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
...Differentiated T...
...operative neck US for cervical (ce...
...ided FNA of sonographically suspicious lymph nodes...
...C) The addition of FNA-Tg washout in t...
...ative use of cross-sectional imagi...
...utine preoperative 18FDG-PET scanning is...
...operative measurement of serum Tg or Tg...
...1. Ultrasound Features of Lymph Node...
...ble 2. AJCC 7th edition/TNM Classific...
Treatment
...Trea...
...patients with thyroid cancer >4 cm...
...For patients with thyroid cancer >1 cm and...
...surgery is chosen for patients with thyr...
...apeutic central-compartment (level...
...phylactic central-compartment neck diss...
...Thyroidectomy without prophylactic central...
...lateral neck compartmental lymph node...
...pletion thyroidectomy should be offered to th...
...tive iodine ablation in lieu of completion thyroid...
...r to surgery, the surgeon should commun...
...All patients undergoing thyroid surgery should...
...rative voice abnormalities (SR, M)62...
...cervical or upper chest surgery, which places the...
C) Known thyroid cancer with posterior ex...
...entification of the recurrent laryngeal ner...
...Intraoperative neural stimulation (with or...
...Pre-operative Factors Which May Be Assoc...
...athyroid glands and their blood supply...
...atients should have their voice assessed in the po...
...mportant intraoperative findings and details...
...In addition to the basic tumor feature...
...Histopathologic variants of thyroid c...
...C) Histopathologic variants associated...
...AJCC/UICC staging is recommended for all p...
...2009 ATA Initial Risk Stratificat...
.... B) Additional prognostic variables (such as th...
...e not routinely recommended for initial post-ope...
...Response to Therapy...
DTC: Long-Term Management and Advanced Cancer Management
...DTC: Long-Te...
...re 1. Clinical Decision-making and Managem...
Table 5. Clinical Implications of Response T...
...ial recurrence risk estimates should...
...Post-operative disease status (i.e....
...erative serum thyroglobulin (on thyroid h...
...imal cut-off value for post-operative serum t...
...st-operative diagnostic radioiodine whole-body...
...ure 2. Clinical Decision-making and Managem...
...mnant ablation is not routinely recommended afte...
...B) RAI remnant ablation is not routinely reco...
...remnant ablation is not routinely recommended af...
.... D) RAI adjuvant therapy should be cons...
...1. E) RAI adjuvant therapy is routine...
...The role of molecular testing in guiding post-op...
...hyroid hormone withdrawal is plann...
...B) A goal TSH of >30 mIU/L has been general...
...e 3. Clinical Decision-making and Management Recom...
...acteristics According to the ATA Risk Stratif...
...ical Decision-making and Management Recommenda...
...In patients with ATA low risk and...
54. B) In patients with ATA intermediate ris...
...ents with ATA high risk DTC with attendant...
...n patients with DTC of any risk level w...
...If radioactive iodine remnant ablation is...
...gher administered activities may need to be cons...
...e 7. Response to Therapy Re-Classifi...
...RAI is intended for initial adjuvant...
...w-iodine diet for approximately 1–2 weeks sho...
...rapy whole-body scan (with or without single-...
...r high-risk thyroid cancer patient...
...r intermediate-risk thyroid cancer patie...
...risk patients who have undergone r...
...risk patients who have undergone remnant ab...
...risk patients who have undergone lobect...
...There is no role for routine adjuvant external bea...
...here is no role for routine systemic adjuvant...
...um thyroglobulin should be measured by an a...
...B) During initial follow-up, serum Tg on thyroxi...
62. C) In ATA low and intermediate risk pat...
...should be measured at least every 12 months...
...risk patients (regardless of respon...
...low-risk and intermediate-risk patie...
...B) Repeat TSH stimulated Tg testing is not recom...
...equent TSH stimulated Tg testing may...
.... Periodic serum Tg measurements on...
...) Following surgery, cervical US to evaluate t...
65. B) If a positive result would chan...
...spicious lymph nodes...
...Low-risk patients who have had remnant abla...
...first post-treatment WBS performed following RAI r...
...A) Diagnostic WBS, either following thyroid hormon...
...) SPECT-CT radioiodine imaging is preferre...
...-PET scanning should be considered in...
...-PET scanning may also be considered a) as...
.... A) Cross-sectional imaging of the neck...
...CT imaging of the chest without intravenous contr...
...) Imaging of other organs including MRI brain,...
...e 8. TSH Targets for Long-term Thyroid Horm...
...0. A) In patients with a structural or biochemical...
...ients with a biochemical incomplete response...
70. C) In patients with an excellent (clini...
...patients with an excellent (clinically...
...0. E) In patients who have not undergone remn...
...Therapeutic compartmental central and/or lateral...
...hen technically feasible, surgery for...
...gh there are theoretical advantages to...
...ically administered amounts of 131I exceeding 1...
...re currently insufficient outcome data to r...
...Recombinant human TSH–mediated therap...
...Since there are no outcome data that de...
...ulmonary micrometastases should be treated...
...tion of RAI activity to administer for pulmonar...
...odine-avid macronodular metastases may...
...py of iodine-avid bone metastases has been...
...AI activity administered can be given e...
...absence of structurally evident disease, patients...
...iric (100–200 mCi) or dosimetrically-determin...
...f persistent nonresectable disease i...
...he evidence is insufficient to recommend for o...
...ts with xerostomia are at increased risk o...
...rection should be considered for nasolacrimal ou...
...Although patients should be counseled on the ris...
...ents receiving therapeutic doses of RA...
...n of childbearing age receiving RAI therapy s...
...ive iodine should not be given to nurs...
...receiving cumulative radioiodine activities >...
...e-refractory structurally-evident DTC is de...
...ents with I refractory metastatic 1...
...AF or other mutational testing is not rou...
...3. A) Both stereotactic radiation and thermal...
...3. B) Stereotactic radiation or thermal ablat...
...al resection and stereotactic external bea...
95. Patients should be considered for referra...
.... A) Kinase inhibitor therapy should be consid...
...) Patients who are candidates for kinase inh...
97. Patients who have disease progress...
...tive surveillance: Proactive monitoring and...
...without established efficacy in DTC should b...
...oxic chemotherapy can be considered in RAI-refrac...
...01. Bisphosphonate or denosumab therapy shou...
...ctors to Review When Considering Kinase I...
...e 10. Potential Toxicities and Recommende...