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14 Differentiated Thyroid Cancer Î Neck US is recommended in the follow-up of children with PTC (Table 3 and Figure 3). Neck US should be performed at least 6 months after initial surgery and then at 6-12 month intervals for ATA Pediatric Intermediate- and High-Risk patients and at annual intervals for ATA Pediatric Low-Risk patients. Follow-up beyond 5 years should be individualized based on recurrence risk. (A) Î During the follow up of children with PTC who are suspected to have residual disease, a DxWBS can be used to inform the decision of whether or not to use 131 I and the activity of 131 I to be administered (Figure 3). A final DxWBS can be considered to confirm the absence of iodine-avid disease in children who were previously treated with 131 I and who have no evidence of disease 1-2 years after initial therapy. (C) Î A DxWBS should be performed in children with ATA Pediatric High- Risk disease who were previously treated with 131 I or known to have iodine-avid metastatic disease based upon a previous posttreatment scan. The DxWBS should be obtained after at least 12 months of clinical follow-up, and deferred even longer in those children who continue to demonstrate a clinical response to previous treatment. (C) Î Once a negative DxWBS is obtained, there is no benefit from serial DxWBS to survey for disease recurrence as long as the patient otherwise remains without clinical evidence of disease. (B) Î For the child with a detectable TSH-suppressed Tg but a negative cervical US and DxWBS, contrast-enhanced cross-sectional imaging of the neck and chest should be considered once iodine excess has been eliminated as a cause of a false negative DxWBS. (B) Î The utility of 18FDG-PET/CT is poorly studied in pediatric DTC and 18FDG-PET/CT cannot be routinely recommended in the care of children who have persistent evidence of DTC on follow-up. (D) Î Empiric 131 I therapy and a posttreatment scan are not recommended to localize disease in the child with DTC and a negative DxWBS unless there is evidence for clinical progression (e.g. a rising Tg level) and a documented clinical response to previous 131 I therapy. (D) TSH Suppression Therapy Î TSH suppression in children with DTC should be determined by ATA Pediatric Risk level and current disease status (Table 3). In children with known or suspected persistent disease, TSH suppression should be maintained. In children with no evidence of disease, the TSH can be normalized to the low/normal range after an appropriate period of surveillance. (B)

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