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Guideline Updates

NCCN Updates Clinical Practice Guideline for Thyroid Carcinomas

June 22, 2020

The National Comprehensive Cancer Network (NCCN) recently released an updated version of its clinical practice guideline for thyroid carcinomas.

Multiple global updates are included throughout the guideline, including Bethesda classification added and “rhTSH” replaced with “thyrotropin alfa.” Additionally, “Surveillance/Active Surveillance” has been clarified as “Nodule surveillance,” “Monitoring of residual disease,” “Active surveillance,” or “Disease monitoring.” A section for the Principles of Radiation Therapy and Radioactive Iodine Therapy has been added to the guideline.

In the section for FNA results for thyroid carcinoma, a treatment arm for AUS/PLUS without radiographic suspicion of malignancy was added with a new bullet: “Consider diagnostic lobectomy (if Bethesda III on two or more occasions).”

Many changes were made to the sections for papillary carcinoma. After initial FNA results of papillary carcinoma or suspicious for papillary carcinoma, ≥ 1 cm and < 1 cm is new and ≥ 1 cm diagnostic procedures were updated. The page describing postsurgical evaluation was revised extensively, as well as the page describing treatment of patients for whom RAI is being considered.

In the section for known or suspected distant metastatic disease, a new column now reads “6 weeks following cross-sectional imaging” with a bullet for “consider 24-hour urine iodine.” A few sections and arms were removed from the page for disease monitoring and maintenance, including “Chest x-ray and PET/CT” as an option under long-term disease monitoring for NED as well as a bullet for radioiodine imaging under management of abnormal findings.

The sections for follicular carcinoma featured a few significant changes. After FNA results yield a follicular neoplasm diagnosis, a diagnostic procedure bullet now reads, “CT/MRI with contrast for locally advanced disease or vocal cord paresis.” Additionally, pathways following lobectomy or isthmusectomy were revised extensively.

After FNA results yield a medullary thyroid carcinoma diagnosis, a new bullet is listed under diagnostic procedures for additional cross-sectional imaging as indicated, including “Consider contrast-enhanced CT of neck/chest and liver MRI or three-phase CT of liver” and “Consider Ga-68 DOTATATE PET/CT; if not available, consider bone scan and/or skeletal MRI.” In the section for medullary carcinoma with germline mutation of RET proto-oncogene and multiple endocrine neoplasia and familial disease, “Neck CT with contrast” was added as an additional workup option. For the treatment of recurrent or persistent locoregional disease, selpercatinib (RET mutation-positive) was added as a preferred treatment option.

Lastly, a few significant changes were made to the sections for anaplastic carcinoma. “Molecular testing for actionable mutations” was added under Diagnostic Procedures after FNA or core biopsy finding of anaplastic thyroid carcinoma. For stage IVA or IVB disease, “Resectable” and “Unresectable” bifurcation is new with subsequent pathways revised extensively. In the page for systemic therapy listings, entrectinib was moved from Other Recommended Regimens to Preferred Regimens, and selpercatinib (RET-fusion positive) was added as a preferred regimen with indicated dosing.—Zachary Bessette

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