Interpretation of the 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer: perioperative assessment and management of parathyroid function and precision individualized management of postoperative TSH suppression in adults with differentiated thyroid cancer

doi:10.19401/j.cnki.1007-3639.2025.09.004

Abstract

Abstract:

In recent years, the incidence of differentiated thyroid cancer (DTC) continues to rise, with increasing attention to perioperative management and postoperative thyroid-stimulating hormone (TSH) suppression therapy strategies. The American Thyroid Association (ATA) released the “2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer” in 2025, which include significant updates on perioperative parathyroid function protection and TSH suppression therapy. In terms of perioperative management, the 2025 ATA guidelines recommend intraoperative application of novel methods to identify and protect the parathyroid glands, and adoption of parathyroid hormone (PTH)-guided calcium and vitamin D supplementation protocols following total thyroidectomy. Regarding TSH suppression therapy, the 2025 ATA guidelines eliminate specific TSH target value recommendations for initial treatment, emphasizing that TSH targets should be dynamically adjusted based on patients’ initial recurrence risk and treatment response to achieve individualized management and avoid overtreatment.

Key words: Differentiated thyroid cancer, Perioperative period, Parathyroid function, Thyroid-stimulating hormone suppression, Individualized management

CLC Number:

R736.1

WU Yiming, FENG Chuyao, GAO Ying, WU Xiaohong. Interpretation of the 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer: perioperative assessment and management of parathyroid function and precision individualized management of postoperative TSH suppression in adults with differentiated thyroid cancer[J]. China Oncology, 2025, 35(9): 841-849.

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References 38

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Clinical study	Case, N	Follow-up/year	Main result	Benefit or not
Hovens, 2007^[22]	366	8.85	There is a positive correlation between serum TSH levels and the risk of recurrence and cancer-related mortality. A TSH level exceeding 2 mU/L significantly increases the risk of tumor progression, recurrence, and death	Yes
Pujol, 1996^[23]	141	7.9	Patients with sustained TSH suppression (≤0.05 mU/L) exhibit significantly longer recurrence-free survival compared to those with consistently elevated TSH (≥1 mU/L). Moreover, the degree of TSH suppression is an independent predictor of recurrence in multivariate analysis	Yes
McGriff, 2002^[24]	4 147	4.5-19.5	TSH suppression (maintaining TSH <0.4-0.5 mU/L) significantly reduces the incidence of major adverse clinical events, including disease progression, recurrence, or death	Yes
Carhill, 2015^[25]	3 238	6	Moderate TSH suppression (below the normal range) improves overall survival and disease-free survival across all disease stages. However, further suppression to undetectable levels does not provide additional clinical benefits	Yes
Diessl, 2012^[26]	157	8	Compared to the non-suppressed group, patients with a median TSH level ≤0.1 mU/L show significantly longer thyroid cancer-specific survival. Nonetheless, further suppression to <0.03 mU/L yields no additional survival advantage over ≤0.1 mU/L	Yes
Klubo, 2019^[27]	867	7.2	TSH suppression therapy did not improve 5-year progression-free survival in certain patient cohorts	Not
Tian, 2019^[28]	166	5-9	In intermediate- to high-risk DTC patients with pre-ablation Tg<1 ng/mL, no significant difference in tumor recurrence was observed across TSH groups (<0.1, 0.1-0.5, 0.5-2.0 or >2.0 mU/L)	Not

Clinical study	Case, N	Follow-up/year	Main result	Benefit or not
Sugitani, 2010^[29]	433	7	No significant difference in disease-free survival was observed between the group with TSH suppressed to <0.01 mU/L and the group maintaining TSH within the normal range of 0.4-5.0 mU/L	Not
Lee, 2019^[30]	1 528	5.6	In low-risk patients who underwent lobectomy, the recurrence rate was only 1.4% during a median follow-up of 5.6 years. Furthermore, no statistically significant difference in recurrence rate was found among groups with different TSH levels (<0.5, 0.5-1.9, 2.0-4.4 or >4.5 mU/L)	Not
Xu, 2021^[31]	2 297	5.8	The study cohort consisted of 41.2% low-risk, 42.4% intermediate-risk, and 16.4% high-risk patients. The results indicated that for the entire patient population, the median TSH level was not associated with the risk of recurrence. However, in the intermediate- to high-risk subgroup, recurrence-free survival was significantly higher when the median TSH was controlled between 0.6-2.0 mU/L compared to levels >4.0 mU/L	Partial benefit in a subgroup
Gubbi, 2024^[32]	3 591	5	For intermediate- and high-risk DTC patients, no significant differences were found in progression-free survival, disease-free survival, or recurrence-free survival between the TSH-suppressed group and the non-suppressed group. Moreover, TSH suppression may increase the risk of secondary complications	Not
Park, 2018^[33]	1 047	8.9	The structural recurrence rate after lobectomy for low- to intermediate-risk PTC was 4.0%. The serum TSH level at 1 year post-operation was an independent risk factor for recurrence, with patients having TSH>1.85 mU/L demonstrating a significantly higher recurrence rate	Yes

Clinical study	Case, N	Follow-up/year	Main result	Benefit or not
Sugitani, 2014^[35]	322	6.5	No significant correlation was observed between the mean TSH level and tumor growth	Not
Kim, 2022^[36]	234	55.6	When using the time-weighted average (TW)-TSH, a high TW-TSH was found to be closely associated with PTMC progression. Specifically, for patients under 50 years of age, a TW-TSH level >1.74 mU/L was identified as an independent risk factor for disease progression	Yes
Lee, 2023^[37]	699	4	A baseline serum TSH level ≥7 mU/mL may predict tumor progression	Yes
Yamamoto, 2023^[38]	2 509	10	Patients receiving LT4 treatment showed a significantly reduced tumor volume doubling rate, suggesting that TSH suppression may delay the growth of PTMC	Yes

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