FNA RESULTSa DIAGNOSTIC
PROCEDURES PRIMARY TREATMENT
Hürthle cell neoplasmb (See THYR-3)
• Thyroid and neck ultrasound (including central and lateral compartments), if not previously done
• CT/MRI for fixed, bulky, or substernal lesionsc
• Consider evaluation of vocal cord mobility
• Consider chest x-ray
Total thyroidectomy, if invasive cancer, metastatic disease or patient preference Perform therapeutic neck dissection of involved compartments for clinically apparent/biopsy-proven disease
or
Benign
Hürthle cell carcinomad
Lobectomy/isthmusectomy
Invasive cancer (extensive vascular invasion)
Minimally invasive cancere
Benign
Completion of thyroidectomy
Levothyroxine therapy to keep TSH normalf
See Postsurgical Evaluation (HÜRT-2) Completion of
thyroidectomy or
Observe
Consider levothyroxine therapy to keep TSH low or normalf Observe
See Surveillance and Maintenance (HÜRT-7)
aSee (ST-1) for staging.
bThe diagnosis of Hürthle cell carcinoma requires evidence of either vascular or capsular invasion, which cannot be determined by FNA.
cUse of iodinated contrast will delay treatment with RAI but is required for optimal cervical imaging using CT.
dAlso known as oxyphilic, oncocytic, or follicular carcinoma, oncocytic type.
eMinimally invasive cancer is characterized as a well-defined tumor with microscopic capsular and/or a few foci of vascular invasion and often requires examination of at least 10 histologic sections to demonstrate.
fSee Principles of TSH Suppression (THYR-A).
HÜRT-1
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®.
Thyroid Carcinoma – Hürthle Cell Carcinoma
HÜRT-2 POSTSURGICAL EVALUATION
No gross residual disease in neck
No gross
residual disease
See Consideration for Initial Postoperative RAI Therapy (HÜRT-3)
Gross residual disease in neck
Resectable Resect, if possible
Gross residual disease
Unresectable
• TSH + Tg measurement + antithyroglobulin antibodies (6-12 wk postoperatively)
• Total body
radioiodine imaging (category 2B)
Suspected or proven inadequate RAI uptake Adequate RAI uptake
Noimaging performed
EBRT
• Radioiodine treatment
• Post-treatment
131I imaging
• Consider EBRT
Suppress TSH with levothyroxinef
See Surveillance and Maintenance (HÜRT-7)
fSee Principles of TSH Suppression (THYR-A).
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®.
Thyroid Carcinoma – Hürthle Cell Carcinoma
HÜRT-3 CLINICOPATHOLOGIC FACTORS
RAI not typically recommended (if all present):
• Primary tumor <2cm
• Intrathyroidal
• No vascular invasion
• Clinical N0, M0
• No detectable anti-Tg antibodies
• Postoperative unstimulated Tg <1 ng/mLg
RAI not typically indicated
See HÜRT-4
RAI being considered See HÜRT-5 CONSIDERATION FOR INITIAL POSTOPERATIVE RAI THERAPY
Known or suspected distant metastases at presentation
For general principles related to RAI therapy, See (Discussion)
RAI selectively recommended (if any present):
• Primary tumor 2-4 cm
• Minor vascular invasion
• Cervical lymph node metastases
• Presence of anti-Tg antibodies
• Postoperative unstimulated Tg <5-10 ng/mLg
RAI ablation is recommended when the
combination of individual clinical factors (such as the size of the primary tumor, histology, degree of vascular invasion, lymph node metastases, postoperative thyroglobulin, and age at diagnosis) predicts a significant risk of recurrence, distant metastases, or disease-specific mortality.
RAI recommended (if any present):
• Gross extrathyroidal extension
• Primary tumor > 4 cm
• Extensive vascular invasion
• Postoperative unstimulated Tg >5-10 ng/Lg,h
Amenable to RAI See HÜRT-6 Gross residual disease
not amenable to RAI therapy See HÜRT-8
gTg values obtained 6-12 weeks after total thyroidectomy.
hAdditional cross sectional imaging should be considered to rule out the presence of significant normal thyroid remnant or gross residual disease and to detect clinically significant distant metastases.
RAI ablation is not required for minimally invasive Hürthle cell carcinoma confined to the thyroid when the primary tumor is small and demonstrates only invasion of the tumor capsule without
vascular invasion
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®.
Thyroid Carcinoma – Hürthle Cell Carcinoma
HÜRT-4 RAI TYPICALLY NOT INDICATED BASED ON CLINICOPATHOLOGICFEATURES
RAI NOT TYPICALLY INDICATED BASED ON CLINICOPATHOLOGIC FEATURES
6-12 weeks post- thyroidectomy
Clinicopathologic findings that would not
typically indicate routine RAI ablation (See HÜRT-3)
Unstimulated Tg
Tg >5-10 ng/dL (with negative anti-Tg Ab antibodies
Consider additional cross-sectional imaging of the neck and chest (without iodinated contrast)i
Consider RAI ablation/
adjuvant therapy;
See HÜRT-5
Tg <5-10 ng/dL (with negative anti-Tg antibodies) No concerning finding on ultrasound
Follow without RAI ablation andSee Surveillance and Maintenance HÜRT-7
andLevothyroxine to appropriate TSH target
See THYR-A Clinically
significant cervical nodes
Benign FNA
Malignant FNA
Consider further surgery prior to RAI See HÜRT-2
iIf structural disease is identified, additional evaluation and/or treatment may be clinically indicated.
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®.
Thyroid Carcinoma – Hürthle Cell Carcinoma
HÜRT-5 6-12 weeks post-
thyroidectomy
Clinicopathologic findings prompting consideration for RAI, without gross residual disease or known distant metastasis See HÜRT-3
Pretreatment 123I diagnostic imaging with TSH stimulation (thyroid hormone withdrawal or rhTSH);
(category 2B)j,k
No uptake on scan, stimulated Tg <1 ng/mL (with negative anti-Tg Ab)
Follow without RAI ablation
See Surveillance and Maintenance HÜRT-7
andLevothyroxine to appropriate TSH target (See THYR-A)
Suspectedk,l or proven bed uptake
RAI for remnant ablation (30 mCi) or adjuvant therapy (30-100 mCi)m,n to post-treatment imaging
Suspectedk,l or proven radioiodine avid metastatic foci
RAI therapy (100-200 mCi)m; post-treatment imaging
RAI BEING CONSIDERED BASED ON CLINICOPATHOLOGIC FEATURES
jAlternatively, low-dose 131I (1-3 mCi) may be used.
kWhile pre-ablation diagnostic scans in this setting are commonly done at NCCN member institutions, the panel recommends (category 2B) selective use of pre-ablation diagnostic scans based on pathology, post-operative Tg, intra-operative finds, and available imaging studies. Furthermore, dosimetry studies are considered in patients at high risk of having RAI avid distant metastasis.
lClinically significant structural disease should be surgically resected if possible before radioiodine treatment.
mThe administered activity of RAI therapy should be adjusted for pediatric patients.
nIf RAI ablation is used in T1b/T2 (1-4 cm), clinical N0 disease, 30 mCi of 131I is recommended (category 1) following either recombinant human TSH stimulation or thyroid hormone withdrawal. This RAI ablation dose of 30 mCi may also be considered (category 2B) for patients with T1b/T2 (1-4 cm) with small-volume N1a disease (fewer than 3-5 metastatic lymph node metastases <1 cm in diameter) and for patients with primary tumors <4 cm, clinical M0 with minor extrathyroidal extension.
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®.
Thyroid Carcinoma – Hürthle Cell Carcinoma
HÜRT-6 KNOWN OR SUSPECTED DISTANT METASTATIC DISEASE
6-12 weeks post-
thyroidectomy
Known or
suspected distant metastases at presentation (See HÜRT-3)
Appropriate cross-sectional imaging of known metastatic focil,p
Pretreatment 123I diagnostic imaging with TSH stimulation (thyroid hormone withdrawal
or rhTSH)q,r
Confirmed radioiodine avidtumor
RAI therapy (100-200 mCi, or dose adjusted by dosimetry)o; post-treatment imaging
See
Surveillance and
Maintenance HÜRT-7 and
Cervical uptake only
Consider RAI ablation/adjuvant therapy (30-100 mCi)o; post treatment imaging
Levothyroxine to appropriate target
(See THYR-A)
lClinically significant structural disease should be surgically resected if possible before radioiodine treatment.
oThe administered activity of RAI therapy should be adjusted for pediatric patients.
pTo evaluate macroscopic metastatic foci for potential alterative therapies (such as surgical resection and/or external beam radiation) to prevent invasion/compression.
qIf 123I is not available, low-dose 131I(1-3 mCi) may be used. Dosimetry studies are considered in patients at high risk of having RAI avid distant metastasis.
rWhile pre-ablation diagnostic scans in this setting are commonly done at NCCN member institutions, the panel recommends (category 2B) selective use of pre-ablation diagnostic scans based on pathology, post-operative Tg, intra-operative finds, and avaialble imaging studies. Furthermore, dosimetry studies are considered in patients at high risk of having RAI avid distant metastasis of vital structures or pathological fracture either as a result of disease progression or TSH stimulation.
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®.