Cancer Care Ontario Thyroid Cancer Guideline: An Endorsement of the 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer

Guideline Objective

The objectives of this guideline are to provide clinical practice recommendations for the management of thyroid nodules and differentiated thyroid cancers. Our recommendations are based on the 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer [1] (the 2015 ATA Guidelines).

Patient Population

Adults with thyroid nodules and differentiated thyroid cancers

Intended Guideline Users

Healthcare providers involved in the management of thyroid diseases.

Research Questions

What is the role of thyroid cancer screening in people with familial follicular cell-derived differentiated thyroid cancer?

What is the appropriate laboratory and imaging evaluation for patients with clinically or incidentally discovered thyroid nodules?

What is the role of FNA, cytology interpretation, and molecular testing in patients with thyroid nodules?

What are the principles of the molecular testing of FNA samples?

What is the utility of 18FDG-PET scanning to predict malignant or benign disease when FNA cytology is indeterminate (AUS/FLUS, FN, SUSP)?

What is the appropriate operation for cytologically indeterminate thyroid nodules?

How should multinodular thyroid glands (i.e., two or more clinically relevant nodules) be evaluated for malignancy?

What are the best methods for long-term follow-up of patients with thyroid nodules?

What is the role of medical or surgical therapy for benign thyroid nodules?

How should thyroid nodules in pregnant women be managed?

What is the role of preoperative staging with diagnostic imaging and laboratory tests?

What is the appropriate perioperative approach to voice and parathyroid issues?

What are the basic principles of histopathologic evaluation of thyroidectomy samples?

What initial stratification system should be used to estimate the risk of persistent/recurrent disease?

How should initial risk estimates be modified over time?

Should post-operative disease status be considered in decision-making for RAI therapy for patients with DTC?

What is the role of molecular marker status in therapeutic RAI decision-making?

How long does thyroid hormone need to be withdrawn in preparation for RAI remnant ablation/treatment or diagnostic scanning?

Can recombinant human (rh) TSH (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?

What activity of 131I should be used for remnant ablation or adjuvant therapy?

Is a low-iodine diet necessary before remnant ablation?

Should a post-therapy scan be performed following remnant ablation or adjuvant therapy?

What is the appropriate degree of initial TSH suppression?

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

What are the appropriate features of long-term management?

What are the criteria for absence of persistent tumour (excellent response)?

What are the appropriate methods for following patients after initial therapy?

What is the role of serum Tg measurement in patients who have not undergone radioiodine remnant ablation?

What is the role of US and other imaging techniques (RAI SPECT-CT, CT, MRI, PET-CT) during follow-up?

What is the role of TSH suppression during thyroid hormone therapy in the long-term follow-up of DTC?

What is the most appropriate management of DTC patients with metastatic disease?

What is the optimal directed approach to patients with suspected structural neck recurrence?

What is the surgical management of aerodigestive invasion?

How should RAI therapy be considered for loco-regional or distant metastatic disease?

How should distant metastatic disease to various organs be treated?

When should empiric RAI therapy be considered for Tg-positive, RAI diagnostic scan–negative patients?

What is the management of complications of RAI therapy?

How should patients who have received radioiodine therapy be monitored for risk of secondary malignancies?

What other testing should patients receiving RAI therapy undergo?

How should patients be counselled about radioiodine therapy and pregnancy, nursing, and gonadal function?

How is RAI-refractory DTC classified?

Which patients with metastatic thyroid cancer can be followed without additional therapy?

What is the role for directed therapy in advanced thyroid cancer?

Who should be considered for clinical trials?

What is the role of systemic therapy (kinase inhibitors, other selective therapies, conventional chemotherapy, b-isphosphonates, denosumab) in treating metastatic DTC?