Key Changes in the American Thyroid Association (ATA) 2025 Guidelines for Managing Thyroid Diseases
The 2025 ATA guidelines introduce significant updates to thyroid disease management that focus on patient-centered care, risk stratification, and expanded treatment options throughout the patient journey.
Major Structural Changes
- The 2025 guidelines now separate thyroid nodule management from differentiated thyroid cancer (DTC) management, creating dedicated guidelines for each condition 1
- The new guidelines emphasize the "patient journey" approach, beginning from initial cancer diagnosis through long-term management 1
- More diverse stakeholder input was incorporated, including patient advocates and systematic review experts 1
Risk Stratification Updates
- Introduction of "Ongoing Risk Stratification" or "Delayed Risk Stratification" (DRS) that continuously integrates initial risk assessment with clinical, radiologic, and laboratory data collected during follow-up 2
- Recognition that initial risk stratification may overestimate risk, with approximately 60% of intermediate/high-risk patients achieving complete remission 2
- More nuanced approach to small thyroid nodules, with TIRADS generally not recommending FNA for non-subcapsular thyroid nodules <1cm, even if classified as high risk 2
Treatment Approach Changes
Thermal Ablation Recommendations
- Strong recommendation for thermal ablation for benign thyroid nodules that cause clinical symptoms, have a maximal diameter ≥2cm and are increasing gradually, are autonomously functioning, or are recurrent after chemical ablation 2
- Thermal ablation now considered for select papillary thyroid carcinomas (PTC) with maximal diameter ≤1cm, single cancer nodule, no invasion of critical structures, and no metastasis 2
- Expanded indications for thermal ablation to include cancer nodules located in the isthmus, nodules with US-detected capsular invasion, and multiple cancer nodules (≤3 nodules with maximal diameter ≤1cm) 2, 3
Imaging and Evaluation Updates
- Contrast-enhanced ultrasound (CEUS) now recommended to evaluate blood supply and ablation extent 2, 3
- Standardized formula for assessing nodule volume reduction: Volume reduction rate (VRR) = [(Preoperative nodule volume – ablation zone volume at follow-up) × 100]/preoperative volume (%) 3
- Enhanced pre-treatment evaluation protocols including comprehensive blood work, tumor marker measurement, and more detailed imaging 2
Medication Management Updates
- For progressive and/or symptomatic disease, lenvatinib (preferred) or sorafenib is recommended 2, 3
- Other small-molecular kinase inhibitors now considered if clinical trials or other systemic therapies are not available 3
- Updated TSH suppression therapy guidelines following thermal ablation of malignant thyroid nodules, with target TSH levels based on indication type 3
Surveillance and Follow-up Protocols
- Regular follow-up required after thermal ablation of both benign and malignant thyroid nodules 3
- Follow-up content should include VRR, improvements of compression symptoms and cosmetic problems, presence of residual nodules, recurrence, metastasis, recovery from complications, and thyroid function 3
- Standardized chest X-ray interval recommended every 6 months until 8 years of age, with earlier initiation of pelvic surveillance 2
Patient-Reported Outcomes
- Greater emphasis on patient-reported outcomes and quality of life measurements 1
- Validated instruments such as symptom scores, anxiety scale, and quality of life instruments now recommended to document improvements in nodule-related symptoms 3
Research Priorities
- Identification of critical areas needing additional high-quality research 1
- Recognition that studies on thermal ablation for thyroid nodules have relatively short follow-up periods, and long-term follow-up studies with large samples are still required 3
These updates reflect the evolving science in thyroid disease management and aim to optimize evidence-based clinical care throughout the patient journey with differentiated thyroid cancer.