Guidelines for Management of Thyroid Nodules and ... Guidelines 2009 Low Risk ... Intrathyroidal DTC ... Guidelines for Management of Thyroid Nodules and Differentiated Thyroid Cancer

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  • (Not so) New Guidelines for Management of Thyroid Nodules and Differentiated Thyroid Cancer

    Bryan R. Haugen, MDUniversity of Colorado, School of Medicine

    Minnesota/Midwest Chapter of AACE

  • Outline

    Some statistics

    New guidelines grading system

    New/changed guidelines

    Summary review of the guidelines

    Disclosures

    Research support/honoraria from Genzyme

    Consultant for Eisai

  • Davis MM, JAMA 305:2343, 2011

    2017 2030

  • 2017

    Thyroid Cancer Annual increase(incidence)

    Annual increase (mortality)

    All 3.6% 1.1%

    Distant Mets 2.4% 2.9%

  • Adapted ACP system

  • Are the new guidelines different from the 2009 guidelines?

    2009 2015

    Recommendations 80 101

    Sub-recommendations 103 175

    References 437 1078

    Tables 5 17

    Figures 5 8

    Goal: To be evidence-based and helpful

    New questions 8New recommendations 21

    Significantly changed recommendations - 21

  • Haugen BR, Cancer 2016

  • Example of Strong RecommendationsBased on Low-quality Evidence

    Recommendation 33A: 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.

  • Patient #1

    48 yo male incidental 8 mm thyroid nodule

    High suspicion sonographic pattern, no abnormal LN

    Thyroidectomy, calcitonin, FNA, monitor

    Risk of PTC?Risk of bad outcome?

  • Sonographic patterns High suspicion [malignancy risk 70-90%]: Solid hypoechoic

    nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins, microcalcifications, taller than wide shape.

    Intermediate suspicion [malignancy risk 10-20%]:Hypoechoic solid nodule without high suspicion features

    Low suspicion [malignancy risk 5-10%]: Isoechoic or hyperechoic solid nodule, or partially (> 50%) cystic nodule, with eccentric solid area without high suspicion features

    Very low suspicion [

  • carotid

    jugular

    Microcalcifications ,

    hypoechoic nodule irregular margins taller than wideirregular margins,

    extrathyroidal

    extension

    nodule with irregular margins,

    suspicious left lateral lymph node

    hypoechoic solid regular margin

    isoechoic solid regular marginhyperechoic solid regular margin

    spongiform

    partially cystic no suspicious

    features partially cystic no suspicious features

    cyst

    Ris

    k o

    f m

    ali

    gn

    an

    cy

    partially cystic with

    eccentric solid area

    hypoechoic solid

    regular margin

    microcalcifications,

    hyperechoic cystic

    nodule

    partially cystic with

    eccentric solid areas

    Benign

    1 cm

    > 1.5 cm

    > 2 cmIf at all

    Biopsy not needed to r/o malignancyFigure 2

  • J Am College Radiology 2017

  • Patient #1

    48 yo male incidental 8 mm thyroid nodule

    High suspicion sonographic pattern, no abnormal LN

    Active surveillance (monitor)

    (FNA is not required)

  • Follow-up for nodules that do not meet FNA criteria

    RECOMMENDATION 24 (NEW)

    A) Nodules with high suspicion US pattern: repeat US 6-12 months (Weak recommendation, Low-quality evidence)

    B) Nodules with sonographic features of low to intermediate suspicion US pattern: consider repeat US at 12-24 months. (Weak recommendation, Low-quality evidence).

    C) Nodules 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 (No recommendation, Insufficient evidence)

    D) Nodules < 1 cm without high suspicion US pattern do not require routine sonographic FU and if repeated, the US should be performed at 24 months or later (Weak recommendation, Low-quality evidence)

  • Patient #2

    38 yo female 2.7 cm high suspicion sonographic pattern

    No abnormal neck LN

    FNA - PTC

    Thyroidectomy with central neck dissectionThyroidectomy

    Thyroidectomy or lobectomyLobectomy

    Observation

  • FNA PTC2.7 cm

    2009 Recommendation: ThyroidectomyBilimoria KY, Ann Surg 2007

    RECOMMENDATION 35PTC >1 cm and

  • Patient #3

    56 yo male FNA PTC

    US no abnormal LN

    Thyroidectomy and central neck dissection

    Path report 3.8 cm FVPTC, involved LN

    Helpful pathology report?

  • Recommendation 46 (NEW)Pathology reports should include:AJCC/TNM criteriaVascular invasion and number of vesselsNumber of LN examined and involvedSize of the largest metastatic LN focusExtranodal extension(Strong recommendation, Moderate-quality evidence)

    Randolph GW, Thyroid 2012Yamashita H, Cancer 1997Lango M, Thyroid 2013Collini P, Histopath 2004

    Variants with more favorable and unfavorable outcomes(Strong recommendation, Low-quality evidence)

    Variants associated with familial syndromes(Weak recommendation, Low-quality evidence)

    Cetta F, JCEM 2000Laury AR, Thyroid 2011

    Volante M, Cancer 2004

  • Patient #3

    56 yo male FNA PTC

    US no abnormal LN

    Thyroidectomy and central neck dissection

    Path report: 3.8 cm FVPTC

    Extrathyroid extension, negative margins

    No vascular invasion

    11/12 LN involved, largest 1.2 cm, no ENE

    T3N1aMX, Stage III, ATA intermediate risk

    Post-op TSH 0.2, Tg 1.8, Ab

  • System for Estimating Risk of Persistent or Recurrent DiseaseATA Guidelines 2009

    Low RiskClassic PTC

    No local or distant metsComplete resection

    No ETENo vascular invasion

    If given, no RAI uptake outside TB

    Intermediate RiskMicroscopic ETECervical LN mets

    Aggressive HistologyVascular invasion

    High RiskMacroscopic gross ETE

    Incomplete tumor resectionDistant MetsTg elevationTuttle et al, Thyroid 2010

    Vaisman at al, Clin Endo 2012Pitoia et al, Thyroid 2013

    78-91% NED2-7% Structural Incomplete

    52-63% NED21-34% Structural Incomplete

    14-31% NED56-72% Structural Incomplete

    Cooper et al, Thyroid 2009

  • Risk of Structural Disease Recurrence(In patients without structurally identifiable disease after initial therapy)

    Low RiskIntrathyroidal DTC

    5 LN micrometastases (< 0.2 cm)

    Intermediate RiskAggressive histology , minor

    extrathyroidal extension, vascular invasion,

    or > 5 involved lymph nodes (0.2-3 cm)

    High RiskGross extrathyroidal extension,

    incomplete tumor resection, distant metastases,

    or lymph node >3 cm

    FTC, extensive vascular invasion ( 30-55%)

    pT4a gross ETE ( 30-40%)

    pN1 with extranodal extension, >3 LN involved ( 40%)

    PTC, > 1 cm, TERT mutated BRAF mutated* (>40%)

    pN1, any LN > 3 cm ( 30%)

    PTC, extrathyroidal, BRAF mutated*( 10-40%)

    PTC, vascular invasion ( 15-30%)

    Clinical N1 (20%)

    pN1, > 5 LN involved (20%)

    Intrathyroidal PTC, < 4 cm, BRAF mutated* (10%)

    pT3 minor ETE ( 3-8%)

    pN1, all LN < 0.2 cm (5%)

    pN1, 5 LN involved (5%)

    Intrathyroidal PTC, 2-4 cm ( 5%)

    Multifocal PMC ( 4-6%)

    pN1 without extranodal extension, 3 LN involved (2%)

    Minimally invasive FTC ( 2-3%)

    Intrathyroidal, < 4 cm, BRAF wild type* ( 1-2%)

    Intrathyroidal unifocal PMC, BRAF mutated*, ( 1-2%)

    Intrathyroidal, encapsulated, FV-PTC ( 1-2%)

    Unifocal PMC ( 1-2%)

    Figure 4

  • Risk of Structural Disease Recurrence(In patients without structurally identifiable disease after initial therapy)

    Low RiskIntrathyroidal DTC

    5 LN micrometastases (< 0.2 cm)

    Intermediate RiskAggressive histology , minor

    extrathyroidal extension, vascular invasion,

    or > 5 involved lymph nodes (0.2-3 cm)

    High RiskGross extrathyroidal extension,

    incomplete tumor resection, distant metastases,

    or lymph node >3 cm

    FTC, extensive vascular invasion ( 30-55%)

    pT4a gross ETE ( 30-40%)

    pN1 with extranodal extension, >3 LN involved ( 40%)

    PTC, > 1 cm, TERT mutated BRAF mutated* (>40%)

    pN1, any LN > 3 cm ( 30%)

    PTC, extrathyroidal, BRAF mutated*( 10-40%)

    PTC, vascular invasion ( 15-30%)

    Clinical N1 (20%)

    pN1, > 5 LN involved (20%)

    Intrathyroidal PTC, < 4 cm, BRAF mutated* (10%)

    pT3 minor ETE ( 3-8%)

    pN1, all LN < 0.2 cm (5%)

    pN1, 5 LN involved (5%)

    Intrathyroidal PTC, 2-4 cm ( 5%)

    Multifocal PMC ( 4-6%)

    pN1 without extranodal extension, 3 LN involved (2%)

    Minimally invasive FTC ( 2-3%)

    Intrathyroidal, < 4 cm, BRAF wild type* ( 1-2%)

    Intrathyroidal unifocal PMC, BRAF mutated*, ( 1-2%)

    Intrathyroidal, encapsulated, FV-PTC ( 1-2%)

    Unifocal PMC ( 1-2%)

  • Dr Saul Hertz treating a hyperthyroid patientJanuary 1941

    JAMA 1946

  • JCEM 2015

  • ATA recurrence riskTNM Staging

    Description Post-surgical RAI indicated?

    ATA Low RiskT1a/N0,NX/M0,MX

    T < 1cm(unifocal or multifocal)

    No (Strong, Mod)

    ATA Low RiskT1b, T2/N0,NX/M0,MX

    T 1-4 cm Not routine (W,L)

    ATA Low to intermediate riskT3/N0,NX/M0,MX

    T > 4cm or microscopic invasion

    Consider

    ATA Low to intermediate riskT1-3/N1a/M0,MX

    Central compartment LN metastases

    Consider(size and number)

    ATA Low to intermediate riskAnyT1-3/N1b/M0,MX

    Lateral compartmentLN metastases

    Consider(size