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

...iated Thyroid Cancer...

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


...FNA of sonographically suspicious lymph nodes >8â...


...he addition of FNA-Tg washout in the evaluat...


...Preoperative use of cross-sectional...


...Routine preoperative 18FDG-PET scanning is...


34. Routine preoperative measurement of serum Tg...


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


...able 2. AJCC 7th edition/TNM Classi...


Treatment

...reatme...

...) For patients with thyroid cancer >4 cm or with g...


...B) For patients with thyroid cancer >1...


...) If surgery is chosen for patients with thyroid...


.... A) Therapeutic central-compartment (...


...ophylactic central-compartment neck dissection...


...) Thyroidectomy without prophylactic centra...


...eutic lateral neck compartmental lymph node d...


...tion thyroidectomy should be offered...


...ve iodine ablation in lieu of complet...


...to surgery, the surgeon should communicate wi...


...All patients undergoing thyroid surgery should...


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

...cervical or upper chest surgery,...

...wn thyroid cancer with posterior ex...


...entification of the recurrent laryngeal nerve (RLN...


...perative neural stimulation (with or wi...


...ble 3. Pre-operative Factors Which May Be Assoc...


.... The parathyroid glands and their blo...


...tients should have their voice assessed in the...


...portant intraoperative findings and detai...


...ition to the basic tumor features required for A...


...ologic variants of thyroid carcinoma...


...pathologic variants associated with fami...


...JCC/UICC staging is recommended for all p...


...ATA Initial Risk Stratification System (Cooper DS...


...dditional prognostic variables (such...


...not routinely recommended for initial post-o...


...esponse to Therapy Excell...


DTC: Long-Term Management and Advanced Cancer Management

...g-Term Management and Advanced Cancer Management...

...inical Decision-making and Management Recommenda...


.... Clinical Implications of Response...


...9. Initial recurrence risk estimates should be con...


...A) Post-operative disease status (i...


...Post-operative serum thyroglobulin...


...e optimal cut-off value for post-operative serum...


...Post-operative diagnostic radioiodine w...


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


...nant ablation is not routinely recommended aft...


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


...remnant ablation is not routinely recommende...


...AI adjuvant therapy should be cons...


...I adjuvant therapy is routinely recommen...


...The role of molecular testing in guiding post-o...


...If thyroid hormone withdrawal is planned...


...SH of >30 mIU/L has been generally adopt...


...Clinical Decision-making and Manag...


...cteristics According to the ATA Risk Stratif...


...igure 4. Clinical Decision-making and M...


...4. A) In patients with ATA low risk and ATA int...


...n patients with ATA intermediate risk DTC...


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


...n patients with DTC of any risk level with...


55. A) If radioactive iodine remnant a...


...gher administered activities may need to be...


...ponse to Therapy Re-ClassificationHaving trouble...


...s intended for initial adjuvant therapy to treat...


...low-iodine diet for approximately 1...


...A post-therapy whole-body scan (with or without...


...-risk thyroid cancer patients, initial TSH supp...


...B) For intermediate-risk thyroid can...


...C) For low risk patients who have und...


...risk patients who have undergone remnant...


...w risk patients who have undergone...


...is no role for routine adjuvant exte...


61. There is no role for routine systemic adju...


62. A) Serum thyroglobulin should be measured b...


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


...A low and intermediate risk patients that...


...erum TSH should be measured at least...


...igh risk patients (regardless of response to...


...low-risk and intermediate-risk patients w...


...SH stimulated Tg testing is not recommended for...


...Subsequent TSH stimulated Tg testing may b...


...serum Tg measurements on thyroid hormone therapy...


...) Following surgery, cervical US to e...


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


...Suspicious lymph nodes...


...Low-risk patients who have had remnant abl...


...rst post-treatment WBS performed following R...


...ostic WBS, either following thyroid hormon...


...radioiodine imaging is preferred over planar...


...scanning should be considered in high risk 18D...


68. B) 18FDG-PET scanning may also be co...


...ctional imaging of the neck and upper ch...


...maging of the chest without intrave...


...Imaging of other organs including MRI brain...


...TSH Targets for Long-term Thyroid Hormone The...


...0. A) In patients with a structural or biochemic...


...ents with a biochemical incomplete res...


...In patients with an excellent (clinically and...


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


...In patients who have not undergone rem...


...apeutic compartmental central and/...


72. When technically feasible, surgery for...


...) Although there are theoretical advant...


...lly administered amounts of 131I exceeding...


...There are currently insufficient outcome...


...Recombinant human TSH–mediated therapy may be in...


...there are no outcome data that dem...


...monary micrometastases should be trea...


...7. B) The selection of RAI activity t...


...oiodine-avid macronodular metastase...


...RAI therapy of iodine-avid bone metastas...


...I activity administered can be given empirica...


...the absence of structurally evident dise...


...c (100–200 mCi) or dosimetrically-determined ra...


...ent nonresectable disease is localized after a...


...he evidence is insufficient to rec...


...Patients with xerostomia are at in...


...l correction should be considered for n...


...Although patients should be counseled...


...Patients receiving therapeutic doses...


...en of childbearing age receiving RAI t...


...Radioactive iodine should not be given...


...eiving cumulative radioiodine activities...


...-refractory structurally-evident DTC...


...nts with I refractory metastatic 131DTC that is...


...BRAF or other mutational testing is not routinel...


...reotactic radiation and thermal ablation (RFA...


...actic radiation or thermal ablation sh...


...al resection and stereotactic externa...


...nts should be considered for referral to...


...ase inhibitor therapy should be considered...


...s who are candidates for kinase inhibitor ther...


...7. Patients who have disease progression while on...


...e surveillance: Proactive monitoring and timel...


99. Agents without established efficacy in DT...


...ic chemotherapy can be considered i...


...Bisphosphonate or denosumab therapy should be...


...rs to Review When Considering Kinase Inhibitor Th...


...otential Toxicities and Recommended S...