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
...ferentiated Thyroid...
...eoperative neck US for cervical (central and...
...ded FNA of sonographically suspicious lymph nodes...
...dition of FNA-Tg washout in the evaluation of s...
...Preoperative use of cross-sectional...
...preoperative 18FDG-PET scanning is NOT recomme...
...utine preoperative measurement of ser...
...e 1. Ultrasound Features of Lymph Node...
...able 2. AJCC 7th edition/TNM Classif...
Treatment
...atment...
.... A) For patients with thyroid cancer >4 cm or wi...
...patients with thyroid cancer >1 cm and...
...If surgery is chosen for patients with thyroid c...
...A) Therapeutic central-compartment...
...ctic central-compartment neck diss...
...oidectomy without prophylactic central neck...
...c lateral neck compartmental lymph no...
...on thyroidectomy should be offered t...
...ioactive iodine ablation in lieu of c...
...Prior to surgery, the surgeon should communicat...
...patients undergoing thyroid surgery should hav...
...ve voice abnormalities (SR, M)623...
...tory of cervical or upper chest surgery,...
...own thyroid cancer with posterior extrathyroi...
...ual identification of the recurrent lar...
...perative neural stimulation (with or without mon...
...perative Factors Which May Be Associ...
.... The parathyroid glands and their blood su...
...hould have their voice assessed in the post-operat...
...t intraoperative findings and details of post...
...tion to the basic tumor features required for...
...B) Histopathologic variants of thyroid...
...hologic variants associated with fam...
...taging is recommended for all patients w...
...2009 ATA Initial Risk Stratification System (...
...itional prognostic variables (such as the ext...
...While not routinely recommended for initi...
...able 4. Best Response to Therapy...
DTC: Long-Term Management and Advanced Cancer Management
...C: Long-Term Management and Advanced Cancer Man...
.... Clinical Decision-making and Manage...
...linical Implications of Response To Therapy Re-...
...itial recurrence risk estimates should be con...
...ost-operative disease status (i.e. the pres...
...rative serum thyroglobulin (on thy...
...ptimal cut-off value for post-oper...
...Post-operative diagnostic radioiodine whole-...
...2. Clinical Decision-making and Ma...
...remnant ablation is not routinely recomm...
...1. B) RAI remnant ablation is not rout...
.... C) RAI remnant ablation is not routinely reco...
...) RAI adjuvant therapy should be con...
...I adjuvant therapy is routinely re...
...e of molecular testing in guiding post-operative R...
...A) If thyroid hormone withdrawal is planned pri...
...A goal TSH of >30 mIU/L has been gen...
...Clinical Decision-making and Management...
...teristics According to the ATA Risk...
...inical Decision-making and Managemen...
...ients with ATA low risk and ATA intermediate risk...
...) In patients with ATA intermediate risk DTC who h...
...atients with ATA high risk DTC with atten...
...patients with DTC of any risk level...
.... A) If radioactive iodine remnant ablatio...
55. B) Higher administered activities...
...Response to Therapy Re-ClassificationH...
.... When RAI is intended for initial adjuvant the...
...odine diet for approximately 1–2 weeks should...
.... A post-therapy whole-body scan (wit...
...risk thyroid cancer patients, initia...
...ntermediate-risk thyroid cancer patients, initia...
55. C) For low risk patients who have undergone re...
...or low risk patients who have undergone remna...
...low risk patients who have undergone lobectomy,...
...There is no role for routine adjuv...
...re is no role for routine systemic adjuva...
...m thyroglobulin should be measured by an...
...B) During initial follow-up, serum Tg...
...C) In ATA low and intermediate risk...
...erum TSH should be measured at least...
...ATA high risk patients (regardless of...
63. A) In ATA low-risk and intermediate-risk p...
...Repeat TSH stimulated Tg testing is...
...Subsequent TSH stimulated Tg testing may be con...
...Periodic serum Tg measurements on thyroi...
...surgery, cervical US to evaluate the th...
...a positive result would change managemen...
...C) Suspicious lymph nod...
...patients who have had remnant ablation, ne...
...irst post-treatment WBS performed following RAI...
...agnostic WBS, either following thyroid hormone w...
...radioiodine imaging is preferred over planar i...
...A) FDG-PET scanning should be considered in...
...B) 18FDG-PET scanning may also be considere...
...oss-sectional imaging of the neck and uppe...
...imaging of the chest without intraveno...
.... C) Imaging of other organs including...
...8. TSH Targets for Long-term Thyroid Hormone Ther...
.... A) In patients with a structural or biochemical...
...tients with a biochemical incomplet...
...In patients with an excellent (clinicall...
...n patients with an excellent (clinical...
...patients who have not undergone remnant a...
71. Therapeutic compartmental central and/o...
...n technically feasible, surgery for aerod...
...though there are theoretical advantages to dos...
...rically administered amounts of 13...
...re currently insufficient outcome data to re...
...Recombinant human TSH–mediated ther...
...ce there are no outcome data that demonstr...
...ulmonary micrometastases should be treate...
...e selection of RAI activity to administer for...
...Radioiodine-avid macronodular metastases may...
...apy of iodine-avid bone metastases h...
...activity administered can be given empir...
...bsence of structurally evident disease, patients w...
...(100–200 mCi) or dosimetrically-dete...
...ersistent nonresectable disease is loca...
83. The evidence is insufficient to recommen...
...ts with xerostomia are at increased risk of...
...Surgical correction should be consi...
.... Although patients should be counsele...
...ts receiving therapeutic doses of RAI sh...
...8. Women of childbearing age receiving...
...ioactive iodine should not be given to nursing...
...receiving cumulative radioiodine activities >400...
...e-refractory structurally-evident DTC is...
...with I refractory metastatic 131DTC that is asym...
...B) BRAF or other mutational testing is n...
...stereotactic radiation and thermal ablation (RFA...
...3. B) Stereotactic radiation or thermal a...
...4. While surgical resection and st...
...Patients should be considered for referral to par...
...Kinase inhibitor therapy should be c...
...B) Patients who are candidates for kinase inhi...
...ts who have disease progression while on in...
98. Active surveillance: Proactive monitoring and...
...ithout established efficacy in DTC sho...
...totoxic chemotherapy can be considered in RAI-re...
...Bisphosphonate or denosumab therapy should be...
...e 9. Factors to Review When Considering Kinase...
...otential Toxicities and Recommende...