¿Qué Hay de Nuevo en las Guías ATA? Claves en el Manejo Quirúrgico del Cáncer Diferenciado de Tiroides

¿Qué Hay de Nuevo en las Guías ATA? Claves en el Manejo Quirúrgico del Cáncer Diferenciado de Tiroides

What Is New in the ATA Guidelines? Key Aspects of the Surgical Management of Differentiated Thyroid Cancer

Ángela Santana Valenciano*, Tamara Díaz Vico*/**, Irene Grao Torrente*, María Dolores Picardo Gomendio*, Manuel Durán Poveda*/**

* Unidad de Cirugía Endocrina. Servicio de Cirugía General y del Aparato Digestivo.
     Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
**  Departamento de Especialidades Médicas y Salud Pública,
      Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, España
.

DOI: https://doi.org/10.14679/5173

Resumen:

Introducción: La guía ATA 2025 para el manejo del cáncer diferenciado de tiroides (CDT) actualiza y amplía las recomendaciones de la edición de 2015. Este artículo revisa los principales cambios, con especial atención a las implicaciones quirúrgicas y manejo perioperatorio.
Material y Métodos: Se realizó una revisión narrativa comparativa entre las guías ATA 2015 y ATA 2025, analizando modificaciones en clasificación histopatológica, extensión quirúrgica, linfadenectomía, neuromonitorización, preservación paratiroidea, estratificación de riesgo, evaluación de respuesta clínica y uso de radioyodo.
Resultados: La ATA 2025 incorpora la clasificación del CDT de la OMS 5.ª edición, reconociendo el carcinoma oncocítico como entidad propia e integrando la neoplasia folicular tiroidea no invasiva con características nucleares tipo papilar (NIFTP). Refuerza la derivación a cirujanos de alto volumen, formaliza la vigilancia activa en microcarcinomas seleccionados e incorpora la ablación percutánea como alternativa en casos concretos. En cirugía, mantiene una estrategia conservadora, pero precisa las indicaciones de hemitiroidectomía, totalización y linfadenectomía. Aumenta el respaldo a la neuromonitorización del nervio recurrente y preservación de la rama externa del nervio laríngeo superior. Introduce además un sistema de estratificación de riesgo refinado, una evaluación temprana de la respuesta posquirúrgica y una indicación estructurada del radioyodo.
Discusión: La actualización de 2025 no supone un cambio radical, sino una evolución hacia un modelo más personalizado, basado en el riesgo y la reducción del sobretratamiento.
Conclusión: Las guías ATA 2025 consolidan la desescalada terapéutica en pacientes de bajo riesgo y promueven un abordaje multidisciplinar, individualizado y orientado a optimizar resultados oncológicos y funcionales.
Palabras Clave: Neoplasia tiroidea, carcinoma papilar, tiroidectomía, evaluación del riesgo, monitorización intraoperatoria, radioyodo.

Abstract:

Introduction: The 2025 ATA guidelines for the management of differentiated thyroid cancer (DTC) update and expand the recommendations of the 2015 edition. This article reviews the main changes, with special attention to surgical implications and perioperative management.
Material and Methods: A comparative narrative review was conducted between the ATA 2015 and ATA 2025 guidelines, analyzing changes in histopathological classification, extent of surgery, lymph node dissection, neuromonitoring, parathyroid preservation, risk stratification, clinical response assessment, and radioactive iodine use.
Results: The ATA 2025 guidelines incorporates the 5th edition WHO classification of DTC, recognizes oncocytic carcinoma as a distinct entity, and formally integrates noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). It reinforces referral to high-volume surgeons, formalizes active surveillance in selected microcarcinomas, and incorporates percutaneous ablation as an alternative in selected cases. In surgery, it maintains a conservative strategy, but better defines the indications for hemithyroidectomy, completion thyroidectomy, and lymph node dissection. It provides stronger support for recurrent laryngeal nerve neuromonitoring and preservation of the external branch of the superior laryngeal nerve. It also introduces a more refined risk stratification system, early postoperative response assessment, and a more structured indication for radioactive iodine.
Discussion: The 2025 update does not represent a radical change, but rather an evolution toward a more personalized model based on risk assessment and reduction of overtreatment.
Conclusion: The ATA 2025 guidelines consolidate therapeutic de-escalation in low-risk patients and promote a multidisciplinary, individualized approach aimed at optimizing oncologic and functional outcomes.
Key words: Neoplasia tiroidea, carcinoma papilar, tiroidectomía, evaluación del riesgo, monitorización intraoperatoria, radioyodo.

Bibliografía

1. 1. 1. Aschebrook-Kilfoy B, Ward MH, Sabra MM, Devesa SS. Thyroid cancer incidence patterns in the United States by histologic type, 1992-2006. Thyroid. 2011 Feb 1;21(2):125-34. doi:10.1089/thy.2010.0021 PubMed PMID: 21186939.
      2. Megwalu UC, Moon PK. Thyroid Cancer Incidence and Mortality Trends in the United States: 2000-2018. Thyroid. 2022 May 1;32(5):560-70. doi:10.1089/thy.2021.0662 PubMed PMID: 35132899.
      3. Ringel MD, Sosa JA, Baloch Z, Bischoff L, Bloom G, Brent GA, et al. 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer. Thyroid. 2025 Aug 1;35(8):841-985. doi:10.1177/10507256251363120 PubMed PMID: 40844370.
      4. Kim K, Kim JK, Lee CR, Kang SW, Lee J, Jeong JJ, et al. Comparison of long-term prognosis for differentiated thyroid cancer according to the 7th and 8th editions of the AJCC/UICC TNM staging system. Ther Adv Endocrinol Metab. 2020;11. doi:10.1177/2042018820921019 PubMed PMID: 32489582.
      5. WHO Classification of Tumours Editorial Board. Endocrine and neuroendocrine tumours. 5th ed. Vol. 10. Lyon: International Agency for Research on Cancer; 2025. 595 p.
      6. Nikiforov YE, Seethala RR, Tallini G, Baloch ZW, Basolo F, Thompson LDR, et al. Nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma a paradigm shift to reduce overtreatment of indolent tumors. JAMA Oncol. 2016 Aug 1;2(8):1023-9. doi:10.1001/jamaoncol.2016.0386 PubMed PMID: 27078145.
      7. Al-Qurayshi Z, Robins R, Hauch A, Randolph GW, Kandil E. Association of Surgeon Volume With Outcomes and Cost Savings Following Thyroidectomy: A National Forecast. JAMA Otolaryngology-Head & Neck Surgery. 2016 Jan 1;142(1):32-9. doi:10.1001/jamaoto.2015.2503
      8. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan 1;26(1):1-133. doi:10.1089/thy.2015.0020 PubMed PMID: 26462967.
      9. Ito Y, Miyauchi A, Inoue H, Fukushima M, Kihara M, Higashiyama T, et al. An Observational Trial for Papillary Thyroid Microcarcinoma in Japanese Patients. World J Surg. 2010;34(1):28-35. doi:10.1007/s00268-009-0303-0
      10. Chou R, Dana T, Haymart M, Leung AM, Tufano RP, Sosa JA, et al. Active Surveillance Versus Thyroid Surgery for Differentiated Thyroid Cancer: A Systematic Review. Thyroid. Mary Ann Liebert Inc.; 2022. p. 351-67. doi:10.1089/thy.2021.0539 PubMed PMID: 35081743.
      11. Sakai T, Sugitani I, Ebina A, Fukuoka O, Toda K, Mitani H, et al. Active surveillance for T1bN0M0 papillary thyroid carcinoma. Thyroid. 2019 Jan 1;29(1):59-63. doi:10.1089/thy.2018.0462 PubMed PMID: 30560718.
      12. Gao X, Yang Y, Wang Y, Huang Y. Efficacy and safety of ultrasound-guided radiofrequency, microwave and laser ablation for the treatment of T1N0M0 papillary thyroid carcinoma on a large scale: a systematic review and meta-analysis. International Journal of Hyperthermia. Taylor and Francis Ltd.; 2023. doi:10.1080/02656736.2023.2244713 PubMed PMID: 37604507.
      13. Santra A, Bal S, Mahargan S, Bal C. Long-term outcome of lobar ablation versus completion thyroidectomy in differentiated thyroid cancer. Nucl Med Commun. 2011 Jan;32(1):52-8. doi:10.1097/MNM.0b013e328340e74c PubMed PMID: 21063234.
      14. Kim KE, Kim EK, Yoon JH, Han KH, Moon HJ, Kwak JY. Preoperative prediction of central lymph node metastasis in thyroid papillary microcarcinoma using clinicopathologic and sonographic features. World J Surg. 2013 Feb;37(2):385-91. doi:10.1007/s00268-012-1826-3 PubMed PMID: 23073506.
      15. Likhterov I, Reis LLD, Urken ML. Central compartment management in patients with papillary thyroid cancer presenting with metastatic disease to the lateral neck: Anatomic pathways of lymphatic spread. Head Neck. 2017 May 1;39(5):853-9. doi:10.1002/hed.24568 PubMed PMID: 28252836.
      16. Cheng SP, Lee JJ, Liu TP, Lee KS, Liu CL. Preoperative ultrasonography assessment of vocal cord movement during thyroid and parathyroid surgery. World J Surg. 2012 Oct;36(10):2509-15. doi:10.1007/s00268-012-1674-1 PubMed PMID: 22689020.
      17. Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, Wallin G, et al. Complications to thyroid surgery: Results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg. 2008;393(5):667-73. doi:10.1007/s00423-008-0366-7 PubMed PMID: 18633639.
      18. Farrag TY, Samlan RA, Lin FR, Tufano RP. The utility of evaluating true vocal fold motion before thyroid surgery. Laryngoscope. 2006. p. 235-8. doi:10.1097/01.mlg.0000191472.02720.1f PubMed PMID: 16467711.
      19. Bai B, Chen W. Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Sci Rep. 2018 Dec 1;8(1). doi:10.1038/s41598-018-26219-5 PubMed PMID: 29773852.
      20. Staubitz JI, Watzka F, Poplawski A, Riss P, Clerici T, Bergenfelz A, et al. Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study. BJS Open. 2020 Oct 1;4(5):821-9. doi:10.1002/bjs5.50310 PubMed PMID: 32543773.
      21. Schneider R, Randolph GW, Dionigi G, Wu CW, Barczynski M, Chiang FY, et al. International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. Laryngoscope. John Wiley and Sons Inc.; 2018. p. S1-17. doi:10.1002/lary.27359 PubMed PMID: 30289983.
      22. Uludag M, Aygun N, Kartal K, Citgez B, Besler E, Yetkin G, et al. Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial. Langenbecks Arch Surg. 2017 Sep 1;402(6):965-76. doi:10.1007/s00423-016-1544-7 PubMed PMID: 28035477.
      23. de Ywata Carvalho A, Kohler HF, Gomes CC, Vartanian JG, Kowalski LP. Predictive factors of recurrence of papillary thyroid microcarcinomas: Analysis of 2,538 patients. Int Arch Otorhinolaryngol. 2021 Oct 29;25(4):E585-93. doi:10.1055/S-0040-1722253
      24. Nam SH, Roh JL, Gong G, Cho KJ, Choi SH, Nam SY, et al. Nodal Factors Predictive of Recurrence after Thyroidectomy and Neck Dissection for Papillary Thyroid Carcinoma. Thyroid. 2018 Jan 1;28(1):88-95. doi:10.1089/thy.2017.0334 PubMed PMID: 29117854.
      25. Heaton CM, Chang JL, Orloff LA. Prognostic implications of lymph node yield in central and lateral neck dissections for well-differentiated papillary thyroid carcinoma. In: Thyroid. Mary Ann Liebert Inc.; 2016. p. 434-40. doi:10.1089/thy.2015.0318 PubMed PMID: 26825749.
      26. Diker-Cohen T, Hirsch D, Shimon I, Bachar G, Akirov A, Duskin-Bitan H, et al. Impact of Minimal Extrathyroid Extension in Differentiated Thyroid Cancer: Systematic Review and Meta-Analysis. Journal of Clinical Endocrinology and Metabolism. 2018 Jun 1;103(6):2100-6. doi:10.1210/jc.2018-00081