Eka Yudhanto FK Undip / RSND Semarang
Scoring system : To treat thyroid malignancies appropriately, clinicians must have methods to accurately assess the behavior and outcomes from treatment of differentiated thyroid carcinoma
Scoring system :
Recommendation (ATA guidelines task force 2015): What is the appropriate operation for differentiated thyroid cancer? The goal of thyroid surgery : provision of a diagnosis after a nondiagnostic or indeterminate biopsy removal of the thyroid cancer staging Preparation for radioactive ablation
Because of an increased risk for malignancy, total thyroidectomy is indicated in patients with large tumors ( 4 cm) when marked atypia is seen on biopsy, when the biopsy reading is suspicious for papillary carcinoma, in patients with a family history of thyroid carcinoma, and in patients with a history of radiation exposure Recommendation A Patients with bilateral nodular disease or those who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe should also undergo total thyroidectomy Recommendation A
For patients with thyroid cancer > 1 cm and < 4 cm without extrathyroidal extension, and without clinical evidence of any lymph node metastases (cn0), the initial surgical procedure can be either a bilateral procedure (neartotal or total thyroidectomy) or a unilateral procedure (lobectomy). Thyroid lobectomy alone may be sufficient initial treatment for low-risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable RAI therapy or to enhance followup based upon disease features and/or patient preferences. (Strong recommendation, Moderate-quality evidence)
If surgery is chosen for patients with thyroid cancer < 1 cm without extrathyroidal extension and cn0, the initial surgical procedure should be a thyroid lobectomy unless there are clear indications to remove the contralateral lobe. Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal carcinomas in the absence of prior head and neck radiation, familial thyroid carcinoma, or clinically detectable cervical nodal metastases. (Strong recommendation, Moderate-quality evidence)
Therapeutic central-compartment (level VI) neck dissection for patients with clinically involved central nodes should accompany total thyroidectomy to provide clearance of disease from the central neck. (Strong recommendation, Moderate-quality evidence) Prophylactic central-compartment neck dissection (ipsilateral or bilateral) should be considered in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes (cn0) who have advanced primary tumors (T3 or T4) or clinically involved lateral neck nodes (cn1b), or if the information will be used to plan further steps in therapy. (Weak recommendation, Lowquality evidence)
Thyroidectomy without prophylactic central neck dissection is appropriate for small (T1 or T2), noninvasive, clinically node-negative PTC (cn0) and for most follicular cancers. (Strong recommendation, Moderatequality evidence) Therapeutic lateral neck compartmental lymph node dissection should be performed for patients with biopsy-proven metastatic lateral cervical lymphadenopathy. (Strong recommendation, Moderate-quality evidence)
Completion thyroidectomy should be offered to patients for whom a bilateral thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. Therapeutic central neck lymph node dissection should be included if the lymph nodes are clinically involved. Thyroid lobectomy alone may be sufficient treatment for low-risk papillary and follicular carcinomas. (Strong recommendation, Moderate-quality evidence) RAI ablation in lieu of completion thyroidectomy is not recommended routinely; however, it may be used to ablate the remnant lobe in selected cases. (Weak recommendation, Low-quality evidence)
Implications : Patients : Strong recommendation : Most would want course of action; a person should request discussion if an intervention is not offered. Weak recommendation : Many would want course of action, but some may not; the decision may depend on individual circumstances. Clinicians : Strong recommendation : Most patients should receive the recommended course of action. Weak recommendation : Different choices will be appropriate for different patients; the management decision should be consistent with patients preferences and circumstances.
Implications : Policy Makers : Strong recommendation : The recommendation can be adopted as policy in most circumstances. Weak recommendation : Policymaking will require careful consideration and stakeholder input....
References: