Thyroid Nodules and Differentiated Thyroid Cancer Differentiated Cancer

Publication Date: January 12, 2016

Key Points

Key Points

Differentiated thyroid cancer (DTC), which includes papillary and follicular cancer, comprises the vast majority (90%) of all thyroid cancers.

Preoperative neck US is recommended for all patients undergoing thyroid surgery for malignant or suspicious FNA cytology or molecular findings (recommendation 32)

Preoperative cross-sectional imaging (CT or MRI) is recommended for patients with clinical suspicion of advanced disease (recommendation 33)

Patients with thyroid cancer that is 1-4 cm and no preoperative evidence of clinically apparent lymph nodes or extrathyroidal extension can be treated with thyroidectomy or lobectomy (recommendation 35)

Perioperative voice assessment is important in management of patients with DTC (recommendations 39-45)

For uniform reporting and appropriate risk assessment, pathology reports should include TNM status, unfavorable or favorable histopathologic variants, assessment of vascular invasion, number of LN examined and involved as well as size of largest involved LN and assessment of extranodal invasion (recommendation 46)

The ATA Initial Risk Stratification System is recommended for patients with DTC (recommendation 48)

ATA defined response to therapy should be continually assessed to determine the ongoing risk of recurrence (recommendations 49, 62 and 63)

Radioiodine (RAI) should be considered as remnant ablation, adjuvant therapy or therapy, and many patients with low risk disease do not require RAI remnant ablation (recommendation 51)

In patients with low and intermediate risk DTC, preparation for RAI ablation or adjuvant therapy with rhTSH is an acceptable alternative to thyroid hormone withdrawal (recommendation 54)

Lower administered RAI activities (approximately 30 mCi) are generally favored for patients with ATA low risk and intermediate risk disease with lower risk features (recommendation 55)

Monitoring approaches and TSH targets should be modified by the ATA response to therapy re-classification (recommendations 62-70)

RAI-refractory DTC is classified (recommendation 91)

Patients with RAI-refractory DTC should be carefully evaluated for ongoing monitoring (on TSH-suppressive thyroid hormone therapy), directed therapy (including surgery, radiation or thermal ablation), approved systemic therapy or entry into a clinical trial (recommendations 92-96)

Patients considered for kinase inhibitor therapy should be carefully counseled on the benefits and risks of therapy and carefully monitored during therapy (recommendations 96-98)

Differentiated Thyroid Cancer

...rentiated Thyroid Cancer...

.... A) Preoperative neck US for cervical (central...


32. B) US-guided FNA of sonographic...


...addition of FNA-Tg washout in the evaluation of su...


...operative use of cross-sectional imaging st...


...preoperative 18FDG-PET scanning is NOT recomm...


...Routine preoperative measurement o...


...und Features of Lymph Nodes Predictive of...


...le 2. AJCC 7th edition/TNM Classification Syste...


Treatment

Treatm...

...r patients with thyroid cancer >4 cm or...


...For patients with thyroid cancer >...


...f surgery is chosen for patients w...


...) Therapeutic central-compartment...


...Prophylactic central-compartment ne...


...tomy without prophylactic central neck dissecti...


...lateral neck compartmental lymph node dissection s...


...n thyroidectomy should be offered...


38. B) Radioactive iodine ablation...


...surgery, the surgeon should communicate with...


...ents undergoing thyroid surgery sh...


...ative voice abnormalities (SR, M)6...

...of cervical or upper chest surgery, which places...

...) Known thyroid cancer with posterior extrathyroid...


...dentification of the recurrent laryngeal nerv...


...ntraoperative neural stimulation (with or...


.... Pre-operative Factors Which May Be...


.... The parathyroid glands and their blood supply...


...should have their voice assessed in th...


...intraoperative findings and details of po...


.... A) In addition to the basic tumor features...


...stopathologic variants of thyroid carcinoma ass...


...opathologic variants associated with famili...


47. AJCC/UICC staging is recommended f...


...) The 2009 ATA Initial Risk Stratificat...


...ditional prognostic variables (such a...


...le not routinely recommended for in...


...t Response to Therapy Excellent...


DTC: Long-Term Management and Advanced Cancer Management

...rm Management and Advanced Cancer Ma...

...Clinical Decision-making and Management R...


...inical Implications of Response To...


49. Initial recurrence risk estimate...


50. A) Post-operative disease status (i.e. the...


...B) Post-operative serum thyroglobulin...


50. C) The optimal cut-off value for post-op...


...) Post-operative diagnostic radioiod...


...Clinical Decision-making and Manageme...


...ant ablation is not routinely recommende...


.... B) RAI remnant ablation is not routinely...


...emnant ablation is not routinely rec...


...vant therapy should be considered after...


...E) RAI adjuvant therapy is routinely recommended a...


...f molecular testing in guiding post-operativ...


...If thyroid hormone withdrawal is planned prior t...


...) A goal TSH of >30 mIU/L has been generally...


...e 3. Clinical Decision-making and...


...aracteristics According to the ATA R...


...al Decision-making and Management Recommendations...


...In patients with ATA low risk and ATA inte...


...patients with ATA intermediate risk DTC who ha...


...In patients with ATA high risk DTC with attendant...


...nts with DTC of any risk level with signif...


...) If radioactive iodine remnant abla...


...ministered activities may need to be conside...


...e 7. Response to Therapy Re-Classi...


...intended for initial adjuvant therapy to...


...low-iodine diet for approximately 1–2 weeks sho...


...t-therapy whole-body scan (with or without s...


59. A) For high-risk thyroid cancer pati...


...or intermediate-risk thyroid cancer patients, init...


...isk patients who have undergone remnant...


.... D) For low risk patients who have un...


...low risk patients who have undergon...


...0. There is no role for routine adjuv...


...There is no role for routine systemic adjuvan...


...yroglobulin should be measured by an ass...


...2. B) During initial follow-up, serum Tg on...


...n ATA low and intermediate risk patien...


...Serum TSH should be measured at leas...


...E) ATA high risk patients (regardless of respon...


...A) In ATA low-risk and intermediate-risk patien...


...at TSH stimulated Tg testing is not reco...


...ubsequent TSH stimulated Tg testing may be...


...ic serum Tg measurements on thyroid hormo...


...ing surgery, cervical US to evaluate the thy...


...B) If a positive result would change manage...


...Suspicious lymph nodes...


...sk patients who have had remnant abla...


...the first post-treatment WBS performed fol...


...gnostic WBS, either following thyroid hormone wi...


...7. B) SPECT-CT radioiodine imaging is...


...A) FDG-PET scanning should be considered i...


...) 18FDG-PET scanning may also be consi...


.... A) Cross-sectional imaging of the n...


...maging of the chest without intravenous...


...g of other organs including MRI brain,...


...e 8. TSH Targets for Long-term Thyroid Horm...


...In patients with a structural or bio...


...ients with a biochemical incomplete response to...


...nts with an excellent (clinically and...


.... D) In patients with an excellent (clinically...


...n patients who have not undergone re...


71. Therapeutic compartmental central and...


72. When technically feasible, surgery for...


...ough there are theoretical advantages...


73. B) Empirically administered amounts...


...rrently insufficient outcome data to recomm...


...ant human TSH–mediated therapy may be indicated...


...here are no outcome data that demonstrate a bet...


...ry micrometastases should be treated with...


...ction of RAI activity to administe...


...-avid macronodular metastases may be treat...


...herapy of iodine-avid bone metastases has bee...


...he RAI activity administered can b...


...the absence of structurally evident di...


...–200 mCi) or dosimetrically-determined radi...


...persistent nonresectable disease i...


...The evidence is insufficient to recomme...


...Patients with xerostomia are at increased risk...


...Surgical correction should be considered f...


...patients should be counseled on the ri...


...Patients receiving therapeutic doses of...


...men of childbearing age receiving RAI therapy...


...Radioactive iodine should not be given to nu...


...0. Men receiving cumulative radioiodine activi...


...e-refractory structurally-evident DTC is defined...


...with I refractory metastatic 131DTC tha...


...) BRAF or other mutational testing...


...th stereotactic radiation and thermal abl...


...ereotactic radiation or thermal ablation shoul...


...hile surgical resection and stereotactic ex...


...should be considered for referral t...


...A) Kinase inhibitor therapy should be considere...


...Patients who are candidates for kinase...


...tients who have disease progression while on...


...Active surveillance: Proactive monitoring...


...nts without established efficacy in DTC sho...


...Cytotoxic chemotherapy can be cons...


...onate or denosumab therapy should be con...


...ors to Review When Considering Kinase Inhibitor...


...10. Potential Toxicities and Reco...