ATA Guidelines Tools

Recurrent / Persistent Nodal Disease

American Thyroid Association Quick-Reference GUIDELINES Apps

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Key Points Î Thyroid cancer is the most common endocrine malignancy. In 2014 it is estimated that 96% of all new endocrine organ cancers will originate from the thyroid gland, resulting in approximately 63,000 new cases and taking the lives of 1890 patients. Î Gross lymph node metastases can be present in approximately 35% of patients with differentiated thyroid cancer (DTC). Î Although lymph node metastases are common in DTC, death is not, and the lack of a clear prognostic indication has led to controversy in the management of cervical lymph nodes. Î What may be more significant from a prognostic standpoint are lymph node metastases that are larger than 3 cm, exhibit extranodal extension, or metastasis present in more than five lymph nodes. Î Identification of recurrent/persistent disease requires a team decision- making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Diagnosis Table 1. Variables to Consider When Deciding How Best to Manage a Differentiated Thyroid Cancer Patient with Recurrent/Persistent Nodal Disease Variables Consider active surveillance Consider surgery Key considerations Absolute size of lymph nodes (any dimension) a • ≤0.8 cm (central compartment) • <1 cm (lateral compartment) • >0.8 cm (central compartment) • ≥1 cm (lateral compartment) Rate of lymph node growth on serial imaging Minimal/slow (<3–5 mm/year) Progressive (>3–5 mm/year) Vocal cord paralysis contralateral to the paratracheal nodal basin where the positive lymph node is located (next to only working RLN) Strongly consider observation if node is stable Consider surgery if node is increasing in size and expertise for reoperative surgery available Known systemic metastases Progressive distant disease outpacing nodal metastasis Stable distant metastasis, but nodal disease threatens vital structures

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