NCCN Flash Updates: NCCN Guidelines for Thyroid Carcinoma
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), the NCCN Drugs and Biologics Compendium (NCCN Compendium®), the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), and the NCCN Radiation Therapy Compendium™ for Thyroid Carcinoma. These NCCN Guidelines® are currently available as Version 1.2022.
MS-1
• The discussion has been updated to reflect the changes in the algorithm.
THYR-1
- Footnote modified: Estimated risk of malignancy is 6%–18% exclusive of
NIFTP without NIFTP and 10%–30% with noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).
THYR-2
- Molecular Diagnostic Results
Repeat FNA cytology and/or Consider molecular diagnostics
- Treatment
- Molecular diagnostics not informative or with insufficient or degraded sample
- Nodule surveillance or Consider lobectomy or total thyroidectomy in select situations for definitive diagnosis/treatment or Consider repeat biopsy
- Molecular diagnostics suggestive of malignancy: Consider lobectomy or total thyroidectomy (depending on molecular results) for definitive diagnosis/treatment or Nodule surveillance
PAP-1
- Diagnostic Procedures
- Upper branch modified:
≥ >1 cm
- Lower branch modified:
< ≤1 cm
- Preoperative or intraoperative decision-making criteria
- lower branch modified: Indications for total thyroidectomy or lobectomy
(preferred), if all criteria present:
- Primary Treatment
- Indications for total thyroidectomy or lobectomy: Lobectomy (preferred)
- No concerning lymph nodes: Lobectomy
if high risk
- Footnote added: See Principles of Active Surveillance
PAP-2
- Clinical Presentation
- All of the following, bullet 3 modified: Tumor
<1≤4 cm in diameter
- Primary Treatment
- Lower branch, option removed: Consider thyroglobulin measurement and anti-Tg antibodies 6–12 weeks post-op
PAP-3
- Postsurgical Evaluation (also FOLL-2 and HURT-2)
- Unresectable lower pathway modified: For viscerally invasive disease or rapid progression, upfront EBRT/IMRT, neoadjuvant therapy may be most appropriate
- Footnotes (also FOLL-2 and HURT-2)
- Footnote added: Even in the absence of thyroid bed uptake, RAI treatment may be considered. If higher than expected uptake (residual thyroid uptake or distant metastasis) change dose accordingly.
- Footnote added: A false-negative pretreatment scan is possible and should not prevent the use of RAI if otherwise indicated.
PAP-4
- Clinicopathological Factors
- RAI selectively recommended (if any present), bullet added: Vascular invasion
- Consideration for Initial Postoperative use of RAI after Total Thyroidectomy (also FOLL-3 and HURT-3)
- RAI selectively recommended pathway modified: RAI ablation is recommended when the combination of individual clinical factors (such as the
sizeextent of the primary tumor, histology, degree of lymphatic invasion, lymph node metastases, postoperative thyroglobulin, and age at diagnosis) predicts a significant risk of recurrence, distant metastases, or disease-specific mortality
- Footnotes
- Footnote added: Minimal extrathyroidal extension alone likely does not warrant RAI. (also FOLL-3 and HURT-3)
- Footnote modified:
ieeg, poorly differentiated, tall cell, columnar cell, hobnail variants, diffuse sclerosing, and insular.
PAP-6
- Known or Suspected Distant Metastatic Disease (also FOLL-5 and HURT-5)
- 6–12 weeks post-thyroidectomy pathway modified: Known or suspected distant metastases at presentation or elevated Tg
- 6–12 weeks post-thyroidectomy, no uptake pathway modified: Consider RAI adjuvant therapy and post-treatment imaging (whole body RAI scan, consider PET scan)
PAP-7
- Disease Monitoring: This page has been extensively revised. (Also FOLL-6 and HURT-6)
PAP-8
- Recurrent Disease (also for FOLL-7 and HURT-7)
- Bullet 1 modified:
StimulatedRising or newly elevated Tg ≥ 1–10 ng/mL and negative imaging
- Locoregional recurrence pathway modified: Surgery (preferred) if resectable and
/orConsider radioiodine treatment, if postoperative radioiodine imaging positive
PAP-9
- Treatment, systemic therapies modified (also PAP-10, PAP-11)
- Sub-bullet 1 added: Preferred Regimens
- Sub-sub-bullet 1 modified:
consider Lenvatinib (category 1)
- Sub-bullet 2 added: Other Recommended Regimens
- Sub-sub-bullet 2 added: Sorafenib (category 1)
- Sub-bullet 3 added: Useful in Certain Circumstances
- Sub-sub-bullet 3 added: Cabozantinib (category 1) if progression after lenvatinib and/or sorafenib
- Footnotes deleted (also PAP-10, PAP-11, FOLL-8, FOLL-9, FOLL-10, HURT-8, HURT-9, HURT-10)
- In a subset of patients (>65 years of age), lenvatinib showed an overall survival benefit compared to placebo. Brose MS, et al. J Clin Oncol 2017;35:2692-2699.
- The decision of whether to use lenvatinib (preferred) or sorafenib should be individualized for each patient based on likelihood of response and comorbidities.
- RAI therapy is an option in some patients with bone metastases and RAI sensitive disease.
FOLL-1
- Primary Treatment
- Total thyroidectomy
if invasive cancer, metastatic cancer,if radiographic evidence or intraoperative findings of extrathyroidal extension or tumor >4 cm in diameter, or patient preference perform therapeutic neck dissection of involved compartments for clinically apparent/biopsy-proven disease. (also HURT-1)
FOLL-3
- Clinicopathological Factors (also HURT-3)
- RAI selectively recommended (if any present), bullet 2 modified: Minor vascular invasion (<4 foci)
- RAI recommended (if any present), bullet 3 modified: Extensive vascular invasion (≥4 foci)
FOLL-8
- Treatment, systemic therapies modified (also FOLL-9, FOLL-10, HURT-8, HURT-9, HURT-10)
- Sub-bullet 1 added: Preferred Regimens
- Sub-sub-bullet 1 modified:
consider Lenvatinib (category 1)
- Sub-bullet 2 added: Other Recommended Regimens
- Sub-sub-bullet 2 added: Sorafenib (category 1)
- Sub-bullet 3 added: Useful in Certain Circumstances
- Sub-sub-bullet 3 added: Cabozantinib if progression after lenvatinib and/or sorafenib
HÜRT-3
- Footnotes
- Footnote removed: Minimally invasive HCC is characterized as an encapsulated tumor with microscopic capsular invasion and without vascular invasion.
MEDU-1
- Footnote modified: Germline mutation should prompt specific mutation testing in subsequent family members and genetic counseling. See Principles of Cancer Risk Assessment and Counseling
- Footnote modified: Prior to germline testing, all patients should be offered genetic counseling either by their physician or a genetic counselor. See Principles of Cancer Risk Assessment and Counseling
MEDU-5
- Disease Monitoring
- Detectable basal calcitonin or Elevated CEA, bullet 2 modified: If calcitonin ≥150 pg/mL, CT or MRI with contrast of neck, liver, and chest
- Footnote added: It is unlikely that there will be radiographic evidence of disease when calcitonin is less than 150 pg/mL.
ANAP-1
- Diagnostic procedures, bullet 7 modified: FDG PET/CT or MRI
(skull base to mid-thigh)
- Establish goals of therapy, bullet 4 modified: Discuss palliative care options including airway management
ANAP-A 1 of 3
- Adjuvant/Radiosensitizing Chemotherapy Regimens
- Other recommended regimens modified:
- Docetaxel/doxorubicin:
Docetaxel 60 mg/m2 IV, doxorubicin 60 mg/m2 IV (with pegfilgrastim) every 3-4 weeks or Docetaxel 20 mg/m2 IV, doxorubicin 20 mg/m2 IV, weekly
- Other recommended regimens
- Added: Docetaxel 20mg/m2 IV Weekly
- Removed: cisplatin
- Removed: doxorubicin
ANAP-A 2 of 3
- Systemic Therapy Regimens for Metastatic Disease
- Other recommended regimens modified:
- Paclitaxel/carboplatin (category 2B)
- Docetaxel/doxorubicin (category 2B)
- Useful in certain circumstances regimens added:
- Doxorubicin/cisplatin: Doxorubicin 60 mg/m2 IV, cisplatin 40 mg/m2 IV, Every 3 weeks
ANAP-A 3 of 3
- Reference added: Bible KC, Kebebew E, Brierley J, et al. 2021 American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid 2021;31:337-386.
THYR-A
- Sub-bullet 1 modified: In general, patients with known structural residual carcinoma or at high risk for recurrence should have TSH levels maintained below 0.1 mU/L,
whereas
- Bullet 2 modified: Patients who remain disease free for several years
can probablyshould have their TSH levels maintained within the reference range (0.5–2 mU/L).
THYR-C 2 of 5
- Administered Activity
- Remnant ablation, sub-sub bullet 1 modified: If RAI ablation is used in T1b/T2 (1–4 cm), clinical N0 disease, inthe absence of other adverse pathologic, laboratory, or imaging features, 30-50 mCi of iodine-131 is recommended (category 1) following either thyrotropin alfa stimulation or thyroid hormone withdrawal. This dose of 30–50 mCi may also be considered (category 2B) for patients with T1b/T2 (1–4 cm) with small-volume N1a disease (fewer than 5 lymph node metastases <2 mm in diameter) and for patients with primary tumors <4 cm, clinical M0 with minor extrathyroidal extension.
- Adjuvant therapy, sub-bullet 1 modified: 50–150
100 mCi
THYR-D
- Principles of Active Surveillance for Low-Risk Papillary Thyroid Cancer: new to Guidelines
THYR-E
- Principles of Cancer Risk Assessment and Counseling: new to Guidelines
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