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
...tiated Thyroid Cancer...
...Preoperative neck US for cervical (c...
...2. B) US-guided FNA of sonographically suspicious...
...ddition of FNA-Tg washout in the evaluation of...
...Preoperative use of cross-sectional imaging st...
...ine preoperative 18FDG-PET scanning is...
...e preoperative measurement of serum...
...1. Ultrasound Features of Lymph Nodes Predic...
...JCC 7th edition/TNM Classification Syst...
Treatment
...eatment
...r patients with thyroid cancer >4 cm or with gro...
35. B) For patients with thyroid cancer...
...urgery is chosen for patients with thyroid ca...
...utic central-compartment (level VI) neck dis...
...ylactic central-compartment neck dissection (...
...Thyroidectomy without prophylactic cent...
...Therapeutic lateral neck compartment...
...Completion thyroidectomy should be offered to t...
...ive iodine ablation in lieu of completion...
...rgery, the surgeon should communicate w...
40. All patients undergoing thyroid surger...
...rative voice abnormalities (SR, M)623...
...ry of cervical or upper chest surg...
...roid cancer with posterior extrathyroidal extensio...
.... A) Visual identification of the recurrent laryn...
...ntraoperative neural stimulation (with or wi...
...3. Pre-operative Factors Which May Be Associated W...
...parathyroid glands and their blood sup...
...ts should have their voice assessed in the...
...traoperative findings and details o...
.... A) In addition to the basic tumor features requ...
...stopathologic variants of thyroid carcinoma as...
...C) Histopathologic variants associated with f...
.../UICC staging is recommended for all pat...
...ATA Initial Risk Stratification System (...
...B) Additional prognostic variables (such as the e...
...hile not routinely recommended for...
...esponse to Therapy Excell...
DTC: Long-Term Management and Advanced Cancer Management
DTC: Long-Term Management and Advanced Cancer M...
...Clinical Decision-making and Management Recommen...
...Clinical Implications of Response To Ther...
...ecurrence risk estimates should be con...
...operative disease status (i.e. the presenc...
...B) Post-operative serum thyroglobulin (on t...
...optimal cut-off value for post-operativ...
...ost-operative diagnostic radioiodine...
...igure 2. Clinical Decision-making and Management R...
...emnant ablation is not routinely rec...
...RAI remnant ablation is not routinel...
...I remnant ablation is not routinely...
...uvant therapy should be considered after...
...djuvant therapy is routinely recommended after to...
...of molecular testing in guiding post-oper...
...) If thyroid hormone withdrawal is plan...
...goal TSH of >30 mIU/L has been generally a...
...cal Decision-making and Management Recomm...
...aracteristics According to the ATA Risk Stratific...
...al Decision-making and Management Recommendat...
...n patients with ATA low risk and ATA i...
...patients with ATA intermediate risk DTC wh...
...C) In patients with ATA high risk...
...In patients with DTC of any risk level with s...
...radioactive iodine remnant ablation is perform...
55. B) Higher administered activities may need...
...le 7. Response to Therapy Re-ClassificationHaving...
56. When RAI is intended for initial adjuvant...
...A low-iodine diet for approximately 1–2...
...ost-therapy whole-body scan (with or without s...
59. A) For high-risk thyroid cancer p...
...or intermediate-risk thyroid cancer patient...
...C) For low risk patients who have undergone re...
...5. D) For low risk patients who have underg...
...ow risk patients who have undergone lobectomy, TSH...
...is no role for routine adjuvant external bea...
...1. There is no role for routine syst...
...thyroglobulin should be measured by...
...) During initial follow-up, serum Tg on thyrox...
...In ATA low and intermediate risk patients that ach...
...TSH should be measured at least every 12 mont...
...gh risk patients (regardless of respons...
...In ATA low-risk and intermediate-risk patients wh...
...B) Repeat TSH stimulated Tg testing is not recomme...
...C) Subsequent TSH stimulated Tg testing may be con...
64. Periodic serum Tg measurements on thyroid...
...surgery, cervical US to evaluate the thy...
...5. B) If a positive result would change managem...
...picious lymph nodes...
...) Low-risk patients who have had remnant a...
...After the first post-treatment WBS performed f...
...A) Diagnostic WBS, either following thy...
...B) SPECT-CT radioiodine imaging is...
...PET scanning should be considered in high risk 18D...
...scanning may also be considered a) a...
...A) Cross-sectional imaging of the neck...
...aging of the chest without intravenous cont...
...) Imaging of other organs including MRI brain, MR...
...e 8. TSH Targets for Long-term Thyroid Hormone T...
70. A) In patients with a structural or bioc...
...ents with a biochemical incomplete response to the...
...patients with an excellent (clinically...
...0. D) In patients with an excellent...
...In patients who have not undergone remnant ab...
...peutic compartmental central and/or lateral neck...
...nically feasible, surgery for aerodigestive invas...
...hough there are theoretical advantage...
...3. B) Empirically administered amoun...
...currently insufficient outcome data...
...human TSH–mediated therapy may be indicated i...
...nce there are no outcome data that demonstr...
...micrometastases should be treated wit...
77. B) The selection of RAI activity to a...
78. Radioiodine-avid macronodular met...
...A) RAI therapy of iodine-avid bone metastases has...
...activity administered can be given empiricall...
...the absence of structurally evident dise...
...–200 mCi) or dosimetrically-determined radio...
...If persistent nonresectable disease is localize...
...e is insufficient to recommend for or against t...
...ith xerostomia are at increased risk of dental ca...
...rgical correction should be considered for...
...Although patients should be counseled o...
...7. Patients receiving therapeutic doses of RAI sh...
...ldbearing age receiving RAI therapy shoul...
89. Radioactive iodine should not be given to...
.... Men receiving cumulative radioiodine activiti...
...odine-refractory structurally-evident...
...A) Patients with I refractory metastatic...
...RAF or other mutational testing is...
...eotactic radiation and thermal ablation (RFA...
...ctic radiation or thermal ablation should...
...surgical resection and stereotactic external beam...
...should be considered for referral to participate...
...se inhibitor therapy should be considered in R...
...Patients who are candidates for kinase...
...o have disease progression while on in...
...Active surveillance: Proactive monito...
.... Agents without established effica...
...totoxic chemotherapy can be considered in RA...
...hosphonate or denosumab therapy should...
...rs to Review When Considering Kinase Inhibito...
...10. Potential Toxicities and Recomme...