ATA Guidelines Tools

11 Î In patients with persistent or recurrent MTC following thyroidectomy one should consider laparoscopic or open evaluation and biopsy of the liver to exclude occult metastases before subjecting them to a long and arduous repeat neck operation. (C) Î Brain imaging should be performed in patients with metastatic MTC and neurologic symptoms, including patients who are candidates for systemic therapy. Patients with isolated brain metastases are candidates for surgical resection or EBRT (including stereotactic radiosurgery). Whole brain EBRT is indicated for multiple brain metastasis. (C) Î Patients with spinal cord compression require urgent treatment with glucocorticoid therapy and surgical decompression. If patients are not candidates for surgery, EBRT alone should be administered. (C) Î Patients with MTC who have fractures or impending fractures require treatment. Therapeutic options include surgery, thermoablation (radiofrequency or cryotherapy), cement injection, and EBRT. (C) Î Treatment with denosumab or bisphosphonates is recommended for patients with painful osseous metastases. (C) Î Surgical resection should be considered in patients with large solitary lung metastases. Radiofrequency ablation should be considered when the metastases are peripheral and small. Systemic therapy should be considered in patients with multiple metastases that are progressively increasing in size. (C) Î Surgical resection should be considered in patients with large isolated hepatic metastases. Chemoembolization should be considered in patients with disseminated tumors <30 mm in size involving less than a third of the liver. (C) Î If possible cutaneous metastases should be excised surgically. Multiple cutaneous lesions are best treated by EBRT or ethanol injection. (C) Î Palliative therapy, including surgery, EBRT, or systemic therapy, should be considered in patients with metastases causing pain, mechanical compression, or signs and symptoms of hormonal excess. (C) Î The use of single agent or combinatorial cytotoxic chemotherapeutic regimens should not be administered as first-line therapy in patients with persistent or recurrent MTC, given the low response rates and the advent of promising new treatment options. (D) Î Treatment with radiolabeled molecules or pre-targeted radio- immunotherapy may be considered in selected patients, ideally in the setting of a well-designed clinical trial. (C)

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