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  • Review Article
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Current practice in patients with differentiated thyroid cancer

Nature Reviews Endocrinology volume 17, pages 176–188 (2021)Cite this article

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Abstract

Considerable changes have occurred in the management of differentiated thyroid cancer (DTC) during the past four decades, based on improved knowledge of the biology of DTC and on advances in therapy, including surgery, the use of radioactive iodine (radioiodine), thyroid hormone treatment and availability of recombinant human TSH. Improved diagnostic tools are available, including determining serum levels of thyroglobulin, neck ultrasonography, imaging (CT, MRI, SPECT–CT and PET–CT), and prognostic classifications have been improved. Patients with low-risk DTC, in whom the risk of thyroid cancer death is <1% and most recurrences can be cured, currently represent the majority of patients. By contrast, patients with high-risk DTC represent 5–10% of all patients. Most thyroid cancer-related deaths occur in this group of patients and recurrences are frequent. Patients with high-risk DTC require more aggressive treatment and follow-up than patients with low-risk DTC. Finally, the strategy for treating patients with intermediate-risk DTC is frequently defined on a case-by-case basis. Prospective trials are needed in well-selected patients with DTC to demonstrate the extent to which treatment and follow-up can be limited without increasing the risk of recurrence and thyroid cancer-related death.

Key points

  • Prognostic classifications currently distinguish the risk of differentiated thyroid cancer (DTC)-related death from the risk of recurrence.

  • The majority of patients with DTC have low-risk disease; postoperative administration of radioiodine is indicated in selected patients and thyroid hormone treatment maintains serum levels of TSH within the normal range.

  • Follow-up is based on determination of serum levels of thyroglobulin and neck ultrasonography.

  • Fluorodeoxyglucose PET–CT is useful for the detection of neoplastic foci in patients with high-risk DTC and in those with detectable serum levels of thyroglobulin that increases over time during follow-up.

  • Patients with distant metastases are first treated with radioiodine, and with focal treatment modalities as necessary; patients with progression might benefit from systemic targeted therapies.

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Fig. 1: Indications and protocols for postoperative administration of 131I.
Fig. 2: Papillary thyroid cancer with miliary lung metastases in a 16-year-old girl.
Fig. 3: Poorly differentiated thyroid cancer in a 56-year-old man.
Fig. 4: Lymph node metastasis in a patient with poorly differentiated thyroid cancer.
Fig. 5: Left paratracheal lymph node metastasis in a patient with poorly differentiated thyroid cancer.
Fig. 6: Bone metastases in a patient with poorly differentiated thyroid cancer.

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  1. Department of Nuclear Medicine and Endocrine Oncology, Institut Gustave Roussy and Université Paris Saclay, Villejuif, France

    Martin Schlumberger & Sophie Leboulleux

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The authors contributed equally to all aspects of the article.

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M.S. and S.L. have received personal fees and research support from Bayer, Eisai, Exilixis-IPSEN and Sanofi-Genzyme. No financial support was received from these entities for writing this review.

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Thyroid Cancer Genome Atlas (TCGA): https://www.cancer.gov/about-nci/organization/ccg/research/structural-genomics/tcga/studied-cancers/thyroid

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Schlumberger, M., Leboulleux, S. Current practice in patients with differentiated thyroid cancer. Nat Rev Endocrinol 17, 176–188 (2021). https://doi.org/10.1038/s41574-020-00448-z

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