11
Figure 3. Management of the Pediatric Patient with
Known or Suspected Residual/Recurrent Disease
(No Known Distant Metastases)
Cervical
uptake
No
uptake
Distant
metastases
Tg
1
on LT4
Detectable
Neck US
FNA if feasible &
surgical consultation;
consider CT/MRI neck
Previous
therapeutic RAI
123
I diagnostic whole body
scan & TSH-stimulated Tg
1
;
CT chest without contrast
Negative
Positive
YES
Not amenable
to surgery
Amenable
to surgery
Surgery
Previous therapeutic RAI
123
I diagnostic whole body
scan & TSH-stimulated Tg
1
(see Figure 2)
NO
NO
Observation on
LT4 Suppression
YES
Surgery
Amenable
to surgery
Stimulated Tg
1
>10 ng/ml
Stimulated Tg
1
2-10 ng/ml
Stimulated Tg
1
<2 ng/ml
Not amenable
to surgery
Imaging
2
to identify
resectable disease
& surgical consult
131
I therapy
3
&
post-treatment
scan (see Figure 4)
Tg
1
stable or declining
YES
NO
1
Assumes a negative TgAb. In TgAb-positive patients, the presence of TgAb alone cannot be
interpreted as a sign of disease unless the titer is clearly rising.
2
Imaging includes SPECT/CT at the time of the diagnostic thyroid scan and/or contrast-enhanced
CT/MRI neck.
3
Repeat
131
I therapy in patients previously treated with high-dose
131
I should generally be
undertaken only if iodine-avid disease is suspected and a response to previous
131
I therapy was
observed.
