Regional Thyroid Cancer Guidelines

• Matthew Beasley• Consultant Clinical

Oncologist• Bristol Cancer

Institute

• Head & Neck SSG • June 2015

Regional Thyroid Cancer Guidelines

• Published in Clinical Endocrinology 3.7.14 (online)

• Volume 81, Issue supplement s1• Meeting at UHBristol 20.3.15 to rewrite our

regional guidelines

Main Changes

1. Introduction of Personalised Decision Making2. Expanded indications for hemithyroidectomy3. Evaluation of remission status4. Dynamic Risk Stratification5. Move away from long term TSH suppression

for the majority6. Follow-up

(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 making

(2) Expanded indications for hemithyroidectomy

• Personalised 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)

• Radiation induced tumours 1-4cm

(3) Evaluation of Remission Status

• Original Guidelines• Stimulated

thyroglobulin at 6-9 months

• Whole 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)

(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 risk

(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

(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.

Challenges

• More pressure on ultrasound services• More discussions about uncertainty• Possible confusion over varied TSH target

ranges• Safe discharge to primary care