Table 3.
ATA Guidelines on Low-Risk DTC Management Over the Past 10 years
| 2006 | 2009 | 2015 | |
|---|---|---|---|
| Surgery | |||
| Total thyroidectomy vs lobectomy | Recommend total thyroidectomy if DTC >1–1.5 cm, contralateral thyroid nodules, regional or distant metastases, history of head/neck radiation, or first-degree family member with thyroid cancer; age > 45 also may result in total thyroidectomy | Recommend total thyroidectomy if DTC >1 cm | Recommend either total thyroidectomy or lobectomy for cancer >1 cm and <4 cm without ETE and nodal metastases |
| Lobectomy may be sufficient if small (<1 cm), low-risk, isolated intrathyroidal PTC without nodal metastases | Lobectomy may be sufficient for small (<1 cm), low-risk, unifocal intrathyroidal PTC if no history of head or neck radiation or clinically involved nodal metastases | Recommend lobectomy for cancers <1 cm without ETE or nodal metastases, unless indications to remove contralateral lobe | |
| Prophylactic central neck dissection | Routine pCLND should be considered for patients with PTC and suspected Hurthle cell cancer | Routine pCLND may be performed in patients with PTC, especially if T3 or T4 tumors | pCLND should be considered for PTC if tumors are T3 or T4, if lateral neck lymph nodes are clinically involved, or if the information will help plan further treatment |
| RAI ablation | |||
| When to treat | Recommended for all patients with stage II disease <45 years, most patients with stage II disease >45 years | Remnant ablation is not recommended if unifocal or multifocal tumor <1 cm without other high-risk features | RAI remnant ablation is not routinely recommended for unifocal PTmC, multifocal PTmC, and other low-risk DTC; however, specific features of the patient that affect recurrence risk, disease follow-up implications, and patient preferences should be considered |
| Recommended for select stage I disease and if multifocal disease, nodal metastases, extrathyroidal or vascular invasion, and/or more aggressive histologies | Selective use for other low-risk patients when age, tumor size, lymph node status, and individual histology predict an intermediate to high risk of recurrence or death | ||
| Preparation | LT4 withdrawal or rhTSH stimulation | LT4 withdrawal or rhTSH stimulation | rhTSH stimulation is an acceptable alternative to withdrawal |
| Dose for remnant ablation | 30–100 mCi | 30–100 mCi | 30 mCi is favored over higher doses |
| Goal TSH | |||
| Initial goal | 0.1–0.5 mIU/L for low-risk patients | 0.1–0.5 mIU/L for low-risk patients | 0.5–2.0 mIU/L unless there is a low-level serum Tg, in which case goal is 0.1–0.5 mIU/L; after total thyroidectomy with RAI, Tg ≥0.2 ng/mL is considered to be low level, whereas the Tg cutoff is less clear if total thyroidectomy and no RAI or if lobectomy |
| Long-term goal | 0.3–2.0 mIU/L in patients free of disease, especially if low risk of recurrence | 0.3–2.0 mIU/L in patients free of disease, especially if low risk of recurrence | 0.5–2.0 mIU/L in patients with an excellent or indeterminate response to therapy, especially those at low risk for recurrence |