Thyroid Nodules and Differentiated Thyroid Cancer Differentiated Cancer
Key Points
Key Points
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...
...reoperative neck US for cervical (cen...
...ed FNA of sonographically suspicious ly...
...tion of FNA-Tg washout in the evaluation...
...erative use of cross-sectional imaging st...
...Routine preoperative 18FDG-PET scanning is NO...
...reoperative measurement of serum T...
...Ultrasound Features of Lymph Nodes P...
...C 7th edition/TNM Classification System for Di...
Treatment
...atment...
...tients with thyroid cancer >4 cm or with gross ex...
...ents with thyroid cancer >1 cm and...
...C) If surgery is chosen for patien...
...erapeutic central-compartment (level VI) neck dis...
...phylactic central-compartment neck...
...C) Thyroidectomy without prophylact...
37. Therapeutic lateral neck compartmental ly...
...n thyroidectomy should be offered to...
...ioactive iodine ablation in lieu of complet...
...urgery, the surgeon should communicate with...
...l patients undergoing thyroid surgery should...
...ve voice abnormalities (SR, M)623...
...tory of cervical or upper chest surgery, wh...
...thyroid cancer with posterior extrath...
...l identification of the recurrent lary...
42. B) Intraoperative neural stimulation (wi...
...-operative Factors Which May Be Assoc...
...he parathyroid glands and their blood supply...
...Patients should have their voice assessed in the...
45. Important intraoperative findings a...
...ion to the basic tumor features requi...
...thologic variants of thyroid carcinoma a...
...6. C) Histopathologic variants associ...
...UICC staging is recommended for al...
...009 ATA Initial Risk Stratification System (Cooper...
...) Additional prognostic variables (such as the ex...
...C) While not routinely recommended for...
...est Response to Therapy...
DTC: Long-Term Management and Advanced Cancer Management
...Management and Advanced Cancer Management...
...linical Decision-making and Management Recom...
...ical Implications of Response To Therapy Re-Cl...
...tial recurrence risk estimates should be contin...
...Post-operative disease status (i.e. the pre...
...t-operative serum thyroglobulin (on t...
...The optimal cut-off value for post-operative s...
...D) Post-operative diagnostic radioiodine w...
...linical Decision-making and Management Recomm...
...nant ablation is not routinely recommended after t...
...I remnant ablation is not routinely recomm...
...I remnant ablation is not routinely recommende...
...adjuvant therapy should be considered af...
...uvant therapy is routinely recommended...
...e role of molecular testing in guiding...
...If thyroid hormone withdrawal is plan...
...oal TSH of >30 mIU/L has been generally a...
...3. Clinical Decision-making and Mana...
...aracteristics According to the ATA Risk Stratific...
...re 4. Clinical Decision-making and Managemen...
...A) In patients with ATA low risk and ATA...
...nts with ATA intermediate risk DTC who have exten...
...n patients with ATA high risk DTC wi...
...4. D) In patients with DTC of any risk level w...
...active iodine remnant ablation is perfor...
...Higher administered activities may need to be co...
...onse to Therapy Re-ClassificationHaving...
...is intended for initial adjuvant therapy...
...A low-iodine diet for approximately 1–2 weeks sh...
...py whole-body scan (with or without s...
...risk thyroid cancer patients, initial TSH su...
...termediate-risk thyroid cancer patients, initia...
...ow risk patients who have undergone r...
...isk patients who have undergone remnant ablation...
...r low risk patients who have undergone...
...s no role for routine adjuvant external b...
...is no role for routine systemic adjuvant...
.... A) Serum thyroglobulin should be meas...
...itial follow-up, serum Tg on thyroxine thera...
.... C) In ATA low and intermediate risk patients...
...TSH should be measured at least every 12 months in...
...E) ATA high risk patients (regardless of respons...
...A low-risk and intermediate-risk patient...
...SH stimulated Tg testing is not recommend...
...uent TSH stimulated Tg testing may be consider...
64. Periodic serum Tg measurements on thyroid horm...
...g surgery, cervical US to evaluate...
...positive result would change management, ult...
...5. C) Suspicious lymp...
65. D) Low-risk patients who have had remna...
...After the first post-treatment WBS per...
...nostic WBS, either following thyroid hormon...
...) SPECT-CT radioiodine imaging is preferre...
...A) FDG-PET scanning should be considered...
.... B) 18FDG-PET scanning may also be consider...
...ss-sectional imaging of the neck a...
...ing of the chest without intravenous con...
...) Imaging of other organs including...
...H Targets for Long-term Thyroid Hormone Therapy...
...0. A) In patients with a structural or...
70. B) In patients with a biochemica...
...C) In patients with an excellent (clinical...
...ents with an excellent (clinically and bi...
...E) In patients who have not undergone remnan...
...eutic compartmental central and/or lateral ne...
...hnically feasible, surgery for aerodigestive i...
...ugh there are theoretical advantages to dosimet...
...pirically administered amounts of 1...
...currently insufficient outcome data to recommen...
...ombinant human TSH–mediated therapy may be...
...re are no outcome data that demonstrate a be...
77. A) Pulmonary micrometastases shoul...
...election of RAI activity to administer for pulmona...
...8. Radioiodine-avid macronodular me...
...apy of iodine-avid bone metastases has be...
...B) The RAI activity administered can be...
...ce of structurally evident disease...
...iric (100–200 mCi) or dosimetrically-determi...
...ent nonresectable disease is localized af...
.... The evidence is insufficient to re...
...4. Patients with xerostomia are at...
.... Surgical correction should be cons...
...Although patients should be counseled on the...
...ents receiving therapeutic doses of RA...
...n of childbearing age receiving RAI therapy sho...
...oactive iodine should not be given to nursing...
...eiving cumulative radioiodine activit...
...dioiodine-refractory structurally-evident DTC is...
...Patients with I refractory metastatic 131DTC...
...r other mutational testing is not routinely reco...
...3. A) Both stereotactic radiation an...
...otactic radiation or thermal ablation shou...
...hile surgical resection and stereotac...
...s should be considered for referral...
...inhibitor therapy should be considered...
...Patients who are candidates for kin...
97. Patients who have disease progression wh...
.... Active surveillance: Proactive monitorin...
...s without established efficacy in D...
...otoxic chemotherapy can be conside...
...sphosphonate or denosumab therapy sh...
...to Review When Considering Kinase Inh...
...able 10. Potential Toxicities and Re...