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
...Different...
...operative neck US for cervical (cen...
...ded FNA of sonographically suspicious lymp...
...addition of FNA-Tg washout in the eva...
...) Preoperative use of cross-sectional ima...
...reoperative 18FDG-PET scanning is NOT rec...
...eoperative measurement of serum Tg or Tg an...
...Ultrasound Features of Lymph Nodes Predi...
...2. AJCC 7th edition/TNM Classification System for...
Treatment
...Treatment...
...r patients with thyroid cancer >4 cm o...
...B) For patients with thyroid cancer >1...
...C) If surgery is chosen for patients with t...
.... A) Therapeutic central-compartmen...
36. B) Prophylactic central-compartme...
...dectomy without prophylactic central neck di...
...peutic lateral neck compartmental lym...
...mpletion thyroidectomy should be offered...
...active iodine ablation in lieu of completion thy...
...Prior to surgery, the surgeon should com...
40. All patients undergoing thyroid surgery s...
...tive voice abnormalities (SR, M)623...
...History of cervical or upper chest s...
...n thyroid cancer with posterior extrathyroidal ext...
...sual identification of the recurren...
...perative neural stimulation (with or witho...
...3. Pre-operative Factors Which May...
...oid glands and their blood supply should be...
...hould have their voice assessed in the...
...ntraoperative findings and details o...
...addition to the basic tumor features required fo...
...thologic variants of thyroid carcinoma associate...
...pathologic variants associated with f...
47. AJCC/UICC staging is recommended fo...
...) The 2009 ATA Initial Risk Stratification Syste...
...nal prognostic variables (such as the ex...
...C) While not routinely recommended for initial pos...
...e 4. Best Response to Therapy...
DTC: Long-Term Management and Advanced Cancer Management
...DTC: Long-Term Man...
...cal Decision-making and Management Reco...
...Clinical Implications of Response To Therapy...
...al recurrence risk estimates should be co...
...ost-operative disease status (i.e. th...
.... B) Post-operative serum thyroglobulin (o...
...C) The optimal cut-off value for pos...
...ost-operative diagnostic radioiodine whole-body s...
...linical Decision-making and Manage...
...) RAI remnant ablation is not routinely recommen...
...RAI remnant ablation is not routinely...
...RAI remnant ablation is not routinely recommended...
51. D) RAI adjuvant therapy should be cons...
...adjuvant therapy is routinely recommended a...
...e of molecular testing in guiding post-operati...
.... A) If thyroid hormone withdrawal is planned...
...H of >30 mIU/L has been generally adopted in pre...
...igure 3. Clinical Decision-making and Manageme...
.... Characteristics According to the ATA Risk Strati...
...Clinical Decision-making and Management Recom...
...tients with ATA low risk and ATA interm...
...In patients with ATA intermediate risk DTC who ha...
...ients with ATA high risk DTC with atte...
...atients with DTC of any risk level with signif...
55. A) If radioactive iodine remnant ablat...
55. B) Higher administered activities may n...
...se to Therapy Re-ClassificationHaving...
...6. When RAI is intended for initial ad...
...ine diet for approximately 1–2 weeks should be...
...t-therapy whole-body scan (with or with...
...r high-risk thyroid cancer patients, in...
...B) For intermediate-risk thyroid can...
...low risk patients who have undergone remnan...
...risk patients who have undergone remnant abla...
...risk patients who have undergone lobect...
.... There is no role for routine adj...
...s no role for routine systemic adjuvant therap...
...m thyroglobulin should be measured...
...initial follow-up, serum Tg on thyroxine ther...
...) In ATA low and intermediate risk patients tha...
...should be measured at least every 12 months in a...
...E) ATA high risk patients (regardless of res...
...ow-risk and intermediate-risk patients wh...
...B) Repeat TSH stimulated Tg testing is no...
...sequent TSH stimulated Tg testing may be considere...
...4. Periodic serum Tg measurements on thyroid hor...
...Following surgery, cervical US to...
...itive result would change management, ultr...
...uspicious lymph nodes...
...sk patients who have had remnant ablation...
...rst post-treatment WBS performed followin...
.... A) Diagnostic WBS, either following thyro...
...CT radioiodine imaging is preferred over...
...) FDG-PET scanning should be consider...
...18FDG-PET scanning may also be considered a) as...
...Cross-sectional imaging of the neck an...
...aging of the chest without intravenous contra...
69. C) Imaging of other organs including MRI...
...le 8. TSH Targets for Long-term Thyro...
...In patients with a structural or bioche...
...In patients with a biochemical incomple...
70. C) In patients with an excellent (clin...
...D) In patients with an excellent (clinically...
...atients who have not undergone remnant ablation or...
...erapeutic compartmental central and/or later...
...2. When technically feasible, surgery for a...
...) Although there are theoretical advantages to dos...
...ally administered amounts of 131I exceeding 150 m...
...re currently insufficient outcome data t...
...5. Recombinant human TSH–mediated therap...
...ce there are no outcome data that demonstra...
...A) Pulmonary micrometastases should...
77. B) The selection of RAI activity...
...8. Radioiodine-avid macronodular m...
...9. A) RAI therapy of iodine-avid bone metasta...
...I activity administered can be given empiri...
...ence of structurally evident disease, pati...
...ic (100–200 mCi) or dosimetrically-determ...
.... If persistent nonresectable disease is localized...
...The evidence is insufficient to rec...
...th xerostomia are at increased risk...
.... Surgical correction should be consi...
...though patients should be counseled on the risks o...
.... Patients receiving therapeutic doses of RAI shou...
...Women of childbearing age receiving RAI ther...
...iodine should not be given to nursing w...
...ing cumulative radioiodine activities >400 m...
...1. Radioiodine-refractory structurally-evi...
...tients with I refractory metastatic 131...
...BRAF or other mutational testing is not rou...
...th stereotactic radiation and thermal ablation (RF...
...reotactic radiation or thermal ablati...
...e surgical resection and stereotactic...
...hould be considered for referral t...
...A) Kinase inhibitor therapy should be co...
.... B) Patients who are candidates fo...
...who have disease progression while...
...veillance: Proactive monitoring and ti...
...nts without established efficacy in DTC should b...
...Cytotoxic chemotherapy can be considered in RAI...
101. Bisphosphonate or denosumab ther...
...Factors to Review When Considering Ki...
...10. Potential Toxicities and Recommended Scree...