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NCCN Guidelines and Compendium Updated

NCCN Flash Update™ sent December 21, 2012

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and NCCN Drugs and Biologics Compendium (NCCN Compendium®) for Thyroid Carcinoma. These NCCN Guidelines® are currently available as Version 1.2013.

  • Thyroid Carcinoma–Nodule Evaluation (THYR-3)
    • For patients with an FNA result of "Follicular or Hürthle cell neoplasm," the following was added "Consider molecular diagnostics" along with corresponding recommendations.
    • For patients with an FNA result of "Follicular lesions of undetermined significance," consider molecular diagnostics" was added as a treatment option.
    • Footnote "h" was revised to include the following statement: "If molecular testing predicts a risk of malignancy comparable to the risk of malignancy seen with a benign FNA cytology (approximately 5% or less), consider observation."
  • Thyroid Carcinoma: Papillary Carcinoma
    • Footnote b was revised "Use of iodinated contrast will delay treatment with RAI but is required for optimal cervical imaging using CT."  (Similar changes were also made to the Follicular Carcinoma and Hürthle Cell Carcinoma algorithms)
    • Papillary Carcinoma Found Post-lobectomy: "Confirmed contralateral disease" was added to the list of criteria to consider for completion thyroidectomy. (PAP-2)
    • A new page was added to help clinicians decide whether to administer postoperative RAI, "Decision Making for Initial Adjuvant or Therapeutic Administration of RAI". (PAP-4) (Similar changes were also made to the Follicular Carcinoma and Hürthle Cell Carcinoma algorithms)
    • Surveillance and Maintenance (PAP-6) (Similar changes were also made to the Follicular Carcinoma and Hürthle Cell Carcinoma algorithms):
      • Fifth bullet was revised as follows: "In iodine responsive tumors, if detectable Tg or distant metastases or soft tissue invasion on initial staging, radioiodine imaging every 12-24 mo until no clinically significant response is seen to RAI treatment (either withdrawal of thyroid hormone or rhTSH)".
      • New bullet was added: "Patients treated with 131I ablation, with a negative ultrasound, stimulated Tg < 2ng/mL (with negative Tg antibodies), and negative RAI imaging (if performed) may be followed by unstimulated thyroglobulin annually and by periodic neck ultrasound. TSH-stimulated testing, or other imaging as clinically appropriate, may be considered if clinical suggestion of recurrent disease."
    • Recurrent Disease (PAP-6) (Similar changes were also made to the Follicular Carcinoma and Hürthle Cell Carcinoma algorithms):
      • The treatment recommendation for patients with "Stimulated Tg > 10 ng/mL and rising" or "Scans (including PET) negative" was revised as follows: "Consider radioiodine therapy with 100-150 mCi and post-treatment 131I imaging (category 3); additional RAI treatments should be limited to patients who responded to previous RAI therapy".
  • Medullary Thyroid Carcinoma
    • The page regarding "Medullary thyroid carcinoma diagnosed after initial thyroid surgery" was revised. (MEDU-2)
    • Recurrent or persistent disease (MEDU-6)
      • Locoregional: "Cabozantinib (category 1)" was added as an option to consider. Vandetanib changed from category 2A to a category 1 recommendation.
      • Symptomatic, distant metastasis: Vandetanib changed from category 2A to category 1, and the recommendation was modified as follows: "Consider vandetanib (category 1)". The following recommendation was added: "Consider cabozantinib (category 1)".
      • Asymptomatic distant metastases: The recommendation was revised as follows: Consider resection (if possible), ablation (eg, RFA, embolization, or other regional therapy), or vandetanib (category 1), or cabozantinib (category 1) if structurally progressive disease". (vandetanib changed from category 2A to category 1 recommendation).
      • Disseminated symptomatic disease: Vandetanib changed from category 2A to category 1. "Cabozantinib (category 1)" was added as a treatment option.
    • Footnote "k" is new to the algorithm: "Increasing tumor markers, in the absence of structural disease progression, are not an indication for treatment with vandetanib or cabozantinib." (MEDU-6)
    • Footnote "m" was revised as follows: "While not FDA approved for treatment of thyroid cancer, other commercially available small molecule kinase inhibitors (such as sorafenib or sunitinib) can be considered if clinical trials, vandetanib, or cabozantinib are not available or appropriate, or if the patient progresses on vandetanib or cabozantinib." (MEDU-6)
  • Anaplastic Thyroid Carcinoma
    • Systemic Therapy for Anaplastic Thyroid Carcinoma: This is a new page that provides systemic therapy options as follows: (ANAP-A)
      • Concurrent Chemoradiation Regimens: Paclitaxel/Carboplatin, Paclitaxel, Cisplatin, Doxorubicin
      • Chemotherapy Regimens: Paclitaxel/Carboplatin, Paclitaxel, Doxorubicin

 

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