coltrera, MD, professor and vice-chair of otolaryngology at the University of Washington, Seattle; Chris Holsinger, MD, associate professor in the Department of Surgery at the University of Texas MD Anderson Cancer Center, Houston; Arnold Komisar, MD, clinical professor of otolaryngology at New York University School of Medicine, New York; Edmund Pribitkin, MD, professor at Thomas Jefferson University, Philadelphia, PA; Ashok Shaha, MD, professor at Memorial Sloan-Kettering Cancer Center, New York, NY; and Robert Wang, professor at the University of Nevada School of Medicine, Las Vegas.

While the ATA guidelines for differentiated thyroid cancer are widely quoted, the level of evidence on which these recommendations were made varies extensively, leaving considerable room for debate.

The guidelines covered in the session included:

•	Ultrasound indications for fine-needle aspiration (FNA) and the use of molecular markers from FNA
•	Laryngoscopy and neuro-monitoring
•	Extent of initial surgical therapy for low-risk differentiated thyroid neoplasms and the potential role for molecular markers
•	Bronchoscopy, preparation for airway management, and extent of surgery for high-risk patients with extra-thyroidal spread
•	Surgery for recurrent differentiated thyroid cancer and the role of molecular targeted therapy

Panelists and audience members provided opinions on the relevance of the ATA guidelines to their thyroid surgical practices through the use of an audience response system.

Asked if they anticipated performing their own thyroid and neck ultrasounds, as well as whether they would perform their own ultrasound-guided FNAs, 54 percent of audience members said they would. It was a point on which the panelists did not quite agree.

"Sometimes it simply isn't practical to do this," Dr. Shaha said.

Dr. Komisar said, "I'll tell you this, if your referral base does ultrasound, you're not going to do it. I guarantee it."

The audience also voted in favor of neuro-monitoring as an essential aspect of thyroid surgery, with 55 percent voting that it is essential, compared to 41 percent against. While none of the panelists were willing to say it is essential, several indicated they support its use.

"Yes, I am going to continue to use it," Dr. Komisar said. "I use it as a teaching tool."

With regard to the use of molecular markers, 70 percent of the audience members said they anticipate markers would influence their treatment choices in the near future. While the panelists saw promise in some markers, such as BRAF+, they did not stand behind their use from an evidence-based standpoint.

"By the time you read this guideline, you don't really know what (the ATA) is recommending," Dr. Coltrera said. "There is a real problem in terms of phraseology here. It is a coin toss on whether to use it because you won't have a complete answer on BRAF for a long time."