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THYROID
CANCER
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical
doctor, professor of academic
medicine, and medical author. He
graduated from Ross University
School of Medicine and has
completed his clinical clerkship
training in various teaching
hospitals throughout New York,
including King’s County Hospital
Center and Brookdale Medical
Center, among others. Dr. Jouria has passed all USMLE medical board
exams, and has served as a test prep tutor and instructor for Kaplan. He has
developed several medical courses and curricula for a variety of educational
institutions. Dr. Jouria has also served on multiple levels in the academic
field including faculty member and Department Chair. Dr. Jouria continues to
serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also
developed several continuing medical education courses covering various
topics in clinical medicine. Recently, Dr. Jouria has been contracted by the
University of Miami/Jackson Memorial Hospital’s Department of Surgery to
develop an e-module training series for trauma patient management. Dr.
Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
Abstract
The thyroid gland has been called the “Master Gland” because it is
active in virtually every cell of the body, regulating cellular respiration,
energy expenditure, overall metabolism, growth and development of
cells and tissues. Because the thyroid gland’s role is so pervasive in
the body, it is important for clinicians to understand the symptoms of
various thyroid diseases. The management and treatment of thyroid
conditions are discussed.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Statement of Learning Need
The thyroid gland is active in virtually every cell of the body,
regulating cellular respiration, energy expenditure, overall metabolism,
growth and development of cells and tissues. It is important to
understand the symptoms of thyroid diseases, and to know the
management and treatment of these conditions.
Course Purpose
To provide advanced learning for clinicians interested in the diagnosis,
treatment and prevention of thyroid disease.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. Most thyroid tumors are
a.
b.
c.
d.
malignant and usually found on routine examination.
painful, multinodular growths.
benign and usually found on self-examination.
benign and only found on autopsy.
2. True or False: Approximately 1% of new cancers diagnosed
in the U.S., are of the thyroid.
a. True
b. False
3. The sudden onset of pain associated with a thyroid tumor is
associated with
a.
b.
c.
d.
benign disease.
Hürtle cell carcinoma.
incidentalomas.
papillary carcinomas.
4. Some experts consider the Hürtle cell carcinoma as a variant
of
a.
b.
c.
d.
follicular carcinoma.
primary thyroid sarcoma.
anaplastic carcinoma.
medullary carcinoma.
5. __________________ are the most common thyroid cancer
constituting approximately 80% of all thyroid malignancies.
a.
b.
c.
d.
Primary thyroid sarcomas
Follicular carcinomas
Papillary carcinomas
Anaplastic carcinomas
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Introduction
In the United States, thyroid cancer has been called an epidemic,
though this may represent an “epidemic of diagnosis.” Most thyroid
tumors are benign and only found on autopsy. In addition, a majority
of thyroid cancers are found as a palpable and painless thyroid nodule
on routine examination. When a thyroid nodule is diagnosed, it is
important to first understand basic definition and guidelines to treat a
thyroid nodule.
Overview Of Thyroid Cancer
Approximately 1% of new cancers diagnosed in the U.S., are cancers
of the thyroid. Papillary carcinomas are the most common thyroid
cancer constituting approximately 80% of all thyroid malignancies.
Since the mid 1970’s, the incidence of thyroid cancer has nearly
tripled, with most of the increase due to papillary carcinomas.
Follicular carcinomas constitute approximately 10% of thyroid tumors
while medullary thyroid carcinomas comprise from 5-10% of all thyroid
tumors. Anaplastic carcinomas are found in 1-2% of cases while
primary thyroid sarcomas and Hürtle cell carcinomas are the rarest
forms, though some experts consider the Hürtle cell carcinoma as a
variant of follicular carcinoma. Anaplastic carcinomas and metastatic
medullary carcinomas are highly malignant but most thyroid cancers
are not considered highly malignant.74
Solitary nodules are of greatest concern for malignancy in those
patients over the age of 60 or in patients younger than 30 years.
Thyroid tumors have a higher rate of malignancy in males. Other
characteristics include: 1) Most thyroid tumors are painless to
palpation. The sudden onset of pain associated with the tumor is
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associated with benign disease. 2) Rapid growth is a worrying sign.
3) Nodules are hard and fixed.
Fine needle aspiration biopsies (FNAB) are a primary diagnostic tool.
There are no significant differences in results between conventional
smears and liquid-based preparations — the choice should be based on
lab experience, cost and preferences.77
Thyroid nodule ultrasound is increasingly being used to aid in the
diagnosis of thyroid cancer. However, a recent review concluded that
Low- to moderate-quality evidence suggests that individual ultrasound
features are not accurate predictors of thyroid cancer. Two features,
cystic content and spongiform appearance, however, might predict
benign nodules, but this has limited applicability to clinical practice due
to their infrequent occurrence. The authors further concluded that
according to guidelines, a suspicious nodule should undergo a fineneedle aspiration biopsy with cytology (FNAB), which, depending on
the results, could lead to thyroid surgery.77 Within this diagnostic
algorithm, the use of ultrasound (US) evaluation has become widely
accepted as a key diagnostic step in stratifying patients' risk of
malignancy. Nevertheless, there is significant uncertainty surrounding
the diagnostic accuracy of several of the features analyzed during the
sonographic evaluation of thyroid nodules.
Guidelines For The Treatment Of Thyroid Cancer
The American Thyroid Association (ATA) has published guidelines for
adult patients with thyroid nodules and differentiated thyroid cancer.
Recommendations for thyroid nodules are identified in the table below.
The ATA provides the following definition of a thyroid nodule as a:
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discrete lesion within the thyroid gland that is radiologically
distinct from the surrounding thyroid parenchyma. Some
palpable lesions may not correspond to distinct radiologic
abnormalities. Such abnormalities do not meet the strict
definition for thyroid nodules. Nonpalpable nodules detected on
US or other anatomic imaging studies are termed incidentally
discovered nodules or ‘incidentalomas.’ Nonpalpable nodules
have the same risk of malignancy as do sonographically
confirmed palpable nodules of the same size. Generally, only
nodules >1 cm should be evaluated, since they have a greater
potential to be clinically significant cancers. Occasionally, there
may be nodules <1 cm that require further evaluation because
of clinical symptoms or associated lymphadenopathy. In very
rare cases, some nodules <1 cm lack these sonographic and
clinical warning signs yet may nonetheless cause future
morbidity and mortality. This remains highly unlikely, and given
the unfavorable cost/benefit considerations, attempts to
diagnose and treat all such small thyroid cancers in an effort to
prevent exceedingly rare outcomes is deemed to cause more
harm than good. In general, the guiding clinical strategy
acknowledges that most thyroid nodules are low risk, and many
thyroid cancers pose minimal risk to human health and can be
effectively treated.78
In general, thyroid cancer presents as a painless, palpable thyroid
nodule which may be solitary or multiple. The critical issue is to
determine if the nodule(s) is or are benign, which can be managed by
watchful waiting and treatment as necessary, or malignant, in which
case more aggressive treatment as per the recommendations should
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be considered. The physical examination should include the head,
neck, cervical soft tissues and indirect laryngoscopy, particularly if
there is hoarseness in the patient’s voice suggesting the involvement
of the recurrent laryngeal nerve or vocal fold paralysis.
Well-differentiated thyroid carcinomas include both papillary
carcinomas and follicular carcinomas. Women have a threefold higher
risk of papillary carcinoma, with a mean age of 35-40 years. Radiation
is associated with an increased risk of papillary carcinomas.
Hashimoto’s thyroiditis may be associated with a greater risk of
papillary carcinomas, but the association is not yet proven.
Follicular carcinoma is the second most common well-differentiated
thyroid carcinoma. Follicular carcinomas are associated with low iodine
intake and are three times more common in women than in men. Age
of diagnosis is usually between the ages of 40-60.
ATA Recommendations For Thyroid Nodules
This section captures the basic recommendations by the American
Thyroid Association (ATA) to screen for and diagnose thyroid nodules.
The first recommendation is on the role of thyroid cancer screening in
people with familial follicular cell–derived differentiated thyroid cancer
(DTC). This first ATA recommendation establishes the mainstay of all
of the other recommendations that follow: screening people with
familial follicular cell–derived DTC may lead to an earlier diagnosis of
thyroid cancer, however, clinicians are informed that the ATA is unable
to recommend for or against the value of ultrasound (US) screening
because it has not been established through research that such thyroid
testing leads to less morbidity or mortality.78
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Appropriate laboratory and imaging evaluation for patients with
clinically or incidentally discovered thyroid nodules are highlighted in
the table below, beginning with Recommendation 2 (the first ATA
recommendation for thyroid nodule screening is explained above).78
Serum thyrotropin
measurement
RECOMMENDATION 2
(A) Serum thyrotropin (TSH) should be measured
during the initial evaluation of a patient with a
thyroid nodule.
(B) If the serum TSH is subnormal, a radionuclide
(preferably 123I) thyroid scan should be
performed.
(C) If the serum TSH is normal or elevated, a
radionuclide scan should not be performed as the
initial imaging evaluation.
Serum
thyroglobulin
measurement
RECOMMENDATION 3
Serum calcitonin
measurement
RECOMMENDATION 4
Routine measurement of serum thyroglobulin (Tg) for
initial evaluation of thyroid nodules is not recommended.
The panel cannot recommend either for or against routine
measurement of serum calcitonin in patients with thyroid
nodules.
Fluorodeoxyglucose
positron emission
tomography scan
RECOMMENDATION 5
(A) Focal fluorodeoxyglucose positron emission
tomography (FDG-PET) uptake within a
sonographically confirmed thyroid nodule conveys
an increased risk of thyroid cancer, and FNA is
recommended for those nodules >1 cm.
(B) Diffuse FDG-PET uptake, in conjunction with
sonographic and clinical evidence of chronic
lymphocytic thyroiditis, does not require further
imaging or FNA.
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Thyroid sonography
RECOMMENDATION 6
Thyroid sonography with survey of the cervical lymph
nodes should be performed in all patients with known or
suspected thyroid nodules.
US for FNA
decision-making
RECOMMENDATION 7
FNA(B) is the procedure of choice in the evaluation of
thyroid nodules, when clinically indicated.
Recommendations
for diagnostic FNA
of a thyroid nodule
based on
sonographic pattern
RECOMMENDATION 8
I. Thyroid nodule diagnostic FNA(B) is recommended for:
(A) Nodules ≥1 cm in greatest dimension with high
suspicion sonographic pattern.
(B) Nodules ≥1 cm in greatest dimension with
intermediate suspicion sonographic pattern.
(C) Nodules ≥1.5 cm in greatest dimension with low
suspicion sonographic pattern.
II. Thyroid nodule diagnostic FNA(B) may be considered
for:
(D) Nodules ≥2 cm in greatest dimension with very low
suspicion sonographic pattern (i.e., spongiform).
Observation without FNA is also a reasonable
option.
III. Thyroid nodule diagnostic FNA(B) is not required for:
(E) Nodules that do not meet the above criteria.
(F) Nodules purely cystic.
What is the role of
FNA, cytology
interpretation, and
molecular testing in
patients with
thyroid nodules?
RECOMMENDATION 9
Nondiagnostic
cytology
RECOMMENDATION 10
Thyroid nodule FNA cytology should be reported using
diagnostic groups outlined in the Bethesda System for
Reporting Thyroid Cytopathology.
(A) For a nodule with an initial nondiagnostic cytology
result, FNA(B) should be repeated with US guidance
and, if available, on-site cytologic evaluation.
(B) Repeatedly nondiagnostic nodules without a high
suspicion sonographic pattern require close
observation or surgical excision for histopathologic
diagnosis.
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(C) Surgery should be considered for histopathologic
diagnosis if the cytologically nondiagnostic nodule
has a high suspicion sonographic pattern, growth of
the nodule (>20% in two dimensions) is detected
during US surveillance, or clinical risk factors for
malignancy are present.
Benign cytology
RECOMMENDATION 11
If the nodule is benign on cytology, further immediate
diagnostic studies or treatment are not required.
Malignant cytology
RECOMMENDATION 12
If a cytology result is diagnostic for primary thyroid
malignancy, surgery is generally recommended.
Indeterminate
cytology
(AUS/FLUS, FN,
SUSP)
What are the
principles of the
molecular
testing of FNA
samples?
RECOMMENDATION 13
If molecular testing is being considered, patients should be
counseled regarding the potential benefits and limitations
of testing and about the possible uncertainties in the
therapeutic and long-term clinical implications of results.
RECOMMENDATION 14
If intended for clinical use, molecular testing should be
performed in Clinical Laboratory Improvement
Amendments/College of American Pathologists (CLIA/CAP)certified molecular laboratories, or the international
equivalent, because reported quality assurance practices
may be superior compared to other settings.
AUS/FLUS cytology
AUS/FLUS= atypia
of undetermined
significance or
follicular lesion of
undetermined
significance
RECOMMENDATION 15
(A) For nodules with AUS/FLUS cytology, after
consideration of worrisome clinical and sonographic
features, investigations such as repeat FNA(B) or
molecular testing may be used to supplement
malignancy risk assessment in lieu of proceeding
directly with a strategy of either surveillance or
diagnostic surgery.
Informed patient preference and feasibility should
be considered in clinical decision-making.
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(B) If repeat FNA(B) cytology, molecular testing, or
both are not performed or inconclusive, either
surveillance or diagnostic surgical excision may be
performed for an AUS/FLUS thyroid nodule,
depending on clinical risk factors, sonographic
pattern, and patient preference.
Follicular neoplasm
or suspicious for
follicular neoplasm
cytology
RECOMMENDATION 16
(A) Diagnostic surgical excision is the long-established
standard of care for the management of FN/SFN
cytology nodules. However, after consideration of
clinical and sonographic features, molecular testing
may be used to supplement malignancy risk
assessment data in lieu of proceeding directly with
surgery.
Informed patient preference and feasibility should
be considered in clinical decision-making.
(B) 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.
Suspicious for
malignancy
cytology
RECOMMENDATION 17
(A) If the cytology is reported as suspicious for papillary
carcinoma (SUSP), surgical management should be
similar to that of malignant cytology, depending on
clinical risk factors, sonographic features, patient
preference, and possibly results of mutational
testing (if performed).
(B) After consideration of clinical and sonographic
features, mutational testing for BRAF or the sevengene mutation marker panel (BRAF, RAS, RET/PTC,
PAX8/PPARc) may be considered in nodules with
SUSP cytology if such data would be expected to
alter surgical decision-making.
What is the utility of
18FDG-PET
scanning to predict
malignant or benign
disease when FNA
cytology is
indeterminate
(AUS/FLUS, FN,
SUSP)?
RECOMMENDATION 18
FDG-PET imaging is not routinely recommended for the
evaluation of thyroid nodules with indeterminate cytology.
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What is the
appropriate
operation for
cytologically
indeterminate
thyroid nodules?
RECOMMENDATION 19
When surgery is considered for patients with a solitary,
cytologically indeterminate nodule, thyroid lobectomy is
the recommended initial surgical approach. This approach
may be modified based on clinical or sonographic
characteristics, patient preference, and/or molecular
testing when performed.
RECOMMENDATION 20
(A) Because of increased risk for malignancy, total
thyroidectomy may be preferred in patients with
indeterminate nodules that are cytologically
suspicious for malignancy, positive for known
mutations specific for carcinoma, sonographically
suspicious, or large (>4 cm), or in patients with
familial thyroid carcinoma or history of radiation
exposure, if completion thyroidectomy would be
recommended based on the indeterminate nodule
being malignant following lobectomy.
(B) Patients with indeterminate nodules who have
bilateral nodular disease, those with significant
medical comorbidities, or those who prefer to
undergo bilateral thyroidectomy to avoid the
possibility of requiring a future surgery on the
contralateral lobe, may undergo total or near-total
thyroidectomy, assuming completion thyroidectomy
would be recommended if the indeterminate nodule
proved malignant following lobectomy.
How should
multinodular
thyroid glands
(i.e., two or more
clinically relevant
nodules)
be evaluated for
malignancy?
RECOMMENDATION 21
(A) Patients with multiple thyroid nodules ≥1 cm should
be evaluated in the same fashion as patients with a
solitary nodule ≥1 cm, excepting that each nodule
that is >1 cm carries an independent risk of
malignancy and therefore multiple nodules may
require FNA.
(B) When multiple nodules ≥1 cm are present, FNA
should be performed preferentially based upon
nodule sonographic pattern and respective size
cutoff.
(C) If none of the nodules has a high or moderate
suspicion sonographic pattern, and multiple
sonographically (very low or low suspicion pattern
nodules) coalesce with no intervening normal
parenchyma, the likelihood of malignancy is low
and it is reasonable to aspirate the largest nodules
(≥2 cm) or continue surveillance without FNA.
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RECOMMENDATION 22
A low or low-normal serum TSH concentration in patients
with multiple nodules may suggest that some nodule(s)
may be autonomous. In such cases, a radionuclide
(preferably 123I) thyroid scan should be considered and
directly compared to the US images to determine
functionality of each nodule ≥1 cm. FNA should then be
considered only for those isofunctioning or nonfunctioning
nodules, among which those with high suspicion
sonographic pattern should be aspirated preferentially.
RECOMMENDATION 23
Given the low false-negative rate of US-guided FNA
cytology and the higher yield of missed malignancies based
upon nodule sonographic pattern rather than growth, the
follow-up of thyroid nodules with benign cytology
diagnoses should be determined by risk stratification based
upon US pattern.
(A) Nodules with high suspicion US pattern: repeat US
and US-guided FNA within 12 months.
(B) Nodules with low to intermediate suspicion US
pattern: repeat US at 12–24 months. If
sonographic evidence of growth (20% increase in at
least two nodule dimensions with a minimal
increase of 2 mm or more than a 50% change in
volume) or development of new suspicious
sonographic features, the FNA could be repeated or
observation continued with repeat US, with repeat
FNA in case of continued growth.
(C) Nodules with very low suspicion US pattern
(including spongiform nodules): the utility of
surveillance US and assessment of nodule growth
as an indicator for repeat FNA to detect a missed
malignancy is limited. If US is repeated, it should
be done at ≥24 months.
Recommendation
for follow-up of
nodules with two
benign FNA
cytology results
If a nodule has undergone repeat US-guided FNA with a
second benign cytology result, US surveillance for this
nodule for continued risk of malignancy is no longer
indicated.
Follow-up for
nodules that do not
meet FNA criteria
RECOMMENDATION 24
Nodules may be detected on US that do not meet criteria
for FNA at initial imaging (Recommendation 8). The
strategy for sonographic follow-up of these nodules should
be based upon the nodule’s sonographic pattern.
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(A) Nodules with high suspicion US pattern: repeat US
in 6–12 months.
(B) Nodules with low to intermediate suspicion US
pattern: consider repeat US at 12–24 months.
(C) Nodules >1 cm with very low suspicion US pattern
(including spongiform nodules) and pure cyst: the
utility and time interval of surveillance US for risk of
malignancy is not known. If US is repeated, it
should be at ≥24 months.
(D) Nodules ≥1 cm with very low suspicion US pattern
(including spongiform nodules) and pure cysts do
not require routine sonographic follow-up.
What is the role of
medical or surgical
therapy for benign
thyroid nodules?
RECOMMENDATION 25
Routine TSH suppression therapy for benign thyroid
nodules in iodine sufficient populations is not
recommended. Though modest responses to therapy can
be detected, the potential harm outweighs benefit for most
patients.
RECOMMENDATION 26
Individual patients with benign, solid, or mostly solid
nodules should have adequate iodine intake. If inadequate
dietary intake is found or suspected, a daily supplement
(containing 150 μg iodine) is recommended.
RECOMMENDATION 27
(A) Surgery may be considered for growing nodules
that are benign after repeat FNA if they are large
(>4 cm), causing compressive or structural
symptoms, or based upon clinical concern.
(B) Patients with growing nodules that are benign after
FNA should be regularly monitored. Most
asymptomatic nodules demonstrating modest
growth should be followed without intervention.
RECOMMENDATION 28
Recurrent cystic thyroid nodules with benign cytology
should be considered for surgical removal or percutaneous
ethanol injection (PEI) based on compressive symptoms
and cosmetic concerns. Asymptomatic cystic nodules may
be followed conservatively.
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RECOMMENDATION 29
There are no data to guide recommendations on the use of
thyroid hormone therapy in patients with growing nodules
that are benign on cytology.
How should thyroid
nodules in pregnant
women be
managed?
FNA for thyroid
nodules discovered
during pregnancy
RECOMMENDATION 30
(A) FNA of clinically relevant thyroid nodules should be
performed in euthyroid and hypothyroid pregnant
women.
(B) For women with suppressed serum TSH levels that
persist beyond 16 weeks gestation, FNA may be
deferred until after pregnancy and cessation of
lactation.
At that time, a radionuclide scan can be performed
to evaluate nodule function if the serum TSH
remains suppressed.
Approaches to
pregnant patients
with malignant or
indeterminate
cytology
RECOMMENDATION 31
PTC discovered by cytology in early pregnancy should be
monitored sonographically. If it grows substantially before
24–26 weeks gestation, or if US reveals cervical lymph
nodes that are suspicious for metastatic disease, surgery
should be considered during pregnancy.
However, if the disease remains stable by mid-gestation,
or if it is diagnosed in the second half of pregnancy,
surgery may be deferred until after delivery.
Initial And Long-Term Management Of Thyroid Cancer
The ATA Recommendations guide clinicians in the differentiation of
thyroid cancer, including the initial as well as the long-term
management of the disease. These recommendations are listed in the
table below.
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ATA Recommendations for Differentiated Thyroid Cancer
DIFFERENTIATED
THYROID CANCER:
INITIAL MANAGEMENT
GUIDELINES
Goals of initial therapy of
DTC
The basic goals of initial therapy for patients with
DTC are to improve overall and disease-specific
survival, reduce the risk of persistent/recurrent
disease and associated morbidity, and permit
accurate disease staging and risk stratification,
while minimizing treatment-related morbidity and
unnecessary therapy.
The specific goals of initial therapy are to:
1) Remove the primary tumor, disease that has
extended beyond the thyroid capsule, and
clinically significant lymph node metastases.
Completeness of surgical resection is an
important determinant of outcome, while
residual metastatic lymph nodes represent
the most common site of disease
persistence/recurrence.
2) Minimize the risk of disease recurrence and
metastatic spread. Adequate surgery is the
most important treatment variable
influencing prognosis, while RAI treatment,
TSH suppression, and other treatments each
play adjunctive roles in at least some
patients.
3) Facilitate postoperative treatment with RAI,
where appropriate. For patients undergoing
RAI remnant ablation, or RAI treatment of
presumed (adjuvant therapy) or known
(therapy) residual or metastatic disease,
removal of all normal thyroid tissue is an
important element of initial surgery.
4) Permit accurate staging and risk
stratification of the disease. Because disease
staging and risk stratification should be used
to guide initial prognostication, disease
management, and follow-up strategies,
accurate postoperative risk assessment is a
crucial element in the management of
patients with DTC.
5) Permit accurate long-term surveillance for
disease recurrence.
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6) Minimize treatment-related morbidity. The
extent of surgery and the experience of the
surgeon both play important roles in
determining the risk of surgical
complications.
What is the role of
preoperative staging with
diagnostic imaging and
laboratory tests?
RECOMMENDATION 32
(A) Preoperative neck US for cervical (central
and especially lateral neck compartments)
lymph nodes is recommended for all patients
undergoing thyroidectomy for malignant or
suspicious for malignancy cytologic or
molecular findings.
(B) US-guided FNA of sonographically suspicious
lymph nodes ≥8–10 mm in the smallest
diameter should be performed to confirm
malignancy if this would change
management.
(C) The addition of FNA-Tg washout in the
evaluation of suspicious cervical lymph
nodes is appropriate in select patients, but
interpretation may be difficult in patients
with an intact thyroid gland.
Neck imaging—
CT/MRI/PET
RECOMMENDATION 33
(A) Preoperative use of cross-sectional imaging
studies (CT, MRI) with intravenous (IV)
contrast is recommended as an adjunct to
US for patients with clinical suspicion for
advanced disease, including invasive
primary tumor, or clinically apparent
multiple or bulky lymph node involvement.
(B) Routine preoperative 18FDG-PET scanning is
not recommended.
Measurement of serum Tg
and anti-Tg antibodies
RECOMMENDATION 34
Routine preoperative measurement of serum Tg or
anti-Tg antibodies is not recommended.
Operative approach for a
biopsy diagnostic for
follicular cell–derived
malignancy
RECOMMENDATION 35
(A) For patients with thyroid cancer >4 cm, or
with gross extrathyroidal extension (clinical
T4), or clinically apparent metastatic disease
to nodes (clinical N1) or distant sites (clinical
M1), the initial surgical procedure should
include a near-total or total thyroidectomy
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and gross removal of all primary tumor
unless there are contraindications to this
procedure.
(B) For patients with thyroid cancer >1 cm and
<4 cm without extrathyroidal extension, and
without clinical evidence of any lymph node
metastases (cN0), the initial surgical
procedure can be either a bilateral
procedure (near-total or total
thyroidectomy) or a unilateral procedure
(lobectomy).
Thyroid lobectomy alone may be sufficient
initial treatment for low-risk papillary and
follicular carcinomas; however, the
treatment team may choose total
thyroidectomy to enable RAI therapy or to
enhance follow-up based upon disease
features and/or patient preferences.
(C) If surgery is chosen for patients with thyroid
cancer <1 cm without extrathyroidal
extension and cN0, the initial surgical
procedure should be a thyroid lobectomy
unless there are clear indications to remove
the contralateral lobe.
Thyroid lobectomy alone is sufficient
treatment for small, unifocal, intrathyroidal
carcinomas in the absence of prior head and
neck radiation, familial thyroid carcinoma, or
clinically detectable cervical nodal
metastases.
Lymph node dissection
RECOMMENDATION 36
(A) Therapeutic central-compartment (level VI)
neck dissection for patients with clinically
involved central nodes should accompany
total thyroidectomy to provide clearance of
disease from the central neck.
(B) Prophylactic central-compartment neck
dissection (ipsilateral or bilateral) should be
considered in patients with papillary thyroid
carcinoma with clinically uninvolved central
neck lymph nodes (cN0) who have advanced
primary tumors (T3 or T4) or clinically
involved lateral neck nodes (cN1b), or if the
information will be used to plan further steps
in therapy.
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(C) Thyroidectomy without prophylactic central
neck dissection is appropriate for small (T1
or T2), noninvasive, clinically node-negative
PTC (cN0) and for most follicular cancers.
RECOMMENDATION 37
Therapeutic lateral neck compartmental lymph node
dissection should be performed for patients with
biopsy-proven metastatic lateral cervical
lymphadenopathy.
Completion thyroidectomy
RECOMMENDATION 38
(A) Completion thyroidectomy should be offered
to patients for whom a bilateral
thyroidectomy would have been
recommended had the diagnosis been
available before the initial surgery.
Therapeutic central neck lymph node
dissection should be included if the lymph
nodes are clinically involved. Thyroid
lobectomy alone may be sufficient treatment
for low-risk papillary and follicular
carcinomas.
(B) RAI ablation in lieu of completion
thyroidectomy is not recommended
routinely; however, it may be used to ablate
the remnant lobe in selected cases.
What is the appropriate
perioperative approach to
voice and parathyroid
issues?
Preoperative care
communication
RECOMMENDATION 39
Prior to surgery, the surgeon should communicate
with the patient regarding surgical risks, including
nerve and parathyroid injury, through the informed
consent process and communicate with associated
physicians, including anesthesia personnel,
regarding important findings elicited during the
preoperative workup.
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Preoperative voice
assessment
RECOMMENDATION 40
All patients undergoing thyroid surgery should have
preoperative voice assessment as part of their
preoperative physical examination. This should
include the patient’s description of vocal changes,
as well as the physician’s assessment of voice.
RECOMMENDATION 41
Preoperative laryngeal exam should be performed
in all patients with: (A) Preoperative voice
abnormalities; (B) History of cervical or upper chest
surgery, which places the RLN or vagus nerve at
risk; (C) Known thyroid cancer with posterior
extrathyroidal extension or extensive central nodal
metastases.
Intraoperative voice and
parathyroid management
RECOMMENDATION 42
(A) Visual identification of the RLN during
dissection is required in all cases. Steps
should also be taken to preserve the
external branch of the superior laryngeal
nerve (EBSLN) during dissection of the
superior pole of the thyroid gland.
(B) Intraoperative neural stimulation (with or
without monitoring) may be considered to
facilitate nerve identification and confirm
neural function.
RECOMMENDATION 43
The parathyroid glands and their blood supply
should be preserved during thyroid surgery.
Postoperative care
RECOMMENDATION 44
Patients should have their voice assessed in the
postoperative period. Formal laryngeal exam should
be performed if the voice is abnormal.
RECOMMENDATION 45
Important intraoperative findings and details of
postoperative care should be communicated by the
surgeon to the patient and other physicians who are
important in the patient’s postoperative care.
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What are the basic
principles of
histopathologic
evaluation of
thyroidectomy samples?
RECOMMENDATION 46
(A) In addition to the basic tumor features
required for AJCC/UICC thyroid cancer
staging including status of resection
margins, pathology reports should contain
additional information helpful for risk
assessment, such as the presence of
vascular invasion and the number of invaded
vessels, number of lymph nodes examined
and involved with tumor, size of the largest
metastatic focus to the lymph node, and
presence or absence of extranodal extension
of the metastatic tumor.
(B) Histopathologic variants of thyroid carcinoma
associated with more unfavorable outcomes
(i.e., tall cell, columnar cell, and hobnail
variants of PTC; widely invasive FTC; poorly
differentiated carcinoma) or more favorable
outcomes (i.e., encapsulated follicular
variant of PTC without invasion, minimally
invasive FTC) should be identified during
histopathologic examination and reported.
(C) Histopathologic variants associated with
familial syndromes (cribriform-morular
variant of papillary carcinoma often
associated with FAP, follicular or papillary
carcinoma associated with PTEN-hamartoma
tumor syndrome) should be identified during
histopathologic examination and reported.
What is the role of
postoperative staging
systems and risk
stratification in the
management of DTC?
Postoperative staging
RECOMMENDATION 47
AJCC/UICC staging is recommended for all patients
with DTC, based on its utility in predicting disease
mortality, and its requirement for cancer registries.
AJCC/UICC TNM staging
T0
No evidence of primary tumor
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T1a Tumor ≤1 cm, without 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 or any size tumor with minimal
extrathyroidal extension (i.e., extension into
sternothyroid muscle or perithyroidal soft
tissues).
T4a Tumor of any size extending beyond the
thyroid capsule to invade subcutaneous soft
tissues, larynx, trachea, esophagus, or
recurrent laryngeal nerve.
T4b Tumor of any size invading prevertebral fascia
or encasing carotid artery or mediastinal
vessels
N0 No metastatic nodes
N1a Metastases to level VI (pretracheal,
paratracheal, and prelaryngeal/Delphian lymph
nodes).
N1b Metastases to unilateral, bilateral, or
contralateral cervical (levels I, II III, IV, or V)
or retropharyngeal or superior mediastinal
lymph nodes (level VII)
M0 No distant metastases
M1 Distant metastases
Patient age <45 years old at diagnosis:
I: Any T Any N M0
II: Any T Any N M1
Patient age ≥45 years old at diagnosis
I
T1a
N0
M0
T1b
N0
M0
II
T2
N0
M0
III
T1a
N1a
M0
T1b
N1a
M0
T2
N1a
M0
T3
N0
M0
T3
N1a
M0
IVa
T1a
N1b
M0
T1b
N1b
M0
T2
N1b
M0
T3
N1b
M0
T4a
N0
M0
T4a
N1a
M0
T4a
N1b
M0
IVb
T4b
Any N M0
IVc
Any T Any N M1
What initial stratification
RECOMMENDATION 48
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system should be used to
estimate the risk of
persistent/recurrent
disease?
(A) The 2009 ATA Initial Risk Stratification System
is recommended for DTC patients treated with
thyroidectomy, based on its utility in predicting
risk of disease recurrence and/or persistence.
(B) Additional prognostic variables (such as the
extent of lymph node involvement, mutational
status, and/or the degree of vascular invasion in
FTC), not included in the 2009 ATA Initial Risk
Stratification system may be used to further
refine risk stratification for DTC as described in
the following text in the Modified Initial Risk
Stratification system. However, the incremental
benefit of adding these specific prognostic
variables to the 2009 Initial Risk Stratification
system has not been established.
(C) While not routinely recommended for initial
postoperative 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.
How should initial risk
estimates be modified
over time?
RECOMMENDATION 49
Should postoperative
disease status be
considered in decisionmaking for RAI therapy
for patients with DTC?
RECOMMENDATION 50
Initial recurrence risk estimates should be
continually modified during follow-up, because the
risk of recurrence and disease-specific mortality can
change over time as a function of the clinical course
of the disease and the response to therapy.
(A) Postoperative disease status (i.e., the
presence or absence of persistent disease)
should be considered in deciding whether
additional treatment (i.e., RAI, surgery, or
other treatment) may be needed.
(B) Postoperative serum Tg (on thyroid hormone
therapy or after TSH stimulation) can help in
assessing the persistence of disease or
thyroid remnant and predicting potential
future disease recurrence.
The Tg should reach its nadir by 3–4 weeks
postoperatively in most patients.
(C) The optimal cutoff value for postoperative
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serum Tg or state in which it is measured
(on thyroid hormone therapy or after TSH
stimulation) to guide decision-making
regarding RAI administration is not known.
(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 alter the decision to treat or
the activity of RAI that is to be
administered.
Identification and localization of uptake foci
may be enhanced by concomitant single
photon emission computed tomography–
computed tomography (SPECT/CT). When
performed, pretherapy diagnostic scans
should utilize 123I (1.5–3 mCi) or a low
activity of 131I (1–3 mCi), with the
therapeutic activity optimally administered
within 72 hours of the diagnostic activity.
What is the role of RAI
(including remnant
ablation, adjuvant
therapy, or therapy for
persistent disease) after
thyroidectomy in the
primary management of
DTC?
RECOMMENDATION 51
(A) RAI remnant ablation is not routinely
recommended after thyroidectomy for ATA
low-risk DTC patients. Consideration of
specific features of the individual patient
that could modulate recurrence risk, disease
follow-up implications, and patient
preferences are relevant to RAI decisionmaking.
(B) RAI remnant ablation is not routinely
recommended after lobectomy or total
thyroidectomy for patients with unifocal
papillary microcarcinoma, in the absence of
other adverse features.
(C) RAI remnant ablation is not routinely
recommended after thyroidectomy for
patients with multifocal papillary
microcarcinoma in absence of other adverse
features. Consideration of specific features
of the individual patient that could modulate
recurrence risk, disease follow-up
implications, and patient preferences are
relevant to RAI decision-making.
(D) RAI adjuvant therapy should be considered
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after total thyroidectomy in ATA
intermediate-risk level DTC patients.
(E) RAI adjuvant therapy is routinely
recommended after total thyroidectomy for
ATA high-risk DTC patients.
What is the role of
molecular marker status
in therapeutic RAI
decision-making?
RECOMMENDATION 52
How long does thyroid
hormone need to be
withdrawn in preparation
for RAI remnant
ablation/treatment or
diagnostic scanning?
RECOMMENDATION 53
The role of molecular testing in guiding
postoperative RAI use has yet to be established;
therefore, no molecular testing to guide
postoperative RAI use can be recommended at this
time.
(A) If thyroid hormone withdrawal is planned
prior to RAI therapy or diagnostic testing,
LT4 should be withdrawn for 3–4 weeks.
Liothyronine (LT3) may be substituted for
LT4 in the initial weeks if LT4 is withdrawn
for 4 or more weeks, and in such
circumstances, LT3 should be withdrawn for
at least 2 weeks. Serum TSH should be
measured prior to radioisotope
administration to evaluate the degree of TSH
elevation.
(B) A goal TSH of >30 mIU/L has been generally
adopted in preparation for RAI therapy or
diagnostic testing, but there is uncertainty
relating to the optimum TSH level associated
with improvement in long-term outcomes.
Can rhTSH (Thyrogen) be
used as an alternative to
thyroxine withdrawal for
remnant ablation or
adjuvant therapy in
patients who have
undergone near-total or
total thyroidectomy?
RECOMMENDATION 54
(A) In patients with ATA low-risk and ATA
intermediate risk DTC without extensive
lymph node involvement (i.e.,T1–T3,
N0/Nx/N1a, M0), in whom RAI remnant
ablation or adjuvant therapy is planned,
preparation with rhTSH stimulation is an
acceptable alternative to thyroid hormone
withdrawal for achieving remnant ablation,
based on evidence of superior short-term
quality of life, noninferiority of remnant
ablation efficacy, and multiple consistent
observations suggesting no significant
difference in long-term outcomes.
(B) In patients with ATA intermediate-risk DTC
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who have extensive lymph node disease
(multiple clinically involved LN) in the
absence of distant metastases, preparation
with rhTSH stimulation may be considered
as an alternative to thyroid hormone
withdrawal prior to adjuvant RAI treatment.
(C) In patients with ATA high-risk DTC with
attendant higher risks of disease-related
mortality and morbidity, more controlled
data from long-term outcome studies are
needed before rhTSH preparation for RAI
adjuvant treatment can be recommended.
(D) In patients with DTC of any risk level with
significant comorbidity that may preclude
thyroid hormone withdrawal prior to iodine
RAI administration, rhTSH preparation
should be considered. Significant
comorbidity may include:
(a) a significant medical or psychiatric
condition that could be acutely
exacerbated with hypothyroidism,
leading to a serious adverse event, or
(b) inability to mount an adequate
endogenous TSH response with thyroid
hormone withdrawal.
What activity of 131I
should be used for
remnant ablation or
adjuvant therapy?
RECOMMENDATION 55
(A) If RAI remnant ablation is performed after
total thyroidectomy for ATA low-risk thyroid
cancer or intermediate-risk disease with
lower risk features (i.e., low-volume central
neck nodal metastases with no other known
gross residual disease or any other adverse
features), a low administered activity of
approximately of 30 mCi is generally favored
over higher administered activities.
(B) Higher administered activities may need to
be considered for patients receiving less
than a total or near-total thyroidectomy in
which a larger remnant is suspected or in
which adjuvant therapy is intended.
RECOMMENDATION 56
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When RAI is intended for initial adjuvant therapy to
treat suspected microscopic residual disease,
administered activities above those used for
remnant ablation up to 150 mCi are generally
recommended (in absence of known distant
metastases). It is uncertain whether routine use of
higher administered activities (>150 mCi) in this
setting will reduce structural disease recurrence for
T3 and N1 disease.
Is a low-iodine diet
necessary before remnant
ablation?
RECOMMENDATION 57
Should a posttherapy scan
be performed following
remnant ablation or
adjuvant therapy?
RECOMMENDATION 58
A low iodine diet (LID) for approximately 1–2 weeks
should be considered for patients undergoing RAI
remnant ablation or treatment.
A posttherapy WBS (with or without SPECT/CT) is
recommended after RAI remnant ablation or
treatment, to inform disease staging and document
the RAI avidity of any structural disease.
Early management of DTC
after initial therapy
What is the appropriate
degree of initial TSH
suppression?
RECOMMENDATION 59
(A) For high-risk thyroid cancer patients, initial
TSH suppression to below 0.1 mU/L is
recommended.
(B) For intermediate-risk thyroid cancer
patients, initial TSH suppression to 0.1– 0.5
mU/L is recommended.
(C) For low-risk patients who have undergone
remnant ablation and have undetectable
serum Tg levels, TSH may be maintained at
the lower end of the reference range (0.5–2
mU/L) while continuing surveillance for
recurrence.
Similar recommendations hold for low-risk
patients who have not undergone remnant
ablation and have undetectable serum Tg
levels.
(D) For low-risk patients who have undergone
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remnant ablation and have low-level serum
Tg levels, TSH may be maintained at or
slightly below the lower limit of normal (0.1–
0.5 mU/L) while surveillance for recurrence
is continued.
Similar recommendations hold for low-risk
patients who have not undergone remnant
ablation, although serum Tg levels may be
measurably higher and continued
surveillance for recurrence applies.
(E) For low-risk patients who have undergone
lobectomy, TSH may be maintained in the
mid to lower reference range (0.5–2 mU/L)
while surveillance for recurrence is
continued.
Thyroid hormone therapy may not be
needed if patients can maintain their serum
TSH in this target range.
Is there a role for
adjunctive external beam
radiation therapy or
chemotherapy?
External beam radiation
therapy (EBRT)
RECOMMENDATION 60
There is no role for routine adjuvant EBRT to the
neck in patients with DTC after initial complete
surgical removal of the tumor.
Systemic adjuvant therapy
RECOMMENDATION 61
There is no role for routine systemic adjuvant
therapy in patients with DTC (beyond RAI and/or
TSH suppressive therapy using LT4).
DTC: LONG-TERM
MANAGEMENT AND
ADVANCED
CANCER MANAGEMENT
GUIDELINES
What are the appropriate
RECOMMENDATION 62
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methods for following
patients after initial
therapy?
What is the role of serum
Tg measurement in the
follow-up of DTC?
(A) Serum Tg should be measured by an assay
that is calibrated against the CRM457
standard. Thyroglobulin antibodies should be
quantitatively assessed with every
measurement of serum Tg. Ideally, serum
Tg and anti-Tg antibodies should be
assessed longitudinally in the same
laboratory and using the same assay for a
given patient.
(B) During initial follow-up, serum Tg on
thyroxine therapy should be measured every
6–12 months. More frequent Tg
measurements may be appropriate for ATA
high-risk patients.
(C) In ATA low- and intermediate-risk patients
that achieve an excellent response to
therapy, the utility of subsequent Tg testing
is not established. The time interval between
serum Tg measurements can be lengthened
to at least 12–24 months.
(D) Serum TSH should be measured at least
every 12 months in all patients on thyroid
hormone therapy.
(E) ATA high-risk patients (regardless of
response to therapy) and all patients with
biochemical incomplete, structural
incomplete, or indeterminate response
should continue to have Tg measured at
least every 6–12 months for several years.
RECOMMENDATION 63
(A) In ATA low-risk and intermediate-risk
patients who have had remnant ablation or
adjuvant therapy and negative cervical US,
serum Tg should be measured at 6–18
months on thyroxine therapy with a
sensitive Tg assay (<0.2 ng/mL) or after
TSH stimulation to verify absence of disease
(excellent response).
(B) Repeat TSH-stimulated Tg testing is not
recommended for low- and intermediate-risk
patients with an excellent response to
therapy.
(C) Subsequent TSH-stimulated Tg testing may
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be considered in patients with an
indeterminate, biochemical incomplete, or
structural incomplete response following
either additional therapies or a spontaneous
decline in Tg values on thyroid hormone
therapy over time in order to reassess
response to therapy.
What is the role of serum
Tg measurement in
patients who have not
undergone RAI remnant
ablation?
RECOMMENDATION 64
Periodic serum Tg measurements on thyroid
hormone therapy should be considered during
follow-up of patients with DTC who have undergone
less than total thyroidectomy and in patients who
have had a total thyroidectomy but not RAI
ablation. While specific cutoff levels of Tg that
optimally distinguish normal residual thyroid tissue
from persistent thyroid cancer are unknown, rising
Tg values over time are suspicious for growing
thyroid tissue or cancer.
What is the role of US and
other imaging techniques
(RAI SPECT/CT, CT, MRI,
PET-CT) during follow-up?
Cervical ultrasonography
RECOMMENDATION 65
(A) Following surgery, cervical US to evaluate
the thyroid bed and central and lateral
cervical nodal compartments should be
performed at 6–12 months and then
periodically, depending on the patient’s risk
for recurrent disease and Tg status.
(B) If a positive result would change
management, ultrasonographically
suspicious lymph nodes ≥8–10 mm in the
smallest diameter should be biopsied for
cytology with Tg measurement in the needle
washout fluid.
(C) Suspicious lymph nodes less than 8–10 mm
in smallest diameter may be followed
without biopsy with consideration for FNA or
intervention if there is growth or if the node
threatens vital structures.
(D) Low-risk patients who have had remnant
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ablation, negative cervical US, and a low
serum Tg on thyroid hormone therapy in a
sensitive assay (<0.2 ng/mL) or after TSH
stimulation (Tg <1 ng/mL) can be followed
primarily with clinical examination and Tg
measurements on thyroid hormone
replacement.
Diagnostic whole-body
RAI scans
RECOMMENDATION 66
After the first posttreatment WBS performed
following RAI remnant ablation or adjuvant therapy,
low-risk and intermediate-risk patients (lower risk
features) with an undetectable Tg on thyroid
hormone with negative antiTg antibodies and a
negative US (excellent response to therapy) do not
require routine diagnostic WBS during follow-up.
RECOMMENDATION 67
(A) Diagnostic WBS, either following thyroid
hormone withdrawal or rhTSH, 6–12 months
after adjuvant RAI therapy can be useful in
the follow-up of patients with high or
intermediate risk (higher risk features) of
persistent disease (see risk stratification
system, section [B19]) and should be done
with 123I or low activity 131I.
(B) SPECT/CT RAI imaging is preferred over
planar imaging in patients with uptake on
planar imaging to better anatomically
localize the RAI uptake and distinguish
between likely tumors and nonspecific
uptake.
FDG-PET scanning
18
RECOMMENDATION 68
(A) 18FDG-PET scanning should be considered in
highrisk DTC patients with elevated serum
Tg (generally >10 ng/mL) with negative RAI
imaging.
(B) 18FDG-PET scanning may also be considered
as:
(i)
(ii)
a part of initial staging in poorly
differentiated thyroid cancers and
invasive Hürthle cell carcinomas,
especially those with other evidence
of disease on imaging or because of
elevated serum Tg levels;
a prognostic tool in patients with
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(iii)
CT and MRI
metastatic disease to identify lesions
and patients at highest risk for rapid
disease progression and diseasespecific mortality; and,
an evaluation of posttreatment
response following systemic or local
therapy of metastatic or locally
invasive disease.
RECOMMENDATION 69
(A) Cross-sectional imaging of the neck and
upper chest (CT, MRI) with IV contrast
should be considered (i) in the setting of
bulky and widely distributed recurrent nodal
disease where US may not completely
delineate disease, (ii) in the assessment of
possible invasive recurrent disease where
potential aero-digestive tract invasion
requires complete assessment, or (iii) when
neck US is felt to be inadequately visualizing
possible neck nodal disease (high Tg,
negative neck US).
(B) CT imaging of the chest without IV contrast
(imaging pulmonary parenchyma) or with IV
contrast (to include the mediastinum) should
be considered in high risk DTC patients with
elevated serum Tg (generally >10 ng/mL) or
rising Tg antibodies with or without negative
RAI imaging.
(C) Imaging of other organs including MRI brain,
MR skeletal survey, and/or CT or MRI of the
abdomen should be considered in high-risk
DTC patients with elevated serum Tg
(generally >10 ng/mL) and negative neck
and chest imaging who have symptoms
referable to those organs or who are being
prepared for TSH-stimulated RAI therapy
(withdrawal or rhTSH) and may be at risk
for complications of tumor swelling.
What is the role of TSH
suppression during
thyroid hormone therapy
in the long-term follow-up
of DTC?
RECOMMENDATION 70
(A) In patients with a structural incomplete
response to therapy, the serum TSH should
be maintained below 0.1 mU/L indefinitely in
the absence of specific contraindications.
(B) In patients with a biochemical incomplete
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response to therapy, the serum TSH should
be maintained between 0.1and 0.5 mU/L,
taking into account the initial ATA risk
classification, Tg level, Tg trend over time,
and risk of TSH suppression.
(C) In patients who presented with high-risk
disease but have an excellent (clinically and
biochemically free of disease) or
indeterminate response to therapy,
consideration should be given to maintaining
thyroid hormone therapy to achieve serum
TSH levels of 0.1–0.5 mU/L for up to 5 years
after which the degree of TSH suppression
can by reduced with continued surveillance
for recurrence.
(D) In patients with an excellent (clinically and
biochemically free of disease) or
indeterminate response to therapy,
especially those at low risk for recurrence,
the serum TSH may be kept within the low
reference range (0.5–2 mU/L).
(E) In patients who have not undergone
remnant ablation or adjuvant therapy who
demonstrate an excellent or indeterminate
response to therapy with a normal neck US,
and low or undetectable suppressed serum
Tg, and Tg or anti-Tg antibodies that are not
rising, the serum TSH can be allowed to rise
to the low reference range (0.5–2 mU/L).
What is the optimal
directed approach to
patients with suspected
structural neck
recurrence?
RECOMMENDATION 71
What is the surgical
management of
aerodigestive invasion?
RECOMMENDATION 72
Administered activity of
RECOMMENDATION 73
Therapeutic compartmental central and/or lateral
neck dissection in a previously operated
compartment, sparing uninvolved vital structures,
should be performed for patients with biopsyproven persistent or recurrent disease for central
neck nodes ‡8 mm and lateral neck nodes ≥10 mm
in the smallest dimension that can be localized on
anatomic imaging.
When technically feasible, surgery for aerodigestive
invasive disease is recommended in combination
with RAI and/or EBRT.
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131I for loco-regional or
metastatic disease
(A) Although there are theoretical advantages to
dosimetric approaches to the treatment of
loco-regional or metastatic disease, no
recommendation can be made about the
superiority of one method of RAI
administration over another (empiric high
activity versus blood and/or body dosimetry
versus lesional dosimetry).
(B) Empirically administered amounts of 131I
exceeding 150 mCi that often potentially
exceed the maximum tolerable tissue dose
should be avoided in patients over age 70
years.
Use of rhTSH (Thyrogen)
to prepare patients for I
therapy for loco-regional
or metastatic disease
RECOMMENDATION 74
There are currently insufficient outcome data to
recommend rhTSH-mediated therapy for all patients
with distant metastatic disease being treated with I.
RECOMMENDATION 75
Recombinant human TSH–mediated therapy may be
indicated in selected patients with underlying
comorbidities making iatrogenic hypothyroidism
potentially risky, in patients with pituitary disease
whose serum TSH cannot be raised, or in patients in
whom a delay in therapy might be deleterious.
Such patients should be given the same or higher
activity that would have been given had they been
prepared with hypothyroidism or a dosimetrically
determined activity
Use of lithium in
therapy
I
131
RECOMMENDATION 76
Since there are no data that demonstrate a better
outcome of patients treated with lithium as an
adjunct to I therapies, the data are insufficient to
recommend lithium therapy.
Summary
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Thyroid cancer has been called an epidemic in the U.S., although this
may represent an epidemic of diagnosis. A majority of thyroid cancers
are found as a palpable and painless thyroid nodule on routine
examination. When a thyroid nodule is diagnosed, it is important to
first understand basic definition and guidelines to treat a thyroid
nodule. The American Thyroid Association (ATA) has published
guidelines for adult patients with thyroid nodules and differentiated
thyroid cancer. The above review of these guidelines provided the
necessary information for a clinician involved in the diagnosis,
management and treatment of thyroid diseases.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
1. Most thyroid tumors are
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a.
b.
c.
d.
malignant and usually found on routine examination.
painful, multinodular growths.
benign and usually found on self-examination.
benign and only found on autopsy.
2. True or False: Approximately 1% of new cancers diagnosed
in the U.S., are cancers of the thyroid.
a. True
b. False
3. The sudden onset of pain associated with a thyroid tumor is
associated with
a.
b.
c.
d.
benign disease.
Hürtle cell carcinoma.
incidentalomas.
papillary carcinomas.
4. Some experts consider the Hürtle cell carcinoma as a variant
of
a.
b.
c.
d.
follicular carcinoma.
primary thyroid sarcoma.
anaplastic carcinoma.
medullary carcinoma.
5. __________________ are the most common thyroid cancer
constituting approximately 80% of all thyroid malignancies.
a.
b.
c.
d.
Primary thyroid sarcomas
Follicular carcinomas
Papillary carcinomas
Anaplastic carcinomas
6. It is theorized that ___________________ may be
associated with a greater risk of papillary carcinomas.
a.
b.
c.
d.
toxic diffuse goiter
Graves’ disease
Hashimoto’s thyroiditis
Plummer’s disease
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7. True or False: The incidence of thyroid cancer has increased
significantly since the mid-1970s, with most of the increase
due to incidents of papillary carcinomas.
a. True
b. False
8. ___________________ are associated with low iodine
intake and are three times more common in women than in
men.
a.
b.
c.
d.
Spongiform sonographic patterns
Anaplastic carcinomas
Nodules that are purely cystic
Follicular carcinomas
9. The _______________ is of greatest concern for malignancy
in those patients over the age of 60 or in patients younger
than 30 years.
a.
b.
c.
d.
sudden onset of pain
presence of solitary nodules
presence of a discreet lesion
presence of an incidentaloma
10. Since the mid-1970s, the incidence of thyroid cancer has
a.
b.
c.
d.
doubled.
actually declined.
remained level.
nearly tripled.
11. A radionuclide thyroid scan (preferably 123I) should be
performed if
a.
b.
c.
d.
the serum TSH is normal.
the serum TSH is elevated.
the serum TSH is subnormal.
a patient presents with a thyroid nodule.
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12. True or False: The American Thyroid Association (ATA)
recommends ultrasound screening since there is evidence
that this could lead to reduced morbidity or mortality.
a. True
b. False
13. __________________ should be measured during the
initial evaluation of a patient with a thyroid nodule.
a.
b.
c.
d.
Serum thyroglobulin (Tg)
Serum calcitonin
Serum thyrotropin (TSH)
None of the above
14. The American Thyroid Association (ATA) cannot
recommend either for or against routine measurement of
_____________ in patients with thyroid nodules.
a.
b.
c.
d.
serum thyrotropin (TSH)
serum thyroglobulin (Tg)
anti-Tg antibodies
serum calcitonin
15. The American Thyroid Association (ATA) recommends a
fine needle aspiration with biopsy FNA(B) for a thyroid
nodule ____________ with a high suspicion sonographic
pattern.
a.
b.
c.
d.
≥1 cm in greatest dimension
≥0.5 cm in greatest dimension
≥1.5 cm in greatest dimension
≥1.75 cm in greatest dimension
16. Which of the following should be performed to survey the
cervical lymph nodes in patients with known or suspected
thyroid nodules?
a.
b.
c.
d.
Radionuclide thyroid scan (preferably 123I)
Thyroid sonography
A serum TSH measurement
Exploratory surgery
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17. True or False: Surgery should be considered for
histopathologic diagnosis if the cytologically nondiagnostic
nodule has a high suspicion sonographic pattern.
a. True
b. False
18. Thyroid nodule diagnostic fine needle aspiration with
biopsy FNA(B) may be considered for nodules with
sonographic pattern of
a. ≥2 cm in greatest dimension with spongiform pattern.
b. ≥1 cm in greatest dimension with high suspicion sonographic
pattern.
c. ≥1 cm in greatest dimension with intermediate suspicion
sonographic pattern.
d. ≥1.5 cm in greatest dimension with low suspicion sonographic
pattern.
19. If a cytology result is diagnostic for primary thyroid
malignancy,
a.
b.
c.
d.
FNA(B) should be repeated with US guidance.
a radionuclide thyroid scan (preferably 123I) is recommended.
surgery is generally recommended.
a serum thyrotropin (TSH) test is recommended.
20. How should multinodular thyroid glands (i.e., two or more
clinically relevant nodules) be evaluated for malignancy?
a. Patients should be evaluated only if ≥2 cm
b. It is reasonable to aspirate the largest nodules (≥2 cm)
c. Nodule sonographic patterns are not relevant with multinodular
thyroid glands
d. Multiple nodules do not require FNA
21. With nodules with high suspicion ultrasound pattern,
ultrasound and US-guided FNA should be repeated
a.
b.
c.
d.
within 24 months.
within 12 months.
on a case-by-case basis.
every six months.
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22. True or False: If the nodule is benign on cytology, further
immediate diagnostic studies or treatment are not
required.
a. True
b. False
23. Patients with nodules with high suspicion ultrasound
patterns should repeat ultrasound
a.
b.
c.
d.
in 6–12 months.
at 12–24 months.
do not require routine sonographic follow-up.
on a case-by-case basis.
24. What is the role of medical or surgical therapy for benign
thyroid nodules in iodine sufficient populations?
a. Benefits of routine TSH suppression therapy outweighs any
harm.
b. Surgery is recommended in all cases.
c. Thyroid hormone therapy in patients with growing nodules that
are benign on cytology is always recommended.
d. Routine TSH suppression therapy is not recommended.
25. The role of molecular testing in guiding postoperative RAI
use
a.
b.
c.
d.
is recommended after total thyroidectomy.
is recommended with low-risk level DTC patients.
has yet to be established.
is recommended with multifocal papillary microcarcinoma.
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CORRECT ANSWERS:
1. Most thyroid tumors are
d. benign and only found on autopsy.
“Most thyroid tumors are benign and only found on autopsy.”
2. True or False: Approximately 1% of new cancers diagnosed
in the U.S., are cancers of the thyroid.
a. True
“Approximately 1% of new cancers diagnosed in the U.S., are
cancers of the thyroid.”
3. The sudden onset of pain associated with a thyroid tumor is
associated with
a. benign disease.
“The sudden onset of pain associated with the tumor is
associated with benign disease.”
4. Some experts consider the Hürtle cell carcinoma as a variant
of
a. follicular carcinoma.
“Anaplastic carcinomas are found in 1-2% of cases while
primary thyroid sarcomas and Hürtle cell carcinomas are the
rarest forms, though some experts consider the Hürtle cell
carcinoma as a variant of follicular carcinoma.”
5. __________________ are the most common thyroid cancer
constituting approximately 80% of all thyroid malignancies.
c. Papillary carcinomas
“Papillary carcinomas are the most common thyroid cancer
constituting approximately 80% of all thyroid malignancies.”
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6. It is theorized that ___________________ may be
associated with a greater risk of papillary carcinomas.
c. Hashimoto’s thyroiditis
“Hashimoto’s thyroiditis may be associated with a greater risk
of papillary carcinomas, but the association is not yet proven.”
7. True or False: The incidence of thyroid cancer has increased
significantly since the mid-1970s, with most of the increase
due to incidents of papillary carcinomas.
a. True
“Since the mid 1970’s, the incidence of thyroid cancer has
nearly tripled, with most of the increase due to papillary
carcinomas.”
8. ___________________ are associated with low iodine
intake and are three times more common in women than in
men.
d. Follicular carcinomas
“Follicular carcinomas are associated with low iodine intake and
are three times more common in women than in men.”
9. The _______________ is of greatest concern for malignancy
in those patients over the age of 60 or in patients younger
than 30 years.
b. presence of solitary nodules
“Solitary nodules are of greatest concern for malignancy in
those patients over the age of 60 or in patients younger than
30 years.”
10. Since the mid-1970s, the incidence of thyroid cancer has
d. nearly tripled.
“Since the mid 1970’s, the incidence of thyroid cancer has
nearly tripled, with most of the increase due to papillary
carcinomas.”
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11. A radionuclide thyroid scan (preferably 123I) should be
performed if
c. the serum TSH is subnormal.
“Serum thyrotropin measurement: RECOMMENDATION 2 - (A)
Serum thyrotropin (TSH) should be measured during the initial
evaluation of a patient with a thyroid nodule. (B) If the serum
TSH is subnormal, a radionuclide (preferably 123I) thyroid
scan should be performed. (C) If the serum TSH is normal or
elevated, a radionuclidescan should not be performed as the
initial imaging evaluation.”
12. True or False: The American Thyroid Association (ATA)
recommends ultrasound screening since there is evidence
that this could lead to reduced morbidity or mortality.
b. False
“Screening people with familial follicular cell–derived DTC may
lead to an earlier diagnosis of thyroid cancer, but the panel
cannot recommend for or against US screening since there is
no evidence that this would lead to reduced morbidity or
mortality.”
13. __________________ should be measured during the
initial evaluation of a patient with a thyroid nodule.
c. Serum thyrotropin (TSH)
“Serum thyrotropin measurement: RECOMMENDATION 2 - (A)
Serum thyrotropin (TSH) should be measured during the initial
evaluation of a patient with a thyroid nodule.”
14. The American Thyroid Association (ATA) cannot
recommend either for or against routine measurement of
_____________ in patients with thyroid nodules.
d. serum calcitonin
“Serum calcitonin measurement: RECOMMENDATION 4 - The
panel cannot recommend either for or against routine
measurement of serum calcitonin in patients with thyroid
nodules.”
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15. The American Thyroid Association (ATA) recommends a
fine needle aspiration with biopsy FNA(B) for a thyroid
nodule ____________ with a high suspicion sonographic
pattern.
a. ≥1 cm in greatest dimension
“Recommendations for diagnostic FNA of a thyroid nodule
based on sonographic pattern: RECOMMENDATION 8 - I.
Thyroid nodule diagnostic FNA(B) is recommended for: (A)
Nodules ≥1 cm in greatest dimension with high suspicion
sonographic pattern. (B) Nodules ≥1 cm in greatest dimension
with intermediate suspicion sonographic pattern. (C) Nodules
≥1.5 cm in greatest dimension with low suspicion sonographic
pattern. II. Thyroid nodule diagnostic FNA(B) may be
considered for: (D) Nodules ≥2 cm in greatest dimension with
very low suspicion sonographic pattern (i.e., spongiform).
Observation without FNA is also a reasonable option. III.
Thyroid nodule diagnostic FNA(B) is not required for: (E)
Nodules that do not meet the above criteria. (F) Nodules that
are purely cystic.”
16. Which of the following should be performed to survey the
cervical lymph nodes in patients with known or suspected
thyroid nodules?
b. Thyroid sonography
“Thyroid sonography: RECOMMENDATION 6 - Thyroid
sonography with survey of the cervical lymph nodes should be
performed in all patients with known or suspected thyroid
nodules.”
17. True or False: Surgery should be considered for
histopathologic diagnosis if the cytologically nondiagnostic
nodule has a high suspicion sonographic pattern.
a. True
“Surgery should be considered for histopathologic diagnosis if
the cytologically nondiagnostic nodule has a high suspicion
sonographic pattern, growth of the nodule (>20% in two
dimensions) is detected during US surveillance, or clinical risk
factors for malignancy are present.”
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18. Thyroid nodule diagnostic fine needle aspiration with
biopsy FNA(B) may be considered for nodules with
sonographic pattern of
a. ≥2 cm in greatest dimension with spongiform pattern.
“Recommendations for diagnostic FNA of a thyroid nodule
based on sonographic pattern: RECOMMENDATION 8 - … II.
Thyroid nodule diagnostic FNA(B) may be considered for: (D)
Nodules ≥2 cm in greatest dimension with very low suspicion
sonographic pattern (i.e., spongiform). Observation without
FNA is also a reasonable option.”
19. If a cytology result is diagnostic for primary thyroid
malignancy,
c. surgery is generally recommended.
“Malignant cytology: RECOMMENDATION 12 - If a cytology
result is diagnostic for primary thyroid malignancy, surgery is
generally recommended.”
20. How should multinodular thyroid glands (i.e., two or more
clinically relevant nodules) be evaluated for malignancy?
b. It is reasonable to aspirate the largest nodules (≥2 cm)
“How should multinodular thyroid glands (i.e., two or more
clinically relevant nodules) be evaluated for malignancy?:
RECOMMENDATION 21 - (A) Patients with multiple thyroid
nodules ≥1 cm should be evaluated in the same fashion as
patients with a solitary nodule ≥1 cm, excepting that each
nodule that is >1 cm carries an independent risk of malignancy
and therefore multiple nodules may require FNA. (B) When
multiple nodules ≥1 cm are present, FNA should be performed
preferentially based upon nodule sonographic pattern and
respective size cutoff. (C) If none of the nodules has a high or
moderate suspicion sonographic pattern, and multiple
sonographically similar very low or low suspicion pattern
nodules coalesce with no intervening normal parenchyma, the
likelihood of malignancy is low and it is reasonable to aspirate
the largest nodules (≥2 cm) or continue surveillance without
FNA.”
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21. With nodules with high suspicion ultrasound pattern,
ultrasound and US-guided FNA should be repeated
b. within 12 months.
“How should multinodular thyroid glands (i.e., two or more
clinically relevant nodules) be evaluated for malignancy? …
RECOMMENDATION 23 - Given the low false-negative rate of
US-guided FNA cytology and the higher yield of missed
malignancies based upon nodule sonographic pattern rather
than growth, the follow-up of thyroid nodules with benign
cytology diagnoses should be determined by risk stratification
based upon US pattern. (A) Nodules with high suspicion US
pattern: repeat US and US-guided FNA within 12 months. (B)
Nodules with low to intermediate suspicion US pattern: repeat
US at 12–24 months. If sonographic evidence of growth (20%
increase in at least two nodule dimensions with a minimal
increase of 2 mm or more than a 50% change in volume) or
development of new suspicious sonographic features, the FNA
could be repeated or observation continued with repeat US,
with repeat FNA in case of continued growth. (C) Nodules with
very low suspicion US pattern (including spongiform nodules):
the utility of surveillance US and assessment of nodule growth
as an indicator for repeat FNA to detect a missed malignancy is
limited. If US is repeated, it should be done at ≥24 months.”
22. True or False: If the nodule is benign on cytology, further
immediate diagnostic studies or treatment are not
required.
a. True
“Benign cytology: RECOMMENDATION 11 - If the nodule is
benign on cytology, further immediate diagnostic studies or
treatment are not required.”
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23. Patients with nodules with high suspicion ultrasound
patterns should repeat ultrasound
a. in 6–12 months.
“Follow-up for nodules that do not meet FNA criteria:
RECOMMENDATION 24 - Nodules may be detected on US that
do not meet criteria for FNA at initial imaging
(Recommendation 8). The strategy for sonographic follow-up
of these nodules should be based upon the nodule’s
sonographic pattern. (A) Nodules with high suspicion US
pattern: repeat US in 6–12 months….”
24. What is the role of medical or surgical therapy for benign
thyroid nodules in iodine sufficient populations?
d. Routine TSH suppression therapy is not recommended.
“What is the role of medical or surgical therapy for benign
thyroid nodules? RECOMMENDATION 25 - Routine TSH
suppression therapy for benign thyroid nodules in iodine
sufficient populations is not recommended. Though modest
responses to therapy can be detected, the potential harm
outweighs benefit for most patients.”
25. The role of molecular testing in guiding postoperative RAI
use
c. has yet to be established.
“What is the role of molecular marker status in therapeutic RAI
decision-making? The role of molecular testing in guiding
postoperative RAI use has yet to be established; therefore, no
molecular testing to guide postoperative RAI use can be
recommended at this time.”
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