Approach to Thyroid nodules.pdf
Approach to Thyroid nodules.pdf
Papillary > Follicular > Medullary > Anaplastic
From Follicular Cell
From Para-follicular C-cells
| ATA low risk | • Intrathyroidal • No vascular invasion • Either no lymph node metastases OR only ≤5 micrometastatic nodes <0.2 cm • No distant metastasis (M0) | • Lobectomy (T1, T2)/ Total thyroidectomy (bilateral, large) • No RAI • TSH suppression: mild (TSH ~0.5–2) • F/U Yearly Tg ± US | | --- | --- | --- | | ATA intermediate risk | • Microscopic extrathyroidal extension • Vascular invasion • >5 lymph node metastases, or nodes 0.2–3 cm • Aggressive histologic variants (tall cell, hobnail, columnar, insular) • RAI uptake outside thyroid bed after surgery (sus M) | • Total thyroidectomy • Selective RAI depending on burden and progression (often recommended, not mandatory for all) • TSH suppression: moderate (TSH 0.1–0.5) • F/U Tg + US Q6-12 mon | | ATA high risk | • Gross extrathyroidal extension invading soft tissue, trachea, esophagus, RLN, etc. • Large-volume lymph node disease (any node ≥3 cm) • Distant metastases, or Postoperative Tg strongly suggesting metastasis (M1) • Incomplete surgical resection (positive gross margins) | • Total thyroidectomy • RAI is indicated (unless known non-avid disease) • Consider external beam radiation if residual unresectable neck disease • TSH suppression: aggressive (TSH <0.1) • F/U Tg Q3-6 mon, image guided by diseases |