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
...iated Thyroid Cancer...
...rative neck US for cervical (central and es...
...ded FNA of sonographically suspiciou...
...ddition of FNA-Tg washout in the evaluation of s...
...erative use of cross-sectional imaging studies (CT...
...utine preoperative 18FDG-PET scanning is NOT rec...
...ne preoperative measurement of serum Tg or T...
.... Ultrasound Features of Lymph Nodes...
...ble 2. AJCC 7th edition/TNM Classification...
Treatment
...eatment...
...A) For patients with thyroid cancer >4 cm or w...
...atients with thyroid cancer >1 cm and...
...urgery is chosen for patients with thyroid cance...
...Therapeutic central-compartment (level VI) neck d...
...ctic central-compartment neck dissection (ipsilate...
...Thyroidectomy without prophylactic central...
...c lateral neck compartmental lymph node dissection...
...A) Completion thyroidectomy should be offered...
...Radioactive iodine ablation in lieu of com...
...Prior to surgery, the surgeon should co...
...All patients undergoing thyroid surger...
...e voice abnormalities (SR, M)623...
B) History of cervical or upper chest surgery, wh...
C) Known thyroid cancer with posteri...
42. A) Visual identification of the recurrent...
...traoperative neural stimulation (with or without...
...-operative Factors Which May Be Associa...
...rathyroid glands and their blood supply sh...
...should have their voice assessed in the post-...
...tant intraoperative findings and details...
...A) In addition to the basic tumor featur...
...stopathologic variants of thyroid carcinoma...
...6. C) Histopathologic variants associated w...
...staging is recommended for all patients...
...The 2009 ATA Initial Risk Stratification S...
...l prognostic variables (such as the extent of lymp...
...While not routinely recommended for initial p...
...est Response to Therapy Exc...
DTC: Long-Term Management and Advanced Cancer Management
...erm Management and Advanced Cancer Managem...
...Clinical Decision-making and Management Recommen...
...5. Clinical Implications of Response T...
...nitial recurrence risk estimates should be c...
...Post-operative disease status (i.e....
...Post-operative serum thyroglobulin (on thyroi...
...al cut-off value for post-operative serum t...
...perative diagnostic radioiodine whol...
Figure 2. Clinical Decision-making and Managem...
...A) RAI remnant ablation is not routin...
...emnant ablation is not routinely recomm...
...RAI remnant ablation is not routinely reco...
...vant therapy should be considered after t...
...E) RAI adjuvant therapy is routine...
.... The role of molecular testing in guidi...
...) If thyroid hormone withdrawal is p...
53. B) A goal TSH of >30 mIU/L has been genera...
.... Clinical Decision-making and Management Recommen...
...teristics According to the ATA Risk Stratificat...
...ure 4. Clinical Decision-making and Management...
...In patients with ATA low risk and ATA intermedi...
...ients with ATA intermediate risk DTC...
...tients with ATA high risk DTC with attendant highe...
...ients with DTC of any risk level with signi...
...adioactive iodine remnant ablation is performed a...
...5. B) Higher administered activities may n...
.... Response to Therapy Re-ClassificationHaving...
...I is intended for initial adjuvant therapy...
...diet for approximately 1–2 weeks sh...
...A post-therapy whole-body scan (with or w...
...risk thyroid cancer patients, initi...
...For intermediate-risk thyroid cancer...
...5. C) For low risk patients who have under...
.... D) For low risk patients who have u...
...low risk patients who have undergone lobect...
...There is no role for routine adjuva...
.... There is no role for routine system...
...yroglobulin should be measured by an assa...
62. B) During initial follow-up, serum Tg on th...
...In ATA low and intermediate risk patients that...
...D) Serum TSH should be measured a...
...h risk patients (regardless of response to therap...
...ATA low-risk and intermediate-risk patien...
...epeat TSH stimulated Tg testing is not r...
...sequent TSH stimulated Tg testing may be con...
...eriodic serum Tg measurements on thy...
...ollowing surgery, cervical US to evalua...
...5. B) If a positive result would change...
...spicious lymph nodes...
65. D) Low-risk patients who have...
...ter the first post-treatment WBS per...
...) Diagnostic WBS, either following thyroi...
...T radioiodine imaging is preferred ove...
...FDG-PET scanning should be considered...
...18FDG-PET scanning may also be considered...
...) Cross-sectional imaging of the neck and up...
...CT imaging of the chest without intravenous...
69. C) Imaging of other organs including M...
...8. TSH Targets for Long-term Thyroid Hormone Ther...
...atients with a structural or biochem...
...ents with a biochemical incomplete response to...
...0. C) In patients with an excellent (clini...
...ents with an excellent (clinically...
...In patients who have not undergone remnant ablati...
...1. Therapeutic compartmental central...
...n technically feasible, surgery for aerodigestiv...
...there are theoretical advantages to...
...B) Empirically administered amounts of 131I...
...are currently insufficient outcome data to recomm...
75. Recombinant human TSH–mediated therapy ma...
...ere are no outcome data that demonstrate...
...monary micrometastases should be treated with RAI...
...) The selection of RAI activity to adm...
...oiodine-avid macronodular metastases may be tre...
...RAI therapy of iodine-avid bone metastase...
...ctivity administered can be given empiric...
...absence of structurally evident disea...
...1. Empiric (100–200 mCi) or dosimetrica...
...tent nonresectable disease is loca...
...e evidence is insufficient to recomm...
.... Patients with xerostomia are at inc...
...correction should be considered for nas...
...Although patients should be counseled o...
...nts receiving therapeutic doses of RA...
...n of childbearing age receiving RAI...
...ive iodine should not be given to nursing...
...Men receiving cumulative radioiod...
...ioiodine-refractory structurally-e...
92. A) Patients with I refractory...
...F or other mutational testing is not routinely...
...oth stereotactic radiation and thermal...
...tic radiation or thermal ablation s...
...surgical resection and stereotactic exte...
...hould be considered for referral to participate...
...A) Kinase inhibitor therapy should be consider...
...who are candidates for kinase inhib...
...ho have disease progression while on initial...
...ive surveillance: Proactive monitorin...
...ithout established efficacy in DTC should...
...ytotoxic chemotherapy can be considered i...
101. Bisphosphonate or denosumab therapy shou...
...Factors to Review When Considering Kinase Inhib...
...ntial Toxicities and Recommended Screening or S...