Management Guideline

Differentiated Thyroid Cancer

R2 กรชนก
 Content

Update guideline base on literature of Well differentiated

thyroid cancer

1. ATA Guideline 2015

2. Bethesda Guideline 2017

 Outline
• How to diagnosis

History and physical examination

Laboratory

Imaging

• Treatment

Surgery

RAI

TSH suppression

• Follow up
 Historical factor

• Childhood head and neck radiation therapy

• Total body radiation for bone marrow transplantation

• Exposure to ionizing radiation

• Familial thyroid carcinoma in a first-degree relative

• Rapid nodule growth

• Hoarseness
 Physical finding

• Vocal cord paralysis

• Cervical lymphadenopathy

• Fixation of the nodule to surrounding tissue

 Laboratory analysis

Thyroid nodule>1 cm. Serum TSH level should be obtained

• Subnormal ; Radionuclide thyroid scan

• Normal/Elevate ; Thyroid sonography

 Laboratory analysis

• Routine measurement of serum thyroglobulin (Tg) for

initial evaluation of thyroid nodules is not recommended
 Thyroid sonography

• Thyroid sonography with survey of the cervical lymph

nodes should be performed in all patients with known
or suspected thyroid nodules
 Thyroid sonography

• Ultrasound should evaluate the following:

- Thyroid parenchyma (homogeneous or heterogeneous)

- Gland size

- Location

- Sonographic characteristics of any nodule(s); the

presence of any cervical lymph nodes in the central or
lateral compartments
 FNA criteria cytologic
adequacy

• At least 6 groups of follicular cell

• At least 10 epithelial cell/group

(%)
 Nondiagnostic cytology

• FNA should be repeated with US guidance

• Repeatedly nondiagnostic nodules without a high suspicion

sonographic pattern ; close observation or surgical excision

• Surgery should be considered in

1. High suspicion sonographic pattern

2. Growth of the nodule(>20% in two dimensions)

3. Present of malignancy clinical risk factors

 AUS/FLUS cytology

• Repeat FNA or molecular testing may be used to

supplement malignancy risk assessment

• If repeat FNA cytology, molecular testing, or both are not

performed or inconclusive ; surveillance or diagnostic
surgical excision may be performed
Follicular neoplasm/suspicious
for follicular neoplasm cytology

• Diagnostic surgical excision is standard of care

• molecular testing may be used to supplement malignancy

risk assessment

• If molecular testing is either not performed or

inconclusive, surgical excision may be considered for
removal and definitive diagnosis of an FN/SFN thyroid
nodule
 What is the appropriate operation
for cytologically indeterminate thyroid
nodules?

• Thyroid lobectomy is the recommended initial surgical

approach
 Suspicious for malignancy
cytology

• Surgical management should be similar to that of

malignant cytology
 Benign
FNA

HIGH LOW TO INTERMEDIATE VERY LOW

Suspicion Suspicion Suspicion

Repeat US Repeat US at 12-24 months

+ • Growth Repeat US
US-guided FNA - increase 20% in two >24 months
Within 12 months dimensions
- increase 2 mm. FNA
- >50% change in volume
• New suspicion US

2nd Benign FNA cytology

NO US SURVEILLANCE

Adapted from HAUGEN ET AL. ATA THYROID NODULE/DTC GUIDELINE 2015. THYROID 2016; 26: 25.
Adapted from HAUGEN ET AL. ATA THYROID NODULE/DTC GUIDELINE 2015. THYROID 2016; 26: 26.
 DIFFERENTIATED THYROID
CANCER

• Papillary thyroid cancer

• Follicular thyroid cancer

• Hurthle cell thyroid cancer

DIFFERENTIATED THYROID CANCER:
Neck ultrasound

• Preoperative neck US for cervical lymph nodes is

recommended for all patients undergoing
thyroidectomy for malignant or suspicious for
malignancy cytologic

• US-guided FNA of sonographically suspicious lymph

nodes >8–10mm in the smallest diameter should be
performed
 Neck imaging—CT/MRI

• Preoperative use of cross-sectional imaging studies (CT,

MRI) with intravenous (IV) contrast is recommended as an
adjunct to US

1. invasive primary tumor

2. clinically multiple or bulky lymph node

 Operative approach for a biopsy
diagnostic for follicular cell–derived
malignancy

• A Near-total or total thyroidectomy and gross removal

of all primary tumor considered in;

1. Thyroid cancer >4 cm.

2. Gross extrathyroidal extension(clinical T4)

3. Clinically metastasis to nodes(clinical N1)

4. Distant sites metastasis(clinical M1)

 Operative approach for a biopsy
diagnostic for follicular cell–derived
malignancy

• A Near-total and total thyroidectomy or Lobectomy

considered in;

1. Thyroid cancer >1 and <4 cm.

2. No extrathyroidal extension

3. No clinically metastasis to nodes(clinical N0)

 Operative approach for a biopsy
diagnostic for follicular cell–derived
malignancy

• Thyroid lobectomy considered in;

1. Thyroid cancer <1 cm.

2. No extrathyroidal extension

3. No clinically metastasis to nodes(clinical N0)

 Lymph node dissection
• Therapeutic central-compartment (level VI) neck dissection; clinically involved central
nodes

• Prophylactic central-compartment (level VI) neck dissection; advanced primary

tumor(T3 or T4)

• Not need in;

- Small (T1 or T2)

- Noninvasive

- Clinically node-negative PTC (cN0)

- Most Follicular cancer

• Therapeutic lateral neck compartmental lymph node dissection; biopsy-proven

metastatic lymphadenopathy
Initial risk stratification system

• Low risk

• Intermediate risk

• High risk
Initial risk stratification system

• Low-risk patients

• No local or distant metastases

• All macroscopic tumor has been resected

• No tumor invasion of locoregional tissues or structures

• Tumor does not have aggressive histology

• No vascular invasion
Initial risk stratification system

• Intermediate-risk
• Microscopic invasion of tumor into perithyroidal soft
tissues

• Cervical LN metastases

• 131I uptake outside thyroid bed

• Tumor with aggressive histology

• Vascular invasion
Initial risk stratification system

• High-risk patients
• Macroscopic tumor invasion

• Incomplete tumor resection

• Distant metastases
 Post operative management

• Radioactive iodine (RAI)

• TSH suppression
What is the role of postoperative
RAI remnant ablation?

• RAI ablation is recommended for all patients with

– Distant metastases

– Gross extra thyroidal extension of tumor regardless of tumor

size

– Primary tumor size >4 cm

– High risk and intermediated risk patients

What is the role of postoperative
RAI remnant ablation?

• RAI ablation is not recommended for patients with

– Unifocal cancer and tumor <1 cm without higher risk features

– Multifocal cancer when all foci <1 cm without higher risk

features
 How should patients be
prepared for RAI ablation?

• Patients undergoing RAI therapy or diagnostic testing

– LT4 withdrawal for at least 2–3 wks

– LT3 treatment for 2–4 weeks and LT3 withdrawal for 2 wks

– Serum TSH to determine timing of testing or therapy (TSH

>30 mU/L)

– Thyroxine therapy may be resumed on second or third day

after RAI administration
 Is a low-iodine diet necessary
before remnant ablation?

• Low-iodine diet for 1–2 weeks is recommended for

patients undergoing RAI remnant ablation.

• Particularly for patients with high iodine

 Should post therapy scan be
performed following remnant ablation?

• Post therapy scan is recommended following RAI

remnant ablation

• 2–10 days after therapeutic administered

 TSH suppression

• High-risk patients ; < 0.1mU/L

• Low-risk and intermediate-risk patients ; 0.1–0.5mU/L

Is there a role for adjunctive external
beam radiation or chemotherapy?

• External beam irradiation to treat primary tumor should be considered in

patients

– > 45 yrs

– Grossly visible extra thyroidal extension at time of surgery

– High likelihood of microscopic residual disease

– Gross residual tumor in whom further surgery or RAI would likely be

ineffective
Is there a role for adjunctive external
beam irradiation or chemotherapy?

• No role for routine adjunctive use of chemotherapy in

patients with DTC
 Terminology to Classify
Response to Therapy
• Excellent response: no clinical, biochemical or structural
evidence of disease

• Biochemical incomplete response: abnormal Tg or rising

anti-Tg antibody levels in the absence of localizable
disease

• Structural incomplete response: persistent or newly

identified loco-regional or distant metastases

• Indeterminate response: non-specific biochemical or

structural findings
Surveillance
 “Thank you.”

–Kornchanok Thangnaphadol, R2