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NCCN Guidelines for Patients



Thyroid Cancer, Version 1.2017


Treatment guide

Next steps of care

Guide 22. Options for metastatic and recurrent medullary

Test results Next steps of care

Local recurrence

of cancer


• Surgery is preferred, if possible


• Radiation therapy (EBRT/IMRT) when surgery is not possible, or after surgery

(less common)


• Consider vandetanib or cabozantinib when surgery is not possible and

symptoms occur or the disease is progressing (worsening)


• Surveillance

No symptoms of



• Observe


• Consider surgery when possible, ablation (eg, RFA, embolization), or other

local therapy


• Consider vandetanib or cabozantinib when surgery is not possible and

symptoms occur, or the disease is progressing (worsening)

Disease with

symptoms or that

is progressing



• Vandetanib, or cabozantinib, or clinical trial, or consider other small molecule

kinase inhibitor, or dacarbazine (DTIC)-based chemotherapy

• Radiation therapy (EBRT/IMRT) for symptoms

• Consider IV bisphosphonate or denosumab for bone metastases

• Consider surgery to relieve symptoms, ablation (eg, RFA, embolization) or

other local therapy

• Best supportive care (relieve symptoms)

Next steps of care

After primary treatment for medullary thyroid cancer,

the surveillance and maintenance phase will start.

Your doctor will do a blood test to check your

calcitonin and CEA levels to see if they are within

normal range. If the calcitonin or CEA start to rise,

your doctor may order imaging tests to check for

recurrent disease. If things are stable, your doctor

will continue to check the calcitonin and CEA over


See Guide 21.

Guide 22

discusses options for recurrent or

metastatic medullary thyroid cancer. Your doctor

will consider the extent of disease and whether or

not you have symptoms. Surgery is the preferred

option for disease that comes back in the neck area.

Radiation, vandetanib, or cabozantinib will also be

considered. Your doctor may also offer to observe

the disease and not treat it right away.