ATA Guidelines Tools

8 Differentiated Thyroid Cancer Î CND is recommended for children with malignant cytology and clinical evidence of gross extrathyroidal invasion and/or loco-regional metastasis on pre-operative staging or intra-operative findings. This approach may be associated with a decreased need for second surgical procedures and increased DFS. (B) Î For patients with PTC and no clinical evidence of gross extrathyroidal invasion and/or loco-regional metastasis, prophylactic CND may be selectively considered based upon tumor focality and size and the experience of the surgeon. For patients with unifocal disease, ipsilateral CND, with pursuit of contralateral CND based on intra- operative findings, may help balance the risks and benefits. (C) Î Compartment-oriented resection is the recommended approach for lymph node dissection. "Berry picking" and attempting to use palpation to determine if metastatic disease is present in a lymph node are not recommended. (A) Î Future studies to assess if TT with prophylactic CND dissection will lead to reduced reliance on I treatment, re-operative procedures, and improved DFS are recommended. (C) Î Cytological confirmation of metastatic disease to lymph nodes in the lateral neck is recommended prior to surgery. Routine prophylactic lateral neck dissection (levels III, IV, anterior V, and II) is not recommended. However, lateral neck dissection should be performed on patients with cytologic evidence of metastases to the lateral neck. Measurement of Tg in the FNA washout can be considered if the cytological diagnosis is equivocal. (B) Î Pediatric thyroid surgery should be performed in a hospital with the full spectrum of pediatric specialty care, to include, but not be limited to: endocrinology, radiology (ultrasound and anatomic imaging), nuclear medicine, anesthesia, a high volume thyroid surgeon, and intensive care. Î The early incorporation of calcium and calcitriol in patients at high-risk for hypocalcemia may decrease the risks of symptomatic hypocalcemia. Postoperative iPTH measurement may be used to help predict which patients would benefit from more intensive monitoring and treatment. (B) Î Postoperative staging is usually performed within 12 weeks after surgery (Figure 2) and allows for stratification of patients who may or may not benefit from further therapy, to include additional surgery or 131 I therapy. ATA Pediatric Low- Risk patients may be initially assessed and followed with a TSH-suppressed Tg alone. In contrast, a TSH- stimulated Tg and a DxWBS is typically recommended to assess for evidence of persistent disease in ATA Pediatric Intermediate- and High-Risk patients. Additional imaging, to include neck US and/or hybrid imaging using SPECT/CT, may be used conjunctively to more accurately define the anatomic location of RAI uptake noted on a DxWBS. Whenever possible, 123 I should be used for the DxWBS. (B)

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