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s f u la b l a t i o no far e m a i n i n gl o b ei np a - tients with T1b or T2 primary tumors, who had surgicalcontraindications or declined completion thyroidectomy, the remnant ablation success rate was significantly higher using 100 mCi (75% success rate; 1 mCi =37 MBq), compared with 30 mCi (54%), although mild to... |
physicians, includinganesthesia personnel, regarding important findings elicited during the preoperative workup. (Strong recommendation, Moderate-quality evidence) The preoperative consent process should include explicit discussion of the potential for temporary or permanent nerve injury (and its clinical sequelae, incl... |
evidence) &RECOMMENDATION 41 Preoperative laryngeal exam should be performed in all patients with (A) Preoperative voice abnormalities(Strong recommendation, Moderate-quality evidence)(B) History of cervical or upper chest surgery, which places the RLN or vagus nerve at risk (Strong recommendation, Moderate-quality evi... |
Voice alteration is an important complication of thyroid surgery affecting patients’ quality of life (with regard to voice, swallowing, and airway domains), and it can havemedico-legal and cost implications (393–401). Preoperative assessment provides a necessary baseline reference from which to establish perioperative ... |
life and auditory perceptual assessmentvoice instruments (402). It is important to appreciate that vocal cord paralysis, especially when chronic, may not be associated with significant vocal symptoms due to a variety of mecha-nisms, including contralateral vocal cord compensation. Voice assessment alone may not identify... |
cord paralysis is important because surgical algorithms in themanagement of the invaded nerve incorporate nerve func- tional status (415). A laryngeal exam should be performed if the voice is ab- normal during preoperative evaluation. In addition, a patientshould have a laryngeal exam even if the voice is normal if he ... |
of such postsurgical patients; it can be asymptomatic in up to one-third (403,416–422). A laryngeal exam is recommended in patients with the preoperative diagnosis of thyroid cancer if there is evidence for gross extrathyroidal extension of cancer posteriorly or extensive nodal involvement, even if the voice is normal.... |
blood supply should be preserved during thyroid surgery. (Strong recommendation, Moderate-quality evidence) RLN injury rates are lower when the nerve is routinely visualized in comparison with surgeries in which the nerve is simply avoided (402,416,423). If the EBSLN can be visu- alized and preserved, that is ideal. If... |
during thyroidectomy for the outcomesof overall, transient, or permanent RLN palsy when analyzedper nerve at risk or per patient (425). However, second- ary subgroup analyses of high-risk patients (including thoseTable 9.Preoperative Factors Which May Be Associated with Laryngeal Nerve Dysfunction Factor Symptoms/signs... |
with thyroid cancer) suggested statistically significant het- erogeneity (variability) in treatment effect for overall and transient RLN injury, when analyzed per nerve at risk.Several studies show that intraoperative nerve monitoring ismore commonly utilized by higher volume surgeons to fa- cilitate nerve management, a... |
be located, the surgeon should at- tempt to dissect on the thyroid capsule and ligate the inferiorthyroid artery very close to the thyroid, since the majority of parathyroid glands receive their blood supply from this ves- sel. There are exceptions to this rule; for example, superiorglands in particular may receive blo... |
performedif the voice is abnormal (Strong recommendation, Moderate-quality evidence) &RECOMMENDATION 45 Important intraoperative findings and details of postoper- ative care should be communicated by the surgeon to the patient and other physicians who are important in thepatient’s postoperative care. (Strong recommendat... |
only be assessed by laryngeal exam postoperatively. Communication of intraoperative findings and postopera- tive care from the surgeon to other members of the patient’s thyroid cancer care team is critical to subsequent therapy and monitoring approaches. Important elements of communica-tion include (i) surgical anatomic... |
addition to the basic tumor features required for AJCC/UICC thyroid cancer staging including status of resection margins, pathology reports should contain ad-ditional information helpful for risk assessment, such as the presence of vascular invasion and the number of in- vaded vessels, number of lymph nodes examined an... |
drome) should be identified during histopathologic ex- amination and reported. (Weak recommendation, Low-quality evidence) Pathologic examination of thyroid samples establishes the diagnosis and provides important information for riskstratification of cancer and postsurgical patient manage- ment. Histopathologically, pap... |
well-differentiated malignant tumor of thyroid follicular cells that shows transcapsular and/or vascular invasion and lacks the diagnostic nuclear features of papillary carcinoma. Oncocytic(Hu¨rthle cell) follicular carcinoma shows the follicular growth pattern but is composed of cells with abundant granular eosin- oph... |
In this classification scheme, minimally invasivecarcinomas are fully encapsul ated tumors with microscop- ically identifiable foci of capsular or vascular invasion, whereas widely invasive carcinomas are tumors with extensive vascularand/or extrathyroidal, invasi on. More recent approaches con- sider encapsulated tumors... |
extension into the adjacent tissues. It is subdivided into minimal , which is invasion into immediate perithyroidal soft tissues or sternothyroid muscle typicallydetected only microscopically (T3 tumors), and extensive , which is tumor invasion into subcutaneous soft tissues, lar- ynx, trachea, esophagus, or RLN (T4a t... |
evaluated and reported. Vascular invasion is di- agnosed as direct tumor extension into the blood vessel lu- men or a tumor aggregate present within the vessel lumen,typically attached to the wall and covered by a layer of en- dothelial cells. More rigid criteria for vascular invasion proposed by some authors also requ... |
to risk stratification. The vari- ants with more unfavorable outcomes are the tall cell, co-lumnar cell, and hobnail variants. The tall cell variant ischaracterized by predominance ( >50%) of tall columnar tu- mor cells whose height is at least three times their width. These tumors present at an older age and more advan... |
risk of distant metastases and tumor-related mor-tality, the latter seen mostly in patients with an advanced disease stage at presentation (467–470). The BRAFV600E mutation is found in one-third of these tumors (467). Papillary carcinoma with prominent hobnail features is a rare, recently described variant characterize... |
which was 10%–12% in two studies with 10 and 19 years mean follow-up (474,475). However, among children and adoles-cents with post-Chernobyl papillary carcinomas, which fre-quently were of the solid variant, the mortality was very low (<1%) during the first 10 years of follow-up (476,477). Im- portantly, the solid varia... |
46% in a series of 152 patients diagnosed using the Turin criteria (479). The prognostic implication of the diffuse sclerosing variant of papillary cancer remains controversial. This variant ischaracterized by diffuse involvement of the thyroid gland and a higher rate of local and distant metastases at presentation, an... |
or vascular invasion. This variant is characterized by a follicular growth pattern with no papillae formation and total tumor encapsulation, and thediagnosis rests on the finding of characteristic nuclear fea- tures of papillary carcinoma. Although the encapsulated follicular variant of PTC shares the follicular growth ... |
indolent. A summary of six studies that reported107 cases of encapsulated follicular variant revealed 25% with lymph node metastases and 1% with distant metastases (489). Among these 107 patients, one died of disease and twowere alive with disease, whereas the rest (97%) of the patients were alive and well with various... |
had a positive resection margin afterinitial surgery (490). In another study of a cohort of thyroid tumors followed on average for 12 years, none of 66 patients with encapsulated follicular variant of papillary carcinomadied of disease (487). Despite a low probability, some pa- tients with encapsulated follicular varia... |
of these features, a completely excised nonin- vasive encapsulated follicular variant of papillary carcinoma is expected to have a very low risk of recurrence or extra-thyroidal spread, even in patients treated by lobectomy. Similarly, excellent clinical outcomes are seen in FTCs that manifest only capsular invasion wi... |
characterized by a prominent cribriform architecture and formation of whorls ormorules composed of spindle cells. The presence of aberrant b-catenin immunoreactivity provides a strong evidence for this tumor variant (505–507). Approximately 40% of patientswith this variant of papillary carcinoma are found to have FAP, ... |
thyroid glands in these patients is very characteristic and should allow pathologists to suspectthis syndrome (510,511). The glands typically have numer- ous sharply delineated, frequently encapsulated thyroid nodules that microscopically are well-delineated and cellularand have variable growth patterns (510–513). Indi... |
dedifferentiated anaplastic carcinoma. Another term used in the past for this tumor was ‘‘insular carcinoma.’’ Diagnostic criteria for poorly differentiated carcinoma are based on theconsensus Turin proposal and include the following threefeatures: (i) solid/trabecular/insular microscopic growth pattern, (ii) lack of w... |
survival in patients with poorly differentiated carcinoma constitutingmore than 50% of the tumor and in those in whom it was observed as a minor component (518,519). Tumors with in- sular, solid, or trabecular architecture, but lacking other di-agnostic features of poorly differentiated carcinoma, do not demonstrate su... |
thyroid cancer, as for other cancer types, is used (i) to provide prognostic information, which is ofvalue when considering disease surveillance and therapeutic strategies, and (ii) to enable risk-stratified description of pa- tients for communication among health care professionals,tracking by cancer registries, and re... |
providers are outlined in a recent publication of the Sur- gical Affairs Committee of the ATA (440). It is important to emphasize that the identification of a clinico-pathologic or molecular predictor of recurrence ormortality does not necessarily imply that more aggressive therapies (such as more extensive surgery, RAI... |
the years, multiple staging systems have been de- veloped to predict the risk of mortality in patients with DTC (522). Each of the systems uses some combination of age atdiagnosis, size of the primary tumor, specific tumor histol- ogy, and extrathyroidal spread of the tumor (direct extension of the tumor outside the thy... |
staging systems has been shown to be clearly superior to the other systems, several studies have demonstrated that the AJCC/UICC TNM system (Table 10)and the MACIS system consistently provide the highest proportion of variance explained (PVE, a statistical measure of how well a staging system can predict the outcome of... |
pathologic features such as the specific histology (well-differentiated thyroid cancer versus poorly differentiated thyroid cancer), molecular profile, size and location of distant metastases (pulmonary metastases versus bone metastasesversus brain metastases), functional status of the metastases (RAI avid versus 18FDG-P... |
RAI, external beam radiation therapy or other systemic therapies). Furthermore, recent studies have questioned the use of the age of 45 years as a cutoff to upstage patients usingthe AJCC/UICC TNM system (340,531–533). Even though the various staging systems designed to predict mortality from thyroid cancer were develo... |
for papillary carcinomas (154). These potential prognostic markers are promising, but re- quire further study. [B19] What initial stratification system should be used to estimate the risk of persistent/recurrent disease? &RECOMMENDATION 48 (A) The 2009 ATA Initial Risk Stratification System is recommended for DTC patient... |
for initial postop- erative risk stratification in DTC, the mutational status of BRAF , and potentially other mutations such as TERT , have the potential to refine risk estimates when interpreted in the context of other clinico-pathologic risk factors. (Weak recommendation, Moderate-quality evidence) Because the AJCC/TNM... |
extrathyroidal extension T1b Tumor >1 cm but £2 cm in greatest dimension, without extrathyroidal extension T2 Tumor >2 cm but £4 cm in greatest dimension, without extrathyroidal extension. T3 Tumor >4 cm in greatest dimension limited to the thyroid orAny size tumor with minimal extrathyroidalextension (e.g., extension ... |
Any N M1 Patient age ‡45 years old at diagnosis I T1a N0 M0 T1b N0 M0 II T2 N0 M0III T1a N1a M0 T1b N1a M0T2 N1a M0T3 N0 M0 T3 N1a M0 IVa T1a N1b M0 T1b N1b M0 T2 N1b M0T3 N1b M0 T4a N0 M0 T4a N1a M0T4a N1b M0 IVb T4b Any N M0IVc Any T Any N M1 Used with the permission of the American Joint Committee on Cancer (AJCC), ... |
bed, vascular invasion, or aggressive tumor histology. High- risk patients had gross extrathyroidal extension, incomplete tumor resection, distant metastases, or inappropriate post- operative serum Tg values (Table 11). The 2009 ATA risk stratification system was somewhat different than staging systems proposed by a Eur... |
from three respective con- tinents (Table 12). These studies have reported the estimates of patients who subsequently had no evidence of disease(NED) in each ATA Risk Category after total thyroidectomy and RAI remnant ablation: (a) low risk, 78%–91% NED, (b) intermediate risk, 52%–64% NED, and (c) high risk, 31%–32% NE... |
and 8% of ATA intermediate-risk patients who un- derwent thyroid surgery without RAI ablation as the initial therapy (328,544,545). The type of persistent disease also varies according to ATA initial risk stratification, with 70%–80% of the persis- tent disease in ATA low-risk patients manifested by abnor-mal serum Tg l... |
to reflect our best estimates based on the published literaturereviewed in the text. In the left hand column, the three-tiered risk system proposed as the Modified Initial Risk Stratification System is also presented to demonstrate how the continuum of risk estimates informed our modifications of the 2009 ATA Initial Risk ... |
isolated thyroglobulinemia, which may be of less clinical significance than structural disease persistence or recurrence. Similar to what was seen with the staging systems designed to predict risk of mortality from thyroid cancer (see section [B18] above), the PVE by the ATA risk of recurrence system was suboptimal, ran... |
categories (low, intermediate, andTable 11. ATA 2009 Risk Stratification System with Proposed Modifications ATA low risk Papillary thyroid cancer (with all of the following): /C15No local or distant metastases; /C15All macroscopic tumor has been resected /C15No tumor invasion of loco-regional tissues or structures /C15Th... |
first posttreatment whole-body RAI scan Aggressive histology (e.g., tall cell, hobnail variant, columnar cell carcinoma) Papillary thyroid cancer with vascular invasionClinical N1 or >5 pathologic N1 with all involved lymph nodes <3 cm in largest dimensiona Multifocal papillary microcarcinoma with ETE and BRAFV600Emutat... |
et al. (542) 91 NDaNDa Vaisman et al. (539) 88 10 2 Pitoia et al. (543) 78 15 7 IntermediateaTuttle et al. (538) 57 22 21 Vaisman et al. (539) 63 16 21 Pitoia et al. (543) 52 14 34 High Tuttle et al. (538) 14 14 72 Vaisman et al. (539) 16 12 72 Pitoia et al. (543) 31 13 56 aBecause the ATA intermediate- and high-risk g... |
not determined.ATA THYROID NODULE/DTC GUIDELINES 43 |
high) can vary depending on the specific clinical features of individual patients (Fig. 4). In addition, the three-tiered system did not specifically address the risk of recurrenceassociated with specific DTC histologies, multifocality, ge-notype, extent of vascular invasion, or extent of metastatic lymph node involvement... |
if more than five lymph nodes are involved, to 21% if more than 10 lymph nodes are involved, to 22% if macroscopic lymph node me-tastases are clinically evident (clinical N1 disease), and 27%– 32% if any metastatic lymph node is >3 cm (335,548). These risk estimates apply to both N1a and N1b disease becausethere are ins... |
are classified as higher risk N1 disease ( >20% risk of recurrence) (335). Identification of extranodal extension of the tumor through the metastaticlymph node capsule has also been associated with an in-creased risk of recurrent/persistent disease (338,450). It is difficult to estimate the risk associated with extension ... |
RLN) ranges from 23% to 40% (537,550,552–555). The encapsulated follicular variant of papillary thyroid carcinoma also appears to be associated with a low 10-year risk of recurrence (486,490,556). Only two recurrences werereported in the 152 patients (1.3% risk of recurrence) de- scribed in these three reports. No recu... |
invasive FTC with only minor vascular invasion (small number of foci confined to intracapsular vessels) also appears to havea low recurrence rate of approximately 0%–5% (456,500). Furthermore, some studies (456,494,497–500), but not all (496,501), suggest a greater extent of vascular invasion (morethan four foci of vasc... |
but not in the studies by Furlan et al. (562) or Akslen et al. (559). Vascular invasion in PTC was also associated with higher rates of dis- tant metastases (453,561) and disease-specific mortality (559,560). [B21] Potential impact of BRAFV600Eand other mutations on risk estimates in PTC In a pooled univariate analysis ... |
a systematic review and meta- analysis of 14 publications that included 2470 PTC patients from nine different countries, the BRAFV600Emutation was associated with a significantly higher risk of recurrence thanBRAF wild-type tumors (24.9% vs. 12.6%, p<0.00001 [95% CI 1.61–2.32]) (563). In the studies included in this met... |
recurrence in multivariate analysis. Furthermore, a recent publication demonstrated a small, but statistically signifi- cant improvement in risk stratification if BRAF status was used in conjunction with the 2009 ATA initial risk stratifi-cation system (569). In a meta-analysis of 2167 patients, the presence of a BRAFV600... |
appears that the BRAF status in isolation is not sufficient to substantially contribute to risk stratification in most patients.However, an incremental improvement in risk stratification c a nb ea c h i e v e di ft h e BRAF mutational status is considered in the context of other standard clinico-pathological risk factors.... |
recurrence rate of 8% (8 of 106) compared with only 1% (2 of 213) in BRAF wild-type tumors (p=0.003, Fisher’s exact). Furthermore, in multivariate analysis, the only clinico-pathological significant predictor of persistent disease after 5 years of follow-up was the presence of a BRAFV600Emutation. If these findings are v... |
of 7%, no recurrences were detected in the pa-tients with a BRAF V600Emutation and intrathyroidal, unifocal tumors. Conversely, BRAFV600E-mutated multifocal PTMC with extrathyroidal extension demonstrated a 20% recurrencerate (150). Therefore, in the absence of data demonstrating that theBRAFV600Emutation is associated... |
given thyroid carcinoma, including high probability of tumorrecurrence, is likely when it harbors more than one known oncogenic mutation, and specifically a BRAF mutation co- occurring with a TERT promoter, PIK3CA ,TP53 ,o rAKT1 mutation (155–157,577). Such a combination of severalmutations is seen in a much smaller fra... |
andPIK3CA ) and developed lung metastases. All four TP53 -positive FTC (with no other coexisting mutations) were oncocytic, and three out of fourof those were widely invasive FTC. Finally, recent studies identified TERT promoter muta- tions as a likely predictor of more unfavorable outcomes forpatients with thyroid canc... |
same tumor was associated with a high risk of structuraldisease recurrence (155). These results, although pending confirmation in other studies, suggest that these molecular markers, alone or in combination, may be helpful for riskstratification of thyroid cancer and provide significantlymore accurate risk assessment than... |
[B23] Proposed modifications to the 2009 ATA initial risk stratification system While the 2009 risk stratification system has proven to be a valuable tool for initial risk stratification in PTC, modifica-tions are required to better incorporate our new understanding regarding the risks associated with the extent of lymph no... |
uptake outside the thyroid bed atthe time of remnant ablation, and aggressive histologies, butit has been modified to include only a subset of patients with lymph node metastases (clinical N1 or >5 pathologic N1 with all involved lymph nodes <3 cm in largest dimension and multifocal papillary microcarcinoma with extrath... |
ad-ditional modifying factors provide significant incremental improvement in risk stratification. [B24] Risk of recurrence as a continuum of risk While the ATA initial risk stratification system provides a meaningful and valuable tool for predicting risk of recur- rence when used as a three-tiered categorical staging syst... |
invasion, extent of extrathyroidal extension, or other potentially importantfactors. While the risk estimates presented in this section may be useful in guiding initial treatment selections (extent of initialsurgery, need for RAI ablation), it is important to recognizethat these risk estimates likely reflect not only th... |
time as a function of the clinical course of the disease and the re-sponse to therapy. (Strong recommendation, Low-quality evidence) While initial staging systems provide important insights into an individual patient’s risk of recurrence and disease- specific mortality, they provide static, single-point estimates of ris... |
risk of recurrence that issignificantly lower than would have been predicted at the time of initial therapy. Therefore, while the initial staging systems can be infor- mative in guiding therapeutic and early diagnostic follow-up strategy decisions, a risk stratification system that incorpo- rates individual response to t... |
Furthermore, the PVE values associated with staging sys-tems that incorporated response-to-therapy variables into revised risk estimates were significantly higher (62%–84%) than those seen with initial staging systems ( <30%) (538,542). These data indicate that long-term outcomes can be more reliably predicted using sys... |
[B26] Proposed terminology to classify response to ther- apy and clinical implications All clinical, biochemical, imaging (structural and func- tional), and cytopathologic findings obtained during follow-up should be used to redefine the clinical status of the patient and to assess their individual response to therapy. I... |
to therapy restaging system was also not designed or specifically tested by developers to guide specific therapeutic decisions on primary therapy (such as use ofadjuvant treatment) because it has been designed for use afterprimary therapy is completed. Prospective studies of the value of this system for guiding extent of... |
presented here were described by Tuttleet al. (538) and modified in Vaisman et al. (328). As origi- nally conceived, these clinical outcomes described the best response to initial therapy during the first 2 years of follow-up(538,582), but they are now being used to describe the clin- ical status at any point during foll... |
whose primary treatment consisted of total thyroidec- tomy and RAI ablation. While the following sections will provide the details of multiple studies examining response totherapy, a simplified overview of the clinical implications ofthe response-to-therapy reclassification system in patients treated with total thyroidec... |
<1 ng/mL in the absence of struc- tural or functional evidence of disease (and in the absence of anti-Tg antibodies) (538,539,542,586–601). An excellentresponse to initial therapy is achieved in 86%–91% of ATA low-risk patients, 57%–63% of ATA intermediate-risk patients, and 14%–16% of ATA high-risk patients(538,539,54... |
response to therapy has less practical implications than in the intermediate- and high-risk patients. While many of the studies reviewed primarily low-risk DTC patients (586,588,595–598,601), the same low risk of recurrence following achievement of excellent response to therapy was seen in other studies that had substa... |
note that patients at intermediate to high risk of recurrence may require additional structural or functional imaging to rule out disease that may not be detected by USand Tg measurements prior to being classified as having anexcellent response (602). The details for choice of follow-up tests are found in another sectio... |
While most studies have assessed response to therapy using TSH-stimulated Tg values obtained 6–18 months after initialtherapy (538,539,542,586,588–590,593–595,597–600), at least15 other studies have evaluated the response to surgical therapy using a stimulated Tg obtained at the time of RAI remnant ablation (605). Pati... |
therapy. Smallridge et al. (606) described a 4.3% recurrence rate in 163 low- to intermediate-risk DTC patients with nonstimulated Tg <0.1 ng/mL, measured a median of 1.8 years after initial sur- gery. Finally, Giovanella et al. (601) reported a 1.6% recur- rence rate over 5–6 years of follow-up in 185 low-risk patient... |
TSH-stimulated Tg <1 ng/mLb1%–4% recurrencec <1% disease specific deathcAn excellent response to therapy should lead to an earlydecrease in the intensity and frequency of follow up and the degree of TSH suppression Biochemical incomplete responseNegative imaging and Suppressed Tg ‡1 ng/mLb or Stimulated Tg ‡10 ng/mLb or... |
treatmentsor ongoing observation dependingon multiple clinico-pathologic factors including the size, location, rate of growth, RAIavidity, 18FDG avidity, and specific pathology of the structural lesions. Indeterminate responseNonspecific findings on imaging studies Faint uptake in thyroid bed on RAI scanning Nonstimulated... |
FIG. 5. Clinical decision- making and management recommendations in ATA low-risk DTC patients that have undergone total thy-roidectomy. R, recommen- dation in text. FIG. 6. Clinical decision- making and management recommendations in ATA low riskDTC patients that have undergone less than totalthyroidectomy (lobectomy or... |
patients at very low risk for recurrence, Tg cut points need to be defined for patients whose primary treatment consisted of thy-roid lobectomy or total thyroidectomy without RAI ablation. In summary, once a patient achieves an excellent response to therapy, the initial risk of recurrence estimate should bemodified and t... |
[C4–C13] (Figs. 5–8). [B28] Biochemical incomplete response: abnormal Tg values in the absence of localizable disease These patients have persistently abnormal suppressed and/ or stimulated Tg values or rising anti-Tg antibodies withoutstructural evidence of disease that can be detected using risk- appropriate structur... |
are usually very good, with as many as 56%–68% being classified as having NED at final follow-up, while 19%–27% continue to have persis- tently abnormal Tg values without structural correlate, andonly 8%–17% developing structurally identifiable disease over 5–10 years follow-up (538,539,607). No deaths have been reported ... |
Anti-Tg antibody levels measured over time in the same assay can provide clinically useful information (608). Risinganti-Tg antibody titers (or new appearance of anti-Tg anti-bodies) are associated with an increased risk of disease re- currence (609–614). Conversely, patients rendered free of disease with initial thera... |
values over time. In pa-tients treated with total thyroidectomy and RAI remnant ablation, clinically significant increases in unstimulated se- rum Tg values over time as described by Tg doubling times(<1 year, 1–3 years, or >3 years) (622) or rate of rise in unstimulated Tg of ‡0.3 ng/mL/year over time (623), identify p... |
of>5 ng/mL at 6 months (624), nonstimulated Tg values >1 ng/mL more than 12 months after ablation (538,539,542), or TSH-stimulated Tg values >10 ng/mL more than 1 year after ablation (538,539). The precise Tg value for defining abiochemical incomplete response to therapy in patients treatedwith lobectomy or total thyroi... |
making and management recommendations in ATA high risk DTC patients that have undergone total thy-roidectomy and have no gross residual disease re- maining in the neck. R, rec-ommendation in text.ATA THYROID NODULE/DTC GUIDELINES 51 |
(538,539,607). This category includes both patients with biopsy-proven disease and also patients in whom structural or functional disease is identified, which is highly likely to bemetastatic disease based on the clinical scenario (Table 13).A structural incomplete response to initial therapy is seen in 2%–6% of ATA low... |
and in 57% of patientswith structurally identifiable distant metastases (539,607). In summary, a structural incomplete response to initial therapy identifies a cohort of DTC patients that may not becured with additional therapies and consequently demon- strate the highest risk of disease-specific mortality of any of the r... |
selected patients iden- tified for further evaluation with testing designed to establishthe presence or absence of disease (538,539). For example, this category includes patients with sub- centimeter avascular thyroid bed nodules or atypical cervicallymph nodes that have not been biopsied, faint uptake in the thyroid be... |
situation arises when trying to determine the re- sponse to therapy in the 34% of patients that demonstrated nonspecific subcentimeter thyroid bed nodules after totalthyroidectomy (629). Similarly, it is often difficult to be certain whether or not very low-level detectable Tg values represent persistent disease or simpl... |
the majority of patients with an indeterminate response to therapy remain disease-free during prolongedfollow-up. However, up to 20% of these patients will even- tually have biochemical, functional, or structural evidence of disease progression and may require additional therapies. [B31] Using risk stratification to gui... |
the risk of disease recurring without making appreciableamounts of serum Tg, the risk of adjuvant RAI therapy, therisk of additional thyroid surgery, the risk of additional lymph node surgery, the risk of external beam radiation therapy, and the risk of systemic therapy. Individual manage-ment recommendations require t... |
type of follow- up studies required for evaluating response to therapy in theearly years following initial therapy. This approach tailors the aggressiveness of intervention and follow-up to the specific risks associated with the tumor in an individual patient. In summary, this risk-adapted management approach uti- lizes... |
intensity of therapy and follow-up studies to real-time risk estimates that evolve over time for individual patients. [B32] Should postoperative disease status be considered in decision-making for RAI therapy for patients with DTC? &RECOMMENDATION 50 (A) Postoperative disease status (i.e., the presence or ab- sence of ... |
evidence)(D) Postoperative diagnostic RAI WBSs may be useful when the extent of the thyroid remnant or residual disease cannot be accurately ascertained from the surgical report or neck ultrasonography, and when the results may alterthe decision to treat or the activity of RAI that is to be administered. Identification ... |
strategy withthe intention of modulating decision-making on RAI remnantablation or RAI treatment for DTC. [B33] Utility of postoperative serum Tg in clinical decision- making Serum Tg measurements (with anti-Tg antibodies), with or without neck US, are frequently performed as part of the earlypostoperative evaluation. ... |
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