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
...rentiated Thyroid Cancer
...ive neck US for cervical (central and especiall...
.... B) US-guided FNA of sonographica...
...ition of FNA-Tg washout in the evaluation of susp...
...reoperative use of cross-sectional imaging studie...
...ine preoperative 18FDG-PET scanning i...
.... Routine preoperative measurement...
...ltrasound Features of Lymph Nodes P...
...7th edition/TNM Classification System for Di...
Treatment
...eatmen...
...ients with thyroid cancer >4 cm or w...
35. B) For patients with thyroid cancer...
...ry is chosen for patients with thyroid...
...eutic central-compartment (level VI...
...phylactic central-compartment neck dissecti...
...C) Thyroidectomy without prophylact...
...lateral neck compartmental lymph node dissection...
...A) Completion thyroidectomy should be...
...ioactive iodine ablation in lieu of completion t...
...o surgery, the surgeon should communicat...
...s undergoing thyroid surgery should ha...
...rative voice abnormalities (SR,...
...y of cervical or upper chest surgery...
...id cancer with posterior extrathyroida...
...Visual identification of the recurrent lary...
...aoperative neural stimulation (with or witho...
...perative Factors Which May Be Associated With...
...e parathyroid glands and their blood sup...
...should have their voice assessed in the post...
...tant intraoperative findings and details o...
...6. A) In addition to the basic tumor feat...
...opathologic variants of thyroid carcinoma...
...istopathologic variants associated wit...
...ICC staging is recommended for all patients with...
...8. A) The 2009 ATA Initial Risk Stratifi...
...l prognostic variables (such as the ex...
48. C) While not routinely recommended fo...
...esponse to Therapy Excelle...
DTC: Long-Term Management and Advanced Cancer Management
...: Long-Term Management and Advanced Cancer Manag...
...gure 1. Clinical Decision-making and Man...
...5. Clinical Implications of Response To Th...
...urrence risk estimates should be cont...
...Post-operative disease status (i.e. th...
...rative serum thyroglobulin (on thy...
...ptimal cut-off value for post-operative ser...
...erative diagnostic radioiodine whol...
...gure 2. Clinical Decision-making and Mana...
...nant ablation is not routinely recomm...
.... B) RAI remnant ablation is not routine...
...I remnant ablation is not routinely recommende...
...I adjuvant therapy should be considered a...
...juvant therapy is routinely recommended a...
...ole of molecular testing in guiding post-...
...hyroid hormone withdrawal is planne...
...SH of >30 mIU/L has been generally adopted in...
...nical Decision-making and Managemen...
...aracteristics According to the ATA Risk S...
...inical Decision-making and Managemen...
...patients with ATA low risk and ATA i...
.... B) In patients with ATA intermedia...
...4. C) In patients with ATA high ri...
...ients with DTC of any risk level with...
...oactive iodine remnant ablation is performed after...
...administered activities may need to be c...
...se to Therapy Re-ClassificationHaving tro...
...RAI is intended for initial adjuvant t...
57. A low-iodine diet for approximately 1–2 week...
...A post-therapy whole-body scan (with o...
...or high-risk thyroid cancer patients, ini...
...B) For intermediate-risk thyroid cancer p...
...5. C) For low risk patients who have undergone...
...) For low risk patients who have undergone remnant...
...ow risk patients who have undergone lobect...
...re is no role for routine adjuvant external beam...
...role for routine systemic adjuvan...
...yroglobulin should be measured by an assay t...
...initial follow-up, serum Tg on thyroxi...
...ATA low and intermediate risk patients t...
...rum TSH should be measured at least every 12...
...risk patients (regardless of response...
...w-risk and intermediate-risk patients who...
...H stimulated Tg testing is not recommended for...
...3. C) Subsequent TSH stimulated Tg te...
...4. Periodic serum Tg measurements on thyroid h...
...llowing surgery, cervical US to evaluat...
...positive result would change managemen...
...uspicious lymph nodes...
...isk patients who have had remnant ablat...
...r the first post-treatment WBS performe...
...nostic WBS, either following thyroid...
...radioiodine imaging is preferred over planar ima...
...scanning should be considered in high risk 18DT...
...) 18FDG-PET scanning may also be considered...
...ross-sectional imaging of the neck and upper che...
69. B) CT imaging of the chest without intrave...
...C) Imaging of other organs including...
...rgets for Long-term Thyroid Hormone Therapy...
...tients with a structural or biochemical incompl...
...atients with a biochemical incomplete respons...
...C) In patients with an excellent (clinically and...
...tients with an excellent (clinically and...
...tients who have not undergone remnant ablat...
...c compartmental central and/or lateral neck...
...technically feasible, surgery for...
...3. A) Although there are theoretical advantages...
...pirically administered amounts of 1...
...re are currently insufficient outcome...
...Recombinant human TSH–mediated therapy...
...ce there are no outcome data that demonst...
...Pulmonary micrometastases should be treat...
...) The selection of RAI activity to administer f...
.... Radioiodine-avid macronodular metastases may be...
...py of iodine-avid bone metastases has been...
...activity administered can be given empirical...
...he absence of structurally evident dis...
...iric (100–200 mCi) or dosimetrically-deter...
82. If persistent nonresectable disease is loca...
...e evidence is insufficient to recommend...
...with xerostomia are at increased risk...
...rgical correction should be consider...
...though patients should be counseled o...
...ients receiving therapeutic doses...
...men of childbearing age receiving RAI therapy shou...
...active iodine should not be given to nursi...
...eiving cumulative radioiodine activities >400...
...-refractory structurally-evident DTC is...
...nts with I refractory metastatic 131DTC t...
...B) BRAF or other mutational testing is not rout...
...stereotactic radiation and thermal ablation...
...ctic radiation or thermal ablation should be c...
.... While surgical resection and stereotact...
.... Patients should be considered for...
...inhibitor therapy should be considered in...
...ts who are candidates for kinase inhib...
.... Patients who have disease progression while on...
.... Active surveillance: Proactive monitoring and...
99. Agents without established effic...
...toxic chemotherapy can be consider...
...01. Bisphosphonate or denosumab therapy sh...
...Factors to Review When Considering Kinase I...
...0. Potential Toxicities and Recommended Scre...