ATA Guidelines Tools

3 Table 1. Key Steps in the Management of Anaplastic Thyroid Cancer (cont'd) 4. Undertake patient counseling in order to establish individualized patient goals of care Counseling must be provided by a team/individuals skilled in the surgical, medical, and palliative management of complex thyroid malignancies in which tradeoffs counterbalancing risks and benefits with goals of care are completely discussed. This counseling should best involve not only the patient but also involve supportive individuals/family members. 5. Evaluate Surgical Options • The primary goals in stages IVA and IVB ATC patients within an aggressive approach to their care are complete resection and prompt transition to adjuvant definitive-intention therapy, as long-term survival may be attainable. Thus, surgical procedures should not generate a wound or result in complications that would prevent chemotherapy and radiation onset due to the risk of wound breakdown given the lack of data supporting an association between increased extent of surgery and improved survival outcomes. • In IVC ATC, the limited benefit resulting from surgery must be carefully tempered in consideration of other available palliative approaches, including radiation and systemic therapy. 6. Surgical decision making Rapidly assess resectability determining tumor invasion of the larynx, trachea, esophagus and status of the major vessels of the neck. Consider the need for tracheotomy, extent of thyroidectomy, neck dissection, and the need to avoid laryngectomy, esophageal resection, and major vessel reconstruction. Balancing morbidity from surgery with expected benefits within the context of patient anticipated prognosis and individualized goals of care is paramount. Considerations: • Performance score/status • Presence of distant metastasis • Extent of local invasion of trachea and esophagus • Need for urgent tracheostomy, understanding that placement of a tracheostomy results in immediate improvement in upper airway obstruction but requires significant education for care and understanding that tumor location and growth may make management of the tracheotomy complex • Patient goals of care and willingness to accept anticipated morbidity of planned surgery

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