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Regional Thyroid Cancer Guidelines Regional Thyroid Cancer Guidelines

Regional Thyroid Cancer Guidelines - PowerPoint Presentation

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Regional Thyroid Cancer Guidelines - PPT Presentation

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

response risk tsh neck risk response neck tsh imaging guidelines decision making ultrasound hemithyroidectomy personalised medicine nuclear stimulated suppression regional follow excellent

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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