Matthew Beasley Consultant Clinical Oncologist Bristol C ancer Institute Head amp Neck SSG June 2015 Regional Thyroid Cancer Guidelines Published in Clinical Endocrinology 3714 online ID: 310216
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Slide1
Regional Thyroid Cancer Guidelines
Matthew Beasley
Consultant Clinical Oncologist
Bristol
C
ancer Institute
Head & Neck SSG
June 2015Slide2
Regional Thyroid Cancer Guidelines
Published in Clinical Endocrinology 3.7.14 (online)Volume 81, Issue supplement s1Meeting at UHBristol 20.3.15 to rewrite our regional guidelinesSlide3
Main Changes
Introduction of Personalised Decision MakingExpanded indications for
hemithyroidectomy
Evaluation of remission status
Dynamic Risk Stratification
Move away from long term TSH suppression for the majority
Follow-upSlide4
(1) Personalised Decision Making
When the evidence for or against a treatment is inconclusive and no well designed, peer reviewed randomised or prospective national or institutional studies are ongoing to address this issue or if available, declined by the patient, these guidelines recommend a personalised approach to decision makingSlide5
(2) Expanded indications for
hemithyroidectomyPersonalised Decision Making< 4cm without additional risk factors (evidence of nodal spread or suspicious features in the contralateral lobe on ultrasound, high risk histology including Hurtle cell)
R
adiation induced tumours 1-4cmSlide6
(3) Evaluation of Remission Status
Original GuidelinesStimulated thyroglobulin at 6-9 monthsWhole body nuclear medicine scan and/or ultrasound neck at 6-9 months
2014 Guidelines
Stimulated
thyroglobulin at 9-12 months
Ultrasound neck at 9-12 months
(whole body scan only if initial scan shows unexpected findings)Slide7
(4) Dynamic Risk Stratification
Excellent Response
Indeterminate Response
Incomplete Response
All of the following
Suppressed and stimulated
Tg
< 1ug/l*
Neck US without evidence of disease
Cross sectional imaging and/or nuclear medicine imaging negative (if performed)
Any of the following
Suppressed
Tg
< 1ug/l and stimulated
Tg
≥ 1 and < 10ug/l*
Neck US with non specific changes or stable sub
centimetre
nodes
Cross sectional imaging and/or nuclear medicine imaging with non-specific changes, although not completely normal
Any of the following
Suppressed
Tg
≥ 1ug/l or stimulated
Tg
≥ 10ug/l*
Rising
Tg
Persistent or newly identified disease on cross-sectional and/or nuclear medicine imaging
Low risk
Intermediate risk
High riskSlide8
(5) Move away from long term TSH suppression
Classification
TSH target
Hemithyroidectomy
and no radio-iodine
0.3 - 2.0
Excellent Response
0.3 – 2.0
Indeterminate Response
0.1
– 0.5 for 5 – 10 years
Incomplete Response
<0.1 indefinitely Slide9
(6) Follow-up
Patients treated with hemithyroidectomy alone do not require long term follow Patients with excellent response / low risk on ATA criteria who are disease free at 5 years and no longer judged to require TSH suppression may be discharged to a to primary care or a nurse-led clinic with explicit instructions. Slide10
Challenges
More pressure on ultrasound servicesMore discussions about uncertaintyPossible confusion over varied TSH target rangesSafe discharge to primary care