FNA OR CORE
BIOPSY FINDINGa DIAGNOSTIC PROCEDURES
• CT head,neck, chest, abdomen, pelvis
• Fiberoptic (or mirror- laryngoscopy)
aConsider core or open biopsy if FNA is “suspicious” for ATC or is not definitive. Morphologic diagnosis combined with immunohistochemistry is necessary in order to exclude other entities such as poorly differentiated thyroid cancer, medullary thyroid cancer, squamous cell carcinoma and lymphoma.
bPreoperative evaluations need to be completed as quickly as possible and involve integrated decision making in a multidisciplinary team. Consider referral to multidisciplinary high-volume center with expertise in treating ATC.
cResectability for locoregional disease depends on extent of involved structures,potential morbidity, and mortality associated with resection. In most cases, there is no indication for a debulking surgery. See Staging (ST-1) for definitions of R0/R1/R2.
dSee Systemic Therapy For Anaplastic Thyroid Carcinoma (ANAP-A).
STAGE
Discussion
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 2.2014, 08/12/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ANAP-2
Thyroid Carcinoma – Anaplastic Carcinoma
METASTATIC DISEASE
Stage IVCe
Aggressive therapy
Palliative care
• Total thyroidectomy with therapeutic lymph node dissection if resectable (R0/R1)
• Systemic therapy (See ANAP-A)
• Locoregional radiation therapy
• Consider clinical trial
• Palliative locoregional radiation therapy
• Focal lesion control with surgery or radiation (e.g. bonef, brain metastases)
eSee Staging (ST-1) for staging.
fConsider use of bisphosphonates or denosumab. Denosumab and bisphosphonates can be associated with severe hypocalcemia; patients with hypoparathyroidism and vitamin D deficiency are at increased risk.
SURVEILLANCE AND MANAGEMENT
• Cross-sectional imaging of brain, neck, chest, abdomen and pelvis at frequent intervals as clinically indicated.
• Consider 18FDG-PET-CT 3-6 months after initial therapy.
• Continued
observation if NED
• Palliative locoregional radiation therapy
• Focal lesion control (e.g. bone, brain metastases)
• Second-line systemic therapy or clinical trial
• See NCCN Guidelines for Palliative Care
• Best supportive care
TREATMENT
• See NCCN Guidelines for Central Nervous System Cancers
• Best supportive care
Discussion
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 2.2014, 08/12/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ANAP-A
Thyroid Carcinoma – Anaplastic Carcinoma
SYSTEMIC THERAPY FOR ANAPLASTIC THYROID CARCINOMA
Concurrent Chemoradiation Regimens1
• Paclitaxel/Carboplatin
• Paclitaxel
• Cisplatin
• Doxorubicin
Chemotherapy Regimens1
• Paclitaxel/Carboplatin
• Paclitaxel2
• Doxorubicin3
1Smallridge RC, Ain KB, Asa SL, et al. American thyroid association guidelines for management of patients with anaplastic thyroid cancer. Thyroid 2012;22:1104-1139.
2Ain KB, Egorin MJ, DeSimone PA.Treatment of anaplastic thyroid carcinoma with paclitaxel: phase 2 trial using ninety-six-hour infusion. Collaborative Anaplastic Thyroid Cancer Health Intervention Trials (CATCHIT) Group.Thyroid 2000;10:587-594.
3Shimaoka K, Schoenfeld DA, DeWys WD, et al. A randomized trial of doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma. Cancer 1985;56:2155-2160.
Discussion
Version 2.2014, 08/12/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ST-1 Table 1
American Joint Committee on Cancer (AJCC) TNM Staging For Thyroid Cancer (7th ed., 2010) Primary Tumor (T)
Note: All categories may be subdivided: (s) solitary tumor and (m) multifocal tumor (the largest determines the classification).
TX Primary tumor cannot be assessed T0 No evidence of primary tumor
T1 Tumor 2 cm or less in greatest dimension limited to the thyroid T1a Tumor 1 cm or less, limited to the thyroid
T1b Tumor more than 1 cm but not more than 2 cm in greatest dimension, limited to the thyroid
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension limited to the thyroid
T3 Tumor more than 4 cm in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension (eg, extension to sternothyroid muscle or perithyroid soft tissues)
T4a Moderately advanced diseaseTumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve
T4b Very advanced disease
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessel
All anaplastic carcinomas are considered T4 tumors.
T4a Intrathyroidal anaplastic carcinoma
T4b Anaplastic carcinoma with gross extrathyroid extension
Regional Lymph Nodes (N)
Regional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes.
NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
N1a Metastasis to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
N1b Metastasis to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII)
Distant Metastasis (M) M0 No distant metastasis M1 Distant metastasis Residual Tumor (R)
Classification of relevance to assess impact of surgery on outcomes:
R0 No residual tumor
R1 microscopic residual tumor R2 macroscopic residual tumor
Rx presence of residual tumor cannot be determined
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer Science and Business Media LLC (SBM). (For complete information and data supporting the staging tables, visit www.springer.com.) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of this information herein does not authorize any reuse or further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.