management

Last edited 12/2022 and last reviewed 01/2023

Initial treatment of differentiated thyroid cancer

Surgery and active surveillance for primary tumours

• hemithyroidectomy or total thyroidectomy should be offered to people with differentiated thyroid tumours larger than 1 cm or multifocal disease (T1a(m) to T2N0M0)
• total thyroidectomy should be offered to people who have:
  • a T3 or T4 stage primary tumour
  • regional lymph node involvement (N1)
  • adverse pathological features
  • distant metastatic disease (M1)
• a completion thyroidectomy should be offered to people who have had a hemithyroidectomy if it is indicated on review of the histological features of the initial specimen
• hemithyroidectomy or active surveillance should be considered for people with a solitary microcarcinoma (T1a) without evidence of nodal involvement

Surgery for nodal disease

• a compartment-orientated lateral neck dissection should be offered for people with structural nodal disease in the lateral neck
• prophylactic ipsilateral central neck dissection should be considered when doing the compartment-orientated lateral neck dissection for people with structural nodal disease in the lateral neck
• a compartment-orientated central neck dissection should be offered for people with structural nodal disease in the central neck

Surgery during pregnancy

Consider deferring surgery until after pregnancy, taking into account:

• the risk of delaying surgery
• the risk to the pregnancy
• the rate of disease progression.

When surgery cannot be delayed until after pregnancy, it should be done during the second trimester if possible

Thyrotropin alfa and thyroid cancer

• thyrotropin alfa for pretherapeutic stimulation should be offered for people with thyroid cancer (including those with distant metastases)
• thyrotropin alfa should be used with caution in people with thyroid cancer who have brain or spinal metastases, because there is a risk of clinically significant tumour flare
  • any rise in TSH has the theoretical risk of causing flare of thyroid cancer (1)

RAI (radioactive iodine) for initial ablation

• RAI should be offered to people to people who have had a total or completion thyroidectomy
• do not offer RAI to people with T1a or T1b tumours including those with multifocal disease, unless there are adverse features, regional lymph node involvement, or evidence of other metastatic disease
• RAI should be considered for people with T2 disease who have had a total or completion thyroidectomy, but whose disease does not show any of the features in the recommendation on offering total thyroidectomy in the section on surgery and active surveillance for primary tumours.

• external beam radiotherapy (EBRT) should be considered if there is macroscopic disease after surgery or local disease that is unlikely to be controlled with RAI
• EBRT should be considered for symptom control for people receiving palliative care

Reference:

• NICE (December 2022). Thyroid cancer: assessment and management