ATA Guidelines Tools

15 Persistent/Recurrent Cervical Disease Î The decision to treat or to observe structurally identifiable cervical disease should be individualized and include considerations of age, initial ATA Pediatric Risk classification, the presence of distant metastases, and prior treatment history (including complications from previous therapy), in addition to the size, extent, anatomic location and iodine avidity of the disease (see Figure 3). (C) Î Children with macroscopic cervical disease (>1 cm in size) should be assessed by a high-volume thyroid surgeon to determine the feasibility of additional surgery. (B) Î Iodine-avid cervical disease (visualized with DxWBS) could be treated with surgery or 131 I depending on individual patient risks and the presence or absence of distant metastases. Surgery would be favored for disease localized to the neck, especially if located in a lymph node compartment not previously operated upon. (B) Î If repeat surgery is performed, postoperative re-staging can be utilized to determine whether additional 131 I treatment is warranted, especially in the patient who has not received previous therapeutic 131 I. (B) Pulmonary Metastases Î Children with RAI-avid pulmonary metastases visualized with a DxWBS are good candidates for 131 I therapy. (B) Î After a therapeutic activity of 131 I, the TSH-suppressed Tg level and imaging studies should be monitored until the full clinical and biochemical (Tg) response is reached. (B) Î If the full clinical and biochemical (Tg) response suggests persistent disease or if there is documented disease progression >12 months after 131 I therapy, further evaluation with a DxWBS and a TSH- stimulated Tg is indicated. (B) Î Re-treatment of RAI-avid pulmonary metastases should be considered in children who have demonstrated progression of disease and a previous response to 131 I, with each treatment carefully individualized based on the child's unique clinical course, side-effect profile, risk tolerance, and cumulative administered 131 I activity. Treatment with 131 I should be performed by experts with experience in managing children with pulmonary metastases. (B) Î Re-treatment of pulmonary metastases with 131 I is not recommended in children who do not have uptake on a DxWBS and who have not demonstrated a previous response to 131 I. (E)

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