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7 Treatment Î Children with DTC should be cared for by teams of physicians experienced in the management of DTC in children. This will facilitate interdisciplinary decisions regarding optimal therapy and will help to reduce the possibility that treatment and long-term follow up will be either overly aggressive or inadequate. (C) Surgery Î Pediatric thyroid surgery, especially if compartment-focused lymph node resection is indicated, should ideally be performed by a surgeon who performs at least 30 or more cervical endocrine procedures annually. Thyroid surgery performed under these guidelines is associated with lower complications rates, decreased hospital stay and lower cost. (B) Î A comprehensive neck US to interrogate all regions of the neck is required in order to optimize the pre-operative surgical plan. FNA of suspicious lateral neck lymph nodes is recommended. Anatomic imaging by MRI or CT with contrast should be considered in patients with large or fixed thyroid masses, vocal cord paralysis, or bulky metastatic lymphadenopathy in order to optimize surgical planning. (A) Î For the majority of children, total thyroidectomy is recommended. The rationale for this approach is based on multiple studies showing an increased incidence of bilateral and multi-focal disease. In long-term analysis, bilateral lobar resection compared with lobectomy has been shown to decrease the risk for persistent/recurrent disease. (A) Table 3. Footnotes Please refer to Table 2 for AJCC TNM classification system. FTC, follicular thyroid carcinoma; Tg, thyroglobulin; TSH, thyroid stimulating hormone; US, ultrasound 1 "Risk" is defined as the likelihood of having persistent cervical disease and/or distant metastases aer initial total thyroidectomy ± lymph node dissection by a high volume thyroid surgeon and is not the risk for mortality, which is extremely low in the pediatric population. See Section C7 for further discussion. 2 Initial postoperative staging that is done within 12 weeks aer surgery. 3 ese are initial targets for TSH suppression and should be adapted to the patient's known or suspected disease status. In ATA Pediatric Intermediate- and High-risk patients who have no evidence of disease aer 3- 5 years of follow-up, the TSH can be allowed to rise to the low normal range. 4 Postoperative surveillance implies studies done at 6 months aer the initial surgery and beyond in patients who are believed to be disease free. e intensity of follow up and extent of diagnostic studies are determined by initial postoperative staging, current disease status, and whether or not 131 I was given and may not necessarily apply to patients with known or suspected residual disease (See Figure 3) or FTC. 5 Assumes a negative TgAb. In TgAb-positive patients, consideration can be given (except in patients with T4 or M1 disease) to deferred postoperative staging to allow time for TgAb clearance.

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