Regional Thyroid Cancer Guidelines Matthew Beasley Consultant Clinical Oncologist Bristol Cancer Institute Head & Neck SSG June 2015

Regional Thyroid Cancer Guidelines Published in Clinical Endocrinology (online) Volume 81, Issue supplement s1 Meeting at UHBristol to rewrite our regional guidelines

Main Changes 1.Introduction of Personalised Decision Making 2.Expanded indications for hemithyroidectomy 3.Evaluation of remission status 4.Dynamic Risk Stratification 5.Move away from long term TSH suppression for the majority 6.Follow-up

(1) Personalised Decision Making When the evidence for or against a treatment is inconclusive and no well designed, peer reviewed randomised or prospective national or institutional studies are ongoing to address this issue or if available, declined by the patient, these guidelines recommend a personalised approach to decision making

(2) Expanded indications for hemithyroidectomy Personalised Decision Making < 4cm without additional risk factors (evidence of nodal spread or suspicious features in the contralateral lobe on ultrasound, high risk histology including Hurtle cell) Radiation induced tumours 1-4cm

(3) Evaluation of Remission Status Original Guidelines Stimulated thyroglobulin at 6-9 months Whole body nuclear medicine scan and/or ultrasound neck at 6-9 months 2014 Guidelines Stimulated thyroglobulin at 9-12 months Ultrasound neck at 9-12 months (whole body scan only if initial scan shows unexpected findings)

(4) Dynamic Risk Stratification Excellent ResponseIndeterminate ResponseIncomplete Response All of the following Suppressed and stimulated Tg < 1ug/l* Neck US without evidence of disease Cross sectional imaging and/or nuclear medicine imaging negative (if performed) Any of the following Suppressed Tg < 1ug/l and stimulated Tg ≥ 1 and < 10ug/l* Neck US with non specific changes or stable sub centimetre nodes Cross sectional imaging and/or nuclear medicine imaging with non-specific changes, although not completely normal Any of the following Suppressed Tg ≥ 1ug/l or stimulated Tg ≥ 10ug/l* Rising Tg Persistent or newly identified disease on cross-sectional and/or nuclear medicine imaging Low riskIntermediate riskHigh risk

(5) Move away from long term TSH suppression ClassificationTSH target Hemithyroidectomy and no radio-iodine Excellent Response0.3 – 2.0 Indeterminate Response0.1 – 0.5 for 5 – 10 years Incomplete Response<0.1 indefinitely

(6) Follow-up Patients treated with hemithyroidectomy alone do not require long term follow Patients with excellent response / low risk on ATA criteria who are disease free at 5 years and no longer judged to require TSH suppression may be discharged to a to primary care or a nurse-led clinic with explicit instructions.

Challenges More pressure on ultrasound services More discussions about uncertainty Possible confusion over varied TSH target ranges Safe discharge to primary care