{"id":1761,"date":"2021-04-21T14:40:23","date_gmt":"2021-04-21T19:40:23","guid":{"rendered":"http:\/\/tiro.flywheelsites.com\/?page_id=1761"},"modified":"2022-11-10T12:37:04","modified_gmt":"2022-11-10T17:37:04","slug":"recurrent-persistent-disease","status":"publish","type":"page","link":"https:\/\/tiro.expert\/es\/recommendations\/dtc\/recurrent-persistent-disease\/","title":{"rendered":"Enfermedad recurrente y persistente"},"content":{"rendered":"\t<style media=\"screen\">\n\t:root { --row-count: 4; }\n\t<\/style>\n<div class=\"clinical-outline-wrap open\">\n\t<div class=\"outline-header\">\n\t\t<p><strong>Recurrent &#038; Persistent Disease<\/strong><\/p>\t\t<p>Clinical Outline<\/p>\n\t<\/div>\n\n\t<div id=\"toc\">\n\t\t<div class=\"aod-opener opened\"><\/div>\n\t\t<div class=\"toc-content\"><\/div>\n\t<\/div>\n\n\t<div id=\"edu\" class=\"wp-block-group__inner-container legend\">\n\t\t<div class=\"aod-opener\"><\/div>\n\n\t\t<div class=\"table-wrap aod-content\">\n\t\t\t<div class=\"table-grid\">\n\n\t\t\t\t<div class=\"table-header table-row\">\n\t\t\t\t\t<div class=\"fixed-col\">Educational Clips from TIROxMDS<\/div>\n\n\t\t\t\t\t<div><i class=\"fad fa-chalkboard-teacher fa-fw fa-lg\" title=\"Primers in Thyroidology\"><\/i><\/div>\n\t\t\t\t\t<div><i class=\"fad fa-presentation fa-fw fa-lg\" title=\"Journal Club Presentation\"><\/i><\/div>\n\t\t\t\t\t<div><i class=\"fad fa-comments fa-fw fa-lg\" title=\"Case-based Discussion (inc. roundtables)\"><\/i><\/div>\n\t\t\t\t\t<div><i class=\"fad fa-podium fa-fw fa-lg\" title=\"Grand Rounds Lectureship\"><\/i><\/div>\n\n\t\t\t\t<\/div>\n\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#1-local-recurrence\">1. Local Recurrence<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#2-regional-nodal-disease\">2. Regional Nodal Disease<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#3-distant-disease-recurrence\">3. Distant Disease Recurrence<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"null\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col lvl-2\"><a href=\"#edu-3b\">B. Specific Site Management<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"null\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"null\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"null\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"check\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#4-management-of-recurrent-persistent-thyroid-cancer\">4. Management of Recurrent\/Persistent Thyroid Cancer<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#5-management-of-recurrent-dtc-involving-the-upper-aerodigestive-tract-uadt\">5. Management of Recurrent DTC Involving the Upper Aerodigestive Tract (UADT)<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"table-row\">\n\n\t\t\t\t\t<div class=\"fixed-col\"><a href=\"#edu-6\">6. Role of RAI in Recurrent\/Persistent Thyroid Cancer<\/a><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"\"><\/i><\/div>\n\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div><i class=\"check\"><\/i><\/div>\n\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t<div id=\"key\" class=\"legend\">\n\t\t\t\t<div>\n\t\t\t\t\t<div>\n\t\t\t\t\t\t<div><i class=\"fad fa-chalkboard-teacher fa-fw fa-lg\"><\/i><\/div>\n\t\t\t\t\t\t<p> = Primers in Thyroidology<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div>\n\t\t\t\t\t\t<div><i class=\"fad fa-presentation fa-fw fa-lg\"><\/i><\/div>\n\t\t\t\t\t\t<p> = Journal Club Presentation<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div>\n\t\t\t\t\t\t<div><i class=\"fad fa-comments fa-fw fa-lg\"><\/i><\/div>\n\t\t\t\t\t\t<p> = Case-based Discussion (inc. roundtables)<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div>\n\t\t\t\t\t\t<div><i class=\"fad fa-podium fa-fw fa-lg\"><\/i><\/div>\n\t\t\t\t\t\t<p> = Grand Rounds Lectureship<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t<\/div>\n\t<\/div>\n\n\t<div class='outline-tab closer'><i class='fas fa-times'><\/i><\/div>\n\n\t<div id=\"areas-discord\" class=\"legend cloak\">\n\t\t<div class=\"aod-opener\"><\/div>\n\t\t<div class=\"aod-content\"><\/div>\n\t<\/div>\n\t<div class=\"logo-wrap\">\n\t\t<div class=\"widget widget_media_image\"><div class=\"widget-content\"><a href=\"\/\"><img loading=\"lazy\" decoding=\"async\" width=\"250\" height=\"250\" src=\"https:\/\/tiro.expert\/wp-content\/uploads\/2021\/01\/TIRO-monogram-logo@3x-e1610777576269.png\" class=\"image wp-image-1039  attachment-full size-full\" alt=\"TIRO Thyroid International Recommendations Online monogram logo\" style=\"max-width: 100%; height: auto;\" srcset=\"https:\/\/tiro.expert\/wp-content\/uploads\/2021\/01\/TIRO-monogram-logo@3x-e1610777576269.png 250w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/01\/TIRO-monogram-logo@3x-e1610777576269-150x150.png 150w\" sizes=\"auto, (max-width: 250px) 100vw, 250px\" \/><\/a><\/div><\/div>\t<\/div>\n\t<div class=\"site-nav\">\n\t\t<div class=\"menu-primary-tiro-container\"><ul id=\"menu-primary-tiro\" class=\"menu\"><li id=\"menu-item-3048\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-has-children menu-item-3048\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/\" data-ps2id-api=\"true\">Care Recommendations<\/a>\n<ul class=\"sub-menu\">\n\t<li id=\"menu-item-4432\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-4432\"><a href=\"#\" data-ps2id-api=\"true\">Differentiated Thyroid Cancer<\/a>\n\t<ul class=\"sub-menu\">\n\t\t<li id=\"menu-item-1987\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1987\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/initial-evaluation-of-thyroid-nodules\/\" data-ps2id-api=\"true\">Initial Evaluation of Thyroid Nodules<\/a><\/li>\n\t\t<li id=\"menu-item-1986\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1986\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/initial-management\/\" data-ps2id-api=\"true\">Initial Management<\/a><\/li>\n\t\t<li id=\"menu-item-1983\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1983\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/initial-staging-response-to-therapy\/\" data-ps2id-api=\"true\">Initial Staging &#038; Response to Therapy<\/a><\/li>\n\t\t<li id=\"menu-item-1984\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1984\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/systemic-therapy\/\" data-ps2id-api=\"true\">Systemic Therapy<\/a><\/li>\n\t\t<li id=\"menu-item-1985\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1985\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/use-of-rai\/\" data-ps2id-api=\"true\">Use of Radioactive Iodine<\/a><\/li>\n\t\t<li id=\"menu-item-1982\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1982\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/recurrent-persistent-disease\/\" data-ps2id-api=\"true\">Recurrent &#038; Persistent Disease<\/a><\/li>\n\t<\/ul>\n<\/li>\n\t<li id=\"menu-item-4433\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-4433\"><a href=\"#\" data-ps2id-api=\"true\">Medullary Thyroid Cancer<\/a>\n\t<ul class=\"sub-menu\">\n\t\t<li id=\"menu-item-4465\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4465\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/mtc\/initial-evaluation-of-thyroid-nodules-suspicious-of-mtc\/\" data-ps2id-api=\"true\">Initial Evaluation of Thyroid Nodules Suspicious of MTC<\/a><\/li>\n\t\t<li id=\"menu-item-4467\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4467\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/mtc\/surgical-management\/\" data-ps2id-api=\"true\">Surgical Management<\/a><\/li>\n\t\t<li id=\"menu-item-4862\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4862\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/mtc\/evaluation-of-advanced-disease\/\" data-ps2id-api=\"true\">Evaluation of Advanced Disease<\/a><\/li>\n\t\t<li id=\"menu-item-4466\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4466\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/mtc\/management-of-specific-clinical-scenarios\/\" data-ps2id-api=\"true\">Management of Specific Clinical Scenarios<\/a><\/li>\n\t<\/ul>\n<\/li>\n\t<li id=\"menu-item-4434\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-4434\"><a href=\"#\" data-ps2id-api=\"true\">Anaplastic Thyroid Cancer<\/a>\n\t<ul class=\"sub-menu\">\n\t\t<li id=\"menu-item-4502\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4502\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/atc\/diagnostic-procedures\/\" data-ps2id-api=\"true\">Diagnostic Procedures<\/a><\/li>\n\t\t<li id=\"menu-item-4501\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4501\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/atc\/initial-staging-treatment-planning\/\" data-ps2id-api=\"true\">Initial Staging &#038; Treatment Planning<\/a><\/li>\n\t\t<li id=\"menu-item-4500\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4500\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/atc\/surgical-management\/\" data-ps2id-api=\"true\">Surgical Management<\/a><\/li>\n\t\t<li id=\"menu-item-4499\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4499\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/atc\/systemic-therapy\/\" data-ps2id-api=\"true\">Systemic Therapy<\/a><\/li>\n\t\t<li id=\"menu-item-4498\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4498\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/atc\/end-of-life-care\/\" data-ps2id-api=\"true\">End of Life Care<\/a><\/li>\n\t<\/ul>\n<\/li>\n\t<li id=\"menu-item-29263\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-29263\"><a href=\"#\" data-ps2id-api=\"true\">Analysis Tools<\/a>\n\t<ul class=\"sub-menu\">\n\t\t<li id=\"menu-item-29264\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-29264\"><a href=\"https:\/\/tiro.expert\/es\/ata-2025-risk-of-recurrence-calculator\/\" data-ps2id-api=\"true\">Risk of Recurrence Calculator<\/a><\/li>\n\t\t<li id=\"menu-item-20846\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-20846\"><a href=\"https:\/\/tiro.expert\/es\/recommendations\/analysis-tools\/\" data-ps2id-api=\"true\">Anatomic Checklist for Thyroid Cancer<\/a><\/li>\n\t<\/ul>\n<\/li>\n\t<li id=\"menu-item-1990\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1990\"><a href=\"https:\/\/tiro.expert\/es\/clinical-trial-options\/\" data-ps2id-api=\"true\">Clinical Trial Options<\/a><\/li>\n\t<li id=\"menu-item-3818\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3818\"><a href=\"https:\/\/tiro.expert\/es\/tables-and-figures\/\" data-ps2id-api=\"true\">Tables &#038; Figures<\/a><\/li>\n<\/ul>\n<\/li>\n<li id=\"menu-item-1973\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-1973\"><a href=\"#\" data-ps2id-api=\"true\">Events<\/a>\n<ul class=\"sub-menu\">\n\t<li id=\"menu-item-4348\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-4348\"><a href=\"https:\/\/tiro.expert\/es\/webinars\/\" data-ps2id-api=\"true\">Upcoming Webinars<\/a><\/li>\n\t<li id=\"menu-item-20057\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-20057\"><a href=\"https:\/\/tiro.expert\/es\/past-webinars\/\" data-ps2id-api=\"true\">Past Webinars<\/a><\/li>\n\t<li id=\"menu-item-1975\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1975\"><a href=\"\/subscribe\" data-ps2id-api=\"true\">Subscribe <i class=\"fas fa-external-link-alt fa-xs fa-fw\"><\/i><\/a><\/li>\n<\/ul>\n<\/li>\n<li id=\"menu-item-1974\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-1974\"><a href=\"#\" data-ps2id-api=\"true\">About TIRO<\/a>\n<ul class=\"sub-menu\">\n\t<li id=\"menu-item-1977\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1977\"><a href=\"https:\/\/tiro.expert\/es\/what-is-tiro\/\" data-ps2id-api=\"true\">What is TIRO?<\/a><\/li>\n\t<li id=\"menu-item-2407\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-2407\"><a href=\"https:\/\/tiro.expert\/es\/how-to-use-tiro\/\" data-ps2id-api=\"true\">How to Use TIRO<\/a><\/li>\n\t<li id=\"menu-item-1978\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1978\"><a href=\"https:\/\/tiro.expert\/es\/contact\/\" data-ps2id-api=\"true\">Contact<\/a><\/li>\n\t<li id=\"menu-item-1979\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1979\"><a href=\"https:\/\/thancguide.org\/\" data-ps2id-api=\"true\">THANC Guide <i class=\"fas fa-external-link-alt fa-xs fa-fw\"><\/i><\/a><\/li>\n\t<li id=\"menu-item-1980\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1980\"><a href=\"https:\/\/thancfoundation.org\" data-ps2id-api=\"true\">THANC Foundation <i class=\"fas fa-external-link-alt fa-xs fa-fw\"><\/i><\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul><\/div>\t<\/div>\n<\/div>\n<div class=\"clinical-outline-mask\"><\/div>\n\n\n\n<h2 class=\"has-secondary-color has-text-color wp-block-heading\">Management Recommendations<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">Definitions<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Persistent Disease:<\/strong> disease left following initial surgery due to less than an R0 resection of the primary and\/or regional lymph node disease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recurrent Disease:<\/strong> a biochemical and\/or identification of new structural disease in a patient believed to have been rendered disease free.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Local Recurrence:<\/strong> evidence of thyroid cancer in the thyroid bed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Regional Recurrence:<\/strong> nodal disease in either the central, retropharyngeal or the lateral compartments or a combination of these nodal basins.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Distant Recurrence:<\/strong> disease recurrence beyond the regional nodal basins.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">1. Local Recurrence<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Important to distinguish primary recurrence in the thyroid bed vs. residual thyroid tissue vs. nodal recurrence in the central neck. Primary thyroid recurrences are usually found at the insertion of the RLN and the cricothyroid muscle\u2014as such it may result in the loss of the RLN function. This is in contrast to central lymph node recurrences that usually can be dissected free of the RLN. Residual thyroid may have been left to protect the RLN and parathyroid glands and it is important to read the operative note for clues that this is the case.<\/p>\n\n\n\n<h3 class=\"tw-mb-0 wp-block-heading\">2. Regional Nodal Disease<\/h3>\n\n\n\n<p class=\"guidelines wp-block-paragraph\">ATA \/\/ NCCN<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Small volume (&lt; 1 cm) recurrent nodal disease can often be indolent and managed through active surveillance. However, bulky, progressive or invasive nodal disease is often best treated surgically.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The primary factors to consider prior to surgery for recurrent disease in the neck is the balance between:<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Risks of revision surgery, which are often greater than primary surgery, and&nbsp;<\/li><li>Surgical resection generally represents the optimal treatment of macroscopic nodal disease.&nbsp;<\/li><li>The availability of surgical expertise in performance of revision thyroid cancer surgery must be considered.<sup><a href=\"#references\">1<\/a><\/sup><\/li><\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Key considerations to choose when surgery is indicated for recurrent or persistent nodal disease.<span id=\"849b6864-f197-4330-aca1-2c507fa0e4ae\" data-items=\"[&quot;1669419985&quot;,&quot;1464913474&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1\u20133\u200b<\/sup><\/span><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Absolute size of the lymph nodes.<\/li><li>The location of the nodal disease\u2014level VII may require sternotomy, level VI reoperation may place the parathyroid glands and RLN are at risk, retropharyngeal nodes may place cranial nerves as well as key vascular structures at risk.<\/li><li>Virgin versus re-operative territory.&nbsp;<\/li><li>Rate of growth of structural disease or doubling time of thyroglobulin.<\/li><li>Vocal cord paralysis contralateral to the persistent central disease.<\/li><li>Known systemic metastases.<\/li><li>Significant comorbidities for surgery.&nbsp;<\/li><li>The patient\u2019s prognosis\/life expectancy.<\/li><li>Invasion into visceral\/critical anatomic structures.<\/li><li>Patient preferences.<\/li><\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Several biologic factors can also predict the risk of active surveillance versus the need for recurrent surgery and should factor into the decision-making process. Factors which support the need for surgery include:<span id=\"85c3a13c-71bf-4e0e-90ca-9bb16d170cd3\" data-items=\"[&quot;1464913474&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b2,3\u200b<\/sup><\/span><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Non-iodine avid disease\/FDG-PET-avid disease<\/li><li>Aggressive histology<\/li><li>More advanced initial staging and extrathyroidal extension<\/li><li>Extranodal extension at primary surgery<\/li><li>Molecular factors that predict more aggressive biology<\/li><\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Workup for metastatic disease and impact of distant metastases on treatment of nodal and visceral recurrences&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">All guidelines are silent on the work up needed for distant metastases when considering treatment of locoregional disease. Likewise, the impact of distant metastases on whether patients with locoregional disease should undergo treatment is not delineated.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">CT imaging of the chest, abdomen, and pelvis, brain MRI, or CT\/PET imaging is warranted in patients who are clinically suspected of having extensive disease burden. Advanced metastatic disease involving visceral organs or bones may impact performance status and pose a significant threat to the patient\u2019s life, thus compromising the potential success or wisdom of treatment of locoregional recurrent disease.<\/p>\n\n\n\n<h3 class=\"tw-mb-0 wp-block-heading\">3. Distant Disease Recurrence<\/h3>\n\n\n\n<p class=\"guidelines wp-block-paragraph\">ESMO \/\/ JAES \/\/ NCCN<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">A. Workup &amp; Decision-Making<span id=\"f906fd62-4cac-4bd9-8616-d758aee79e41\" data-items=\"[&quot;1160858975&quot;,&quot;454795586&quot;,&quot;609125014&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b3\u20135\u200b<\/sup><\/span><\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Rising Tg in Absence of Demonstrable Structural Disease<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">Early detection of distant metastases does not likely improve survival, and distant metastases are primarily diagnosed by incidental findings from laboratory\/imaging studies (or sometimes clinically).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Presently, there is no panel consensus regarding the work up of patients with rising Tg levels or persistently elevated Tg levels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Routine imaging is not warranted. However, neck ultrasounds, CT or FDG-PET imaging should be considered to evaluate for distant disease in patients with elevated Tg levels whose post-iodine scans are negative.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">B. Specific Site Management<\/h4>\n\n\n\n<h5 class=\"wp-block-heading\">Role of Directed Therapy in Addition to Local Therapy<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">Local therapies include surgery, thermal ablation (including radiofrequency ablation, laser ablation, cryotherapy) and\/or external beam radiation therapy (EBRT) (including stereotactic radiotherapy and intensity-modulated radiotherapy).<span id=\"0671a2a8-f793-4922-81b0-36b902fd986d\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;,&quot;609125014&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u20135\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Local therapy for distant metastases should be considered in isolated metastases or oligometastatic disease when metastases are progressive, symptomatic or at high risk of causing symptoms or complications.<span id=\"734824b7-08d5-46ec-9da1-d461a524ab6e\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Lung metastases: Local therapy should be considered for progressive or symptomatic, oligometastatic or oligoprogressive lesions. Thermal ablation or stereotactic radiotherapy are valid alternatives to surgery.<span id=\"4121ce6a-ee7a-4c6f-a371-4da168a86733\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Bone metastases: Local therapy should be considered for symptomatic lesions or preventively for asymptomatic lesions in weight-bearing sites or at high risk of fracture.<span id=\"d5313118-1905-4db6-99da-4e874307103c\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Brain metastases: Radiation therapy (stereotactic or intensity-modulated) or neurosurgery should be considered for solitary brain metastases. EBRT (stereotactic or intensity-modulated radiation therapy) should be considered for multiple brain or central nervous system metastases.<span id=\"4492a050-f1ec-47ed-ae37-ae255454fdf8\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span><\/p>\n\n\n\n<div id=\"edu-3b\" class=\"wp-block-group edu-info tw-rounded has-white-background-color has-background tw-shadow\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"wp-block-paragraph\">Supplemental Educational Content<\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion lecture gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Management of Thyroid Cancer Brain Metastasis<\/summary><div class=\"gb-accordion-text\">\n<h6 class=\"tw-eyebrow tw-heading-border-bottom wp-block-heading\">Presenter: Adomas Bunevicius, MD<\/h6>\n\n\n\n<h5 class=\"wp-block-heading\">Summary<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Dr. Adomas Bunevicius presents a lecture on the management of brain metastasis in thyroid cancer.<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Thyroid cancer brain metastasis (TCBM) is a rare complication, occuring in &lt;2% of thyroid cancer patients. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=137\">2:17<\/a>)<\/li><li>The discovery rate of asymptomatic cases is expected to increase. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=177\">2:57<\/a>)<\/li><li>The prognosis of TCBMs is grim. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=208\">3:28<\/a>)<\/li><li>Common symptoms of TCBM include headache (50%), focal deficits (40%), and seizures (10-20%). Patients can also be asymptomatic. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=244\">4:04<\/a>)<\/li><li>TCBMs can be diagnosed via imaging (e.g. CT, MRI) or biopsy. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=304\">5:04<\/a>)<\/li><li>Treatment options include observation, surgery, radiation therapy, systemic chemotherapy, targeted therapies, and immunotherapies. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=338\">5:38<\/a>)<\/li><li>Surgery and stereotactic radiosurgery (SRS) are associated with better prognosis in TCBM patients. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=602\">10:02<\/a>)<\/li><li>Radiation therapy is a critical treatment for treating brain metastasis (BM) as it improves local control. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=946\">18:46<\/a>)<\/li><li>Whole brain radiation therapy (WBRT) can be used for patients with multiple BMs or those with poor functional status. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=1341\">22:21<\/a>)<\/li><li>SRS allows for the delivery of high doses of radiation to the brain with very high precision and accuracy. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=1446\">24:06<\/a>)<\/li><li>Gamma Knife (Elekta) is a form of SRS that uses cobalt as a radiation source. Gamma rays are emitted in the form of focused beams that can target a particular area of the brain. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=1745\">29:05<\/a>)<\/li><li>The risk of cognitive deterioration was significantly greater for patients who received WBRT than for those who received SRS. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=1972\">32:52<\/a>)<\/li><li>Quality of life for patients with TCBM treated with Gamma Knife was stable over follow-up. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=2040\">34:00<\/a>)<\/li><li>Overall survival was longer in differentiated thyroid cancer TCBM patients who received tyrosine kinase inhibitors than those who did not. (<a href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU?t=2402\">40:02<\/a>)<\/li><\/ul>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link\" href=\"https:\/\/www.youtube.com\/watch?v=VrDVvohCVPU\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fab fa-fw fa-youtube\"><\/i> Watch this session<\/a><\/div>\n<\/div>\n<\/div><\/details><\/div>\n<\/div><\/div>\n\n\n\n<h3 class=\"tw-mb-0 wp-block-heading\">4. Management of Recurrent\/Persistent Thyroid Cancer<\/h3>\n\n\n\n<p class=\"guidelines wp-block-paragraph\">ATA \/\/ AAES \/\/ NCCN<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Prior to embarking on surgical management or any of the alternative therapeutic maneuvers such as radiofrequency ablation or alcohol injection, the lymph node(s) should be biopsied in order to confirm recurrence, unless it is located in a precarious position (i.e. retrojugular, retrocarotid, mediastinal, or retropharyngeal).<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">A. How to Manage a Patient with Recurrent\/Persistent Nodal Disease<\/h4>\n\n\n\n<h5 class=\"alignwide wp-block-heading\">i. Patient Specific Variables<\/h5>\n\n\n\n<figure class=\"wp-block-table alignwide is-style-tw-border-h-inner\"><table><thead><tr><th><strong>Variables<\/strong><\/th><th><strong>Active Surveillance<\/strong><\/th><th><strong>Surgery<\/strong><\/th><\/tr><\/thead><tbody><tr><td>Absolute size of lymph nodes (any dimension)<\/td><td>\u2264 0.8 cm (central compartment)<br><br>&lt; 1 cm (lateral compartment)<\/td><td>&gt; 0.8 cm (central compartment)<br><br>\u2265 1 cm (lateral compartment)<\/td><\/tr><tr><td>Rate of lymph node growth on serial imaging<\/td><td>Minimal\/slow ( &lt; 3\u20135 mm\/year )<\/td><td>Progressive ( &gt; 3\u20135 mm\/year )<\/td><\/tr><tr><td>Vocal cord paralysis contralateral to the paratracheal nodal basin where the positive lymph node is located (next to only working RLN)<\/td><td>Strongly consider if node is stable<\/td><td>Consider surgery if node is increasing in size and expertise for preoperative surgery available<\/td><\/tr><tr><td>Known systemic metastases<\/td><td>Progressive distant disease outpacing nodal metastasis<\/td><td>Stable distant metastasis, but nodal disease threatens vital structures<\/td><\/tr><tr><td>Comorbidities for surgery<\/td><td>Yes<\/td><td>No<\/td><\/tr><tr><td>Invasion into\/proximity to critical anatomic structures<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Good long-term prognosis<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Patient wishes to undergo surgery<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Disease likely to be identified intraoperatively<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Risk of postoperative functional deficit(s)<\/td><td>Yes<\/td><td>No<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 class=\"alignwide wp-block-heading\">ii. Biological Considerations<\/h5>\n\n\n\n<figure class=\"wp-block-table alignwide is-style-tw-border-h-inner\"><table><thead><tr><th><strong>Variables<\/strong><\/th><th><strong>Active Surveillance<\/strong><\/th><th><strong>Surgery<\/strong><\/th><\/tr><\/thead><tbody><tr><td>RAI-avid<\/td><td>Yes<\/td><td>No (unless other criteria for surgery met)<\/td><\/tr><tr><td>FDG-PET-avid<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Aggressive histology<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Extrathyroidal extension of primary tumor<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>More advanced initial T stage ( &gt; 4 cm) and more advanced nodal disease<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Extranodal extension (features of nodes at initial surgery)<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Molecular prognosticator for aggressive biology<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Thyroglobulin*<\/td><td>Thyroglobulin levels stable<\/td><td>Thyroglobulin levels increasing<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 class=\"alignwide wp-block-heading\">iii. Surgical Technical Considerations<\/h5>\n\n\n\n<figure class=\"wp-block-table alignwide is-style-tw-border-h-inner\"><table><thead><tr><th><strong>Variables<\/strong><\/th><th><strong>Active Surveillance<\/strong><\/th><th><strong>Surgery<\/strong><\/th><\/tr><\/thead><tbody><tr><td>First recurrence in that compartment?<\/td><td>No<\/td><td>Yes<\/td><\/tr><tr><td>Recurrent or persistent disease in previously formally dissected compartment or multiple dissections in same compartment<\/td><td>Stable disease<\/td><td>Limited\/focused dissection if progressive disease and threatening important structures<\/td><\/tr><tr><td>Availability of surgical expertise to perform the surgery<\/td><td>No<\/td><td>Yes<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h4 class=\"wp-block-heading\">B. Nodal Disease: Type of Intervention<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>Active surveillance<\/li><li>Surgery, extent<\/li><li>Alcohol ablation<\/li><li>Radiofrequency Ablation (RFA)<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Surgery for patients with residual\/recurrent neck disease in a previously unoperated compartment follows the general principles of complete compartmental resection (e.g. lateral neck dissection for a patient with residual\/recurrent lateral neck disease after previous thyroid\/central compartment surgery). Therapeutic revision central and\/or lateral compartmental neck dissection in a previously operated compartment may be performed as a focal resection of specific regions and nodes rather than a comprehensive compartmental dissection, depending on the extent of previous surgery in that compartment. In either case, there are a number of variables which should be considered in the setting of a multidisciplinary discussion (See table).&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The decision to offer surgery for recurrent disease in the neck is made considering several opposing decision elements:&nbsp;<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>risks of revision surgery;&nbsp;<\/li><li>the understanding that surgical resection generally represents the optimal treatment of macroscopic gross disease; and&nbsp;<\/li><li>the understanding that active surveillance is often a safe short-term strategy for all but the most aggressive differentiated thyroid cancers.<span id=\"e7759932-edc0-4918-999b-9cd08c3a38d5\" data-items=\"[&quot;1669419985&quot;,&quot;1464913474&quot;,&quot;1160858975&quot;,&quot;677630845&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1\u20133,6\u200b<\/sup><\/span><\/li><\/ol>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>RAI:<\/strong> Empiric RAI therapy is generally not recommended in patients with structurally identifiable disease that is not RAI avid. Empiric RAI is unlikely to have a significant tumoricidal effect due to low iodine uptake.<span id=\"8033a7be-ec79-405c-918b-fc4897fea467\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>EBRT:<\/strong> External beam radiation therapy can be used to treat isolated metastatic disease foci, but it has no role in most patients with resectable lymph node metastases. In patients with loco-regional recurrence that is not surgically resectable modern ERBT techniques (intensity modulated radiotherapy and stereotactic radiation) should be considered, particularly in patients with no evidence of distant disease. This treatment modality&#8217;s efficacy has been suggested only in retrospective studies on limited numbers of patients.<span id=\"4220791f-e46f-4d38-b84b-3b623441b972\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Systemic Therapy:<\/strong> Systemic therapies such as kinase inhibitors for recurrent loco-regional disease are considered only after surgical options have been exhausted.<span id=\"6826066b-1155-476d-8126-368dfc231c3b\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Ethanol Ablation:<\/strong> Ethanol ablation may be considered in patients who are poor surgical candidates. Focal ethanol ablation treatment represents a nonsurgical form of berry picking, and formal neck compartmental dissection is still first-line therapy in DTC patients with residual\/recurrent disease in the neck.<span id=\"519e6643-20ed-49da-b112-996b95890b19\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>RFA:<\/strong> The use of radiofrequency ablation (RFA) in the treatment of recurrent thyroid cancer has been associated with a mean volume reduction in a majority of cases and complete disappearance of the metastatic foci in some cases. Multiple treatment sessions are often required. Complications include pain, skin burn, and voice changes. RFA represents a nonsurgical form of berry picking, and formal neck compartmental dissection is still first-line therapy in DTC patients with residual\/recurrent disease in the neck. RFA may be most useful and preferred over surgical resection in high-risk surgical patients or in patients refusing additional surgery.<span id=\"ab64304e-a6c6-4366-bf24-ae36cbdfc772\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/p>\n\n\n\n<div class=\"wp-block-group edu-info tw-rounded has-white-background-color has-background tw-shadow\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"wp-block-paragraph\">Supplemental Educational Content<\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion presentation gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Long-Term Efficacy of Ethanol Ablation as Treatment of Metastatic Lymph Nodes From Papillary Thyroid Carcinoma<\/summary><div class=\"gb-accordion-text\">\n<h6 class=\"tw-eyebrow tw-heading-border-bottom wp-block-heading\">Presenter: P\u00e5l Stefan Frich, MD<\/h6>\n\n\n\n<ul class=\"is-style-tw-border-inner wp-block-list\"><li><a href=\"https:\/\/www.youtube.com\/watch?v=uHdfhaZhKJM&amp;t=984s\" target=\"_blank\" rel=\"noopener\" title=\"\"><strong>16:24<\/strong><\/a><strong> How Ethanol Ablation Affects Neck Node Metastasis?<\/strong><br>Dr. Frich discusses patient outcomes regarding neck node metastasis (NNM) detection and recurrence after receiving ethanol ablation.<a href=\"https:\/\/www.youtube.com\/watch?v=uHdfhaZhKJM&amp;t=1339s\">\u00a0<\/a><\/li><li><a href=\"https:\/\/www.youtube.com\/watch?v=uHdfhaZhKJM&amp;t=1339s\" target=\"_blank\" rel=\"noopener\" title=\"\"><strong>22:19<\/strong><\/a><strong> Is Ethanol Ablation an Effective Treatment?<\/strong><br>Dr. Frich compares his study results with existing literature and discusses how ethanol ablation efficacy can vary based on various factors.<\/li><li><a href=\"https:\/\/www.youtube.com\/watch?v=uHdfhaZhKJM&amp;t=1770s\" target=\"_blank\" rel=\"noopener\" title=\"\"><strong>29:30<\/strong><\/a><strong> How to Improve Our Understanding of Ethanol Ablation<\/strong><br>Dr. Schmitz summarizes the key characteristics of similar studies on percutaneous ethanol injection (PEI) and discusses how Dr. Frich\u2019s study addresses some limitations of those studies.<\/li><\/ul>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link\" href=\"https:\/\/youtu.be\/uHdfhaZhKJM\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fab fa-fw fa-youtube\"><\/i> Watch this session<\/a><\/div>\n<\/div>\n<\/div><\/details><\/div>\n<\/div><\/div>\n\n\n\n<h3 class=\"wp-block-heading\">5. Management of Recurrent DTC Involving the Upper Aerodigestive Tract (UADT)<\/h3>\n\n\n\n<p class=\"guidelines wp-block-paragraph\">ATA \/\/ ESMO \/\/ JAES \/\/ NCCN<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">A. General Management Considerations<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>Biopsy of persistent\/recurrent disease should be performed to document presence of disease and determine histology (expert opinion)<\/li><li>Consideration of grade progression should be determined by an experienced pathologist (expert opinion)<\/li><li>For gross residual\/recurrent PTC or FTC in the neck, cross-sectional imaging with either contrast enhanced CT or MRI should be performed.<span id=\"8714f4eb-5063-4a02-8672-5f59cc3eac8b\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>Potential delay of using RAI treatment is not deemed to be harmful.<span id=\"0ad0900c-9143-4e05-a063-c400d3685fbc\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/li><li>Consider iodine total body scan to assess RAI avidity of recurrent\/persistent disease and the presence of regional and distant metastases.<span id=\"71f95826-9763-4456-8969-812c46dc2ace\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>FDG PET CT should be considered in patients with recurrent DTC to determine the full extent of local disease and the presence of regional and distant disease.<span id=\"878381f9-9c4c-4d14-a174-9af0f3230483\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span><\/li><li>Endoscopy should be performed in cases of suspected aerodigestive tract invasion.<span id=\"cb223bd6-793a-484f-b93b-974792561ea7\" data-items=\"[&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3,4\u200b<\/sup><\/span><\/li><li>Assessment of laryngeal function by fiberoptic laryngoscopy, indirect mirror laryngoscopy or ultrasound should be performed.<span id=\"6ed36798-e7e0-4cf1-83a9-d07bf405c625\" data-items=\"[&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3,4\u200b<\/sup><\/span><\/li><li>Strong consideration should be given to referral to a high-volume institution with access to a multidisciplinary treatment team.<span id=\"b391b6a2-8ade-4098-8f83-57265aad1604\" data-items=\"[&quot;1160858975&quot;,&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3,7\u200b<\/sup><\/span><\/li><li>The goals of therapy are either to treat for cure or to treat with palliative intent to prevent asphyxiation due to local tumor growth and invasion.<span id=\"4ff701f9-6141-4bfc-b480-08a4b833d8dc\" data-items=\"[&quot;1669419985&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">B. Observation of Patients With Recurrent\/Persistent PTC or FTC<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>In disease that is threatening visceral structures, monitoring is not usually considered.<span id=\"937059d8-262f-48e4-88de-beebc5f0941d\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>If unresectable disease has been radiated and is not RAI avid, then monitoring may be considered if patient is not a candidate for systemic therapy.<span id=\"2f931dc5-44e5-4c1f-9989-842b7970058b\" data-items=\"[&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">C. Patients With Residual\/Recurrent PTC or FTC Disease Amenable to Surgical Resection<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>If disease is deemed resectable then consideration of surgery should be given.<span id=\"0bbedf52-9eb4-4819-b70d-bc83e5c7a86b\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,7\u200b<\/sup><\/span><\/li><li>Preoperative assessment of vocal cord mobility should be performed and documented.<span id=\"c1ded4d4-995a-45bf-937b-25513783cfec\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>Surgical resection may be done in combination with RAI treatment if RAI imaging is positive.<span id=\"7d15c0b4-fb51-4b1f-9769-8183512affc4\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,7\u200b<\/sup><\/span><\/li><li>RAI therapy alone is not considered optimal treatment.<span id=\"6c7368ea-ef67-425a-9a9b-9f67486d851b\" data-items=\"[&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b7\u200b<\/sup><\/span><\/li><li>Consideration should be given to measuring stimulated Tg and TgAB.<span id=\"c275747b-f05e-4648-82b8-b63f1ba9fc1f\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>A postoperative I<sup>123 <\/sup>or I<sup>131 <\/sup>whole body scan<sup> <\/sup>should be performed with TSH stimulation. If adequate uptake is confirmed, then administer Radioiodine treatment and obtain post treatment whole body scan.<span id=\"950d32be-6ded-4dbb-8364-1becb58f916f\" data-items=\"[&quot;1160858975&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">If no uptake on diagnostic scan then consider either external beam radiotherapy or monitoring of residual disease or systemic therapy.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">D. Role of Adjuvant Therapy in Patients With Resectable Disease<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>Consider pretreatment whole body imaging with TSH stimulation<\/li><li>Administer RAI for remnant ablation or adjuvant therapy<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">EBRT<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">E. Management of Patients With Unresectable Recurrent Thyroid Cancer<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>For patients with unresectable thyroid cancer invading visceral structures, measurement of stimulated Tg and Tg Antibodies should be done. An I<sup>123<\/sup> or an I<sup>131 <\/sup>whole body scan with TSH stimulation should be done.<ul><li>If adequate RAI uptake, then treat with RAI.&nbsp;<\/li><li>Continue TSH suppression<\/li><\/ul><\/li><li>For select patients with progressive local disease that is invading visceral structures that are deemed to be unresectable and non-RAI avid, then initial management with external beam radiotherapy should be considered.<span id=\"d52c69b0-28cd-437e-b877-6ed3b759ea29\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>Systemic therapies may be considered. &nbsp;&nbsp;&nbsp;<\/li><li>Genomic testing should be considered and if actionable mutations are identified then consider systemic therapy.<span id=\"5ac5afd7-e4bb-4e25-b96c-f1b60270bad1\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>Lenvatinib or sorafenib should be considered.<\/li><li>Vemurafenib and\/or Dabrafenib should be considered for BRAF positive cancers.<\/li><li>Larotrectinib or entrectinib should be considered for patients identified with NTRK gene fusion cancers. &nbsp;&nbsp;&nbsp;<\/li><li>Selpercatinib should be considered for patients with RET fusion positive cancers.<\/li><li>Pembrolizumab should be considered for patients with tumor mutational burden high tumors (TMB-H, &gt; 10 mut\/Megabase).<\/li><li>Consider referral to Clinical trial.<\/li><li>In patients with symptomatic invasive tumors causing bleeding and\/or obstruction, local treatment such as laser resection should be considered prior to the start of antiangiogenic multikinase inhibitors.<span id=\"9b55c5a1-e6d7-4aca-9d1a-27bf027c63dc\" data-items=\"[&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b4\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">F. Recurrent Hurthle Cell Cancers<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>For recurrent Hurthle Cell cancers involving visceral structures, surgery is preferred if deemed resectable.<span id=\"44bfc50e-25c5-4c32-a328-23c1b0b3bfa0\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>Consider RAI therapy either instead of surgery or postoperative, if RAI imaging positive (round table topic).<\/li><li>For select patients with unresectable progressive disease that is not RAI avid then consider EBRT.<span id=\"1f18efd3-038e-4b6b-89e4-772f592849a0\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>For unresectable progressive disease consider genomic testing to identify mutations that can be targeted and tumor mutational burden (TMB).<\/li><li>Consider Lenvatinib or Sorafenib.<span id=\"79eaa7d5-eddc-480d-a093-c883d4899540\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span><\/li><li>In patients with TMB-H (&gt; 10 mut\/Mb) tumors consider Pembrolizumab.<span id=\"205052b3-b281-47db-8b82-afc9edce98dc\" data-items=\"[&quot;1160858975&quot;,&quot;3102056739&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b3,7\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">G. Decision to Intervene<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Resection of disease involving the visceral structures and the decision to sacrifice the RLN if invaded by disease should be based on consideration of the following factors:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Disease stage<\/li><li>Location and extent of disease in the neck<\/li><li>Risk of surgically related complications<\/li><li>Comorbid conditions<\/li><li>Overall prognosis related to the disease and other conditions<\/li><li>Anticipated quality of life following surgery<\/li><li>The available skills and experience of the treatment team<\/li><li>Patient and caregiver preference<\/li><li>The patient\u2019s life expectancy<span id=\"258fc92f-662b-4e9d-9d04-33f0fe200ce8\" data-items=\"[&quot;3102056739&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b7\u200b<\/sup><\/span><\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Surgical management of recurrent thyroid cancer involving <a href=\"https:\/\/tiro.expert\/initial-management-of-suspicious-or-biopsy-proven-thyroid-cancer\/#2-active-surveillance-as\">visceral\/neurologic\/vascular structures<\/a>.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">6. Role of RAI in Recurrent\/Persistent Thyroid Cancer<\/h3>\n\n\n\n<p class=\"guidelines wp-block-paragraph\">ATA \/\/ ESMO \/\/ JAES \/\/ NCCN<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">There are several roles for RAI in the management of recurrent\/persistent thyroid cancer. Diagnostic whole body scanning may be a useful tool in the follow-up of patients with biochemical or structural evidence of persistent disease, or <a href=\"https:\/\/tiro.expert\/rai-in-diagnosis-therapy-for-initial-long-term-management-of-thyroid-cancer\/#5-role-of-rai-therapy-administered-activity\">indeterminate structural findings<\/a>. &nbsp;<\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Diagnostic Whole Body RAI Scans<\/summary><div class=\"gb-accordion-text\">\n<p class=\"wp-block-paragraph\">Routine use of surveillance diagnostic whole body RAI scanning during follow up is not recommended for low to intermediate risk patients with no biochemical or structural evidence of persistent\/recurrent disease.<span id=\"a3ba048e-7404-4975-9ed6-9e4b11bbff2a\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Diagnostic whole body scanning may be a useful diagnostic tool in the follow up of patients with high risk disease, biochemical or structural evidence of persistent disease, or indeterminate biochemical or structural findings.<span id=\"4accd6f9-d39b-4d9d-a4db-209dc101d9bd\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">SPECT\/CT RAI imaging may provide better anatomic localization of RAI avid foci allowing clinicians to better distinguish between metastatic foci and non-specific uptake.<span id=\"57f53abe-9bf2-42e1-97cb-d961ff34a96b\" data-items=\"[&quot;1669419985&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1\u200b<\/sup><\/span> <\/p>\n<\/div><\/details><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">18F-FDG-PET scanning may also be appropriate to stage the extent of locoregional recurrent\/persistent disease, particularly in the presence of poorly differentiated thyroid cancers, or widely invasive follicular carcinoma or invasive Hurthle cell cancer particularly if Tg elevated and\/or high risk pathology.<span id=\"a01a4657-5258-4122-84de-b3ae95a562b2\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span><\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion gb-block-accordion\"><details><summary class=\"gb-accordion-title\">18F-FDG-PET Scanning<\/summary><div class=\"gb-accordion-text\">\n<p class=\"wp-block-paragraph\">18F-FDG PET scan should be considered in high-risk DTC patients with elevated serum Tg (generally &gt; 10 ng\/mL;<span id=\"83945b77-6289-41f8-b14f-af6042dd37c5\" data-items=\"[&quot;1669419985&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,4\u200b<\/sup><\/span> stimulated Tg &gt; 2\u20135 ng\/ml <span id=\"451d3502-1899-4a08-9851-1b3361fc5875\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span>) with negative RAI imaging. May also be considered for (a) initial staging of poorly differentiated thyroid cancers; (b) widely invasive follicular carcinoma or invasive Hurthle cell cancer particularly if Tg elevated and\/or high risk pathology<span id=\"8d0c5f26-90bb-4a91-9139-532baf7af43e\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span> (c) as a prognostic tool in patients with metastatic disease to identify lesions \/ patients at highest risk of rapid progression \/ mortality;<span id=\"5a469a85-a220-4e41-9ed1-1418bf010b23\" data-items=\"[&quot;1669419985&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,4\u200b<\/sup><\/span> (d) evaluation of post-treatment response following systemic or local therapy of metastatic or locally invasive disease;<span id=\"6f09b2ba-5b89-40b5-96c3-187170f89f85\" data-items=\"[&quot;1669419985&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1\u200b<\/sup><\/span> or (e) first line isotopic imaging (including optional active surveillance) for patients with RAI refractory advanced\/metastatic DTC.<span id=\"307d4afd-f42d-4506-9585-277cf49d038e\" data-items=\"[&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b4\u200b<\/sup><\/span> <\/p>\n<\/div><\/details><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">If locoregional recurrent or persistent thyroid cancer is identified, surgery is the preferred treatment particularly in the presence of bulky or otherwise resectable disease. However, RAI therapy is recommended in several scenarios for <a href=\"https:\/\/tiro.expert\/rai-in-diagnosis-therapy-for-initial-long-term-management-of-thyroid-cancer\/#4-postoperative-disease-status-rai-decision-making-after-initial-thyroid-surgery\">recurrent \/ persistent thyroid cancer<\/a>.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Locoregional disease detected by RAI diagnostic scan (I<sup>123<\/sup> or low dose I<sup>131<\/sup>), particularly if small volume disease.<\/li><li>Post-surgical adjunctive treatment, particularly if disease previously identified on RAI imaging (diagnostic I<sup>123<\/sup> \/ I<sup>131<\/sup> or post-therapy scan) and residual disease is suspected.<\/li><li>Empiric therapy if significantly elevated Tg level but negative RAI diagnostic scan.<\/li><\/ul>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Treatment of Known Disease<\/summary><div class=\"gb-accordion-text\">\n<p class=\"wp-block-paragraph\">Administered activities ranging between 100\u2013200 mCi or 3.7\u20137.4 GBq should be considered for high risk patients or those with known metastatic disease.<span id=\"31fca495-4abb-48a0-a8bc-a68eab972f84\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span> Whole body and blood clearance dosimetry studies can be used to determine a maximal administered activity to be administered outside of this range, but this is only available at certain high volume specialist centers. The 48 hour whole body dose should not exceed 80 mCi (3.0 GBq) to avoid pulmonary fibrosis in patients with lung metastases and the bone marrow retention should not exceed 120 mCi (4.4 GBq) at 48 hours.<span id=\"bb8933cd-4236-4339-bbfd-bb728bac1f6b\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span>  Empirically administered RAI above 150 mCi or 5.5 GBq may exceed the maximum tolerable tissue dose and should be avoided in patients over 70 years of age.<span id=\"3b90251d-562b-47a0-a0be-4ee536e2d4f9\" data-items=\"[&quot;1669419985&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1\u200b<\/sup><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Empiric Therapy for Patients with Negative RAI Diagnostic Scan but Elevated Tg Level<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An empiric dose of RAI in the range of 100\u2013200 mCi (3.7\u20137.4 GBq) or a dosimetrically determined dose may be considered in patients with Tg &gt; 10 ng\/mL with thyroxine withdrawal or Tg &gt; 5 ng\/mL with rhTSH, increasing Tg or Tg antibody levels, with imaging failing to reveal the site of tumor. If the post treatment scan is negative, then the patient has RAI refractory disease and further RAI should not be given. In approximately half of patients, the disease site may be localized on the post treatment scan or a decline in Tg occurs.<span id=\"315ba191-e26e-4a3f-976c-e660dd15bcf7\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span> This is an area of controversy, not supported by Ito 2020 which states that RAI therapy is not recommended in patients with a high thyroglobulin level and no apparent lesion.<\/p>\n<\/div><\/details><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Appropriate preparation for RAI treatment should be used, including low iodine diet, baseline testing and a preference for thyroid hormone withdrawal in high-risk patients. It is recognized that recombinant human TSH preparation is an alternative for patients with intermediate risk disease or significant comorbidity that may preclude thyroid hormone withdrawal.<span id=\"9bdc0cf5-a2b3-4322-bac2-6d06d1a4f653\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;,&quot;3102056739&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,4,7\u200b<\/sup><\/span><\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Preparation for RAI Treatment<\/summary><div class=\"gb-accordion-text\">\n<ol class=\"alpha-lower-list wp-block-list\"><li>Low iodine diet is recommended for 1\u20132 weeks for patients undergoing RAI remnant ablation, adjuvant treatment or treatment of known disease.<span id=\"edc90be6-3425-40ec-9d56-9be052e642a1\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span> <br>Urinary iodine measurement outside of a research setting or suspected iodine contamination may not be necessary.<span id=\"7cf4876f-a825-487e-ae3f-98e1ca6c2e97\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3\u200b<\/sup><\/span> <\/li><li>Thyroid hormone withdrawal\u2014if thyroid hormone withdrawal is planned prior to RAI, levothyroxine should be withdrawn for 3\u20134 weeks. Liothyronine (LT3) may be substituted for levothyroxine in the initial weeks if levothyroxine is withdrawn for 4 or more weeks but liothyronine should be withdrawn for at least 2 weeks. The TSH should be measured prior to I<sup>131<\/sup> administration and should be greater than 30 mIU\/L.<span id=\"66a21a19-cbb9-4bad-a336-9bd44d557d6a\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4\u200b<\/sup><\/span> <\/li><li>Recombinant human TSH preparation can be used as an alternative to thyroxine withdrawal for remnant ablation or adjuvant treatment in patients with ATA low risk or intermediate risk disease or with significant comorbidity that may preclude thyroid hormone withdrawal. In high risk patients, thyroid hormone withdrawal is preferred.<span id=\"2c464cd9-2361-4294-8645-361c54da24f6\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;,&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4,7\u200b<\/sup><\/span> <br>If recombinant TSH (rhTSH) is utilized in patients with metastatic disease, the dose to metastatic foci may be lower than following thyroid hormone withdrawal and so an equivalent or greater administered activity of RAI should be given. Corticosteroid therapy should be considered when brain, spinal or superior vena caval deposits are present to reduce the risk of acute swelling which could result in compression of these vital organs.<span id=\"27aaa360-a9a7-4f98-b679-5934b8268c42\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;454795586&quot;,&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,3,4,7\u200b<\/sup><\/span> <\/li><li>Baseline testing: Patients receiving RAI should have baseline full blood count and kidney function tests performed given renal impairment significantly reduces RAI excretion and the potential insult to the bone marrow from RAI.<span id=\"f3f9bb3b-db46-44dc-bd03-27c27b800378\" data-items=\"[&quot;1669419985&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1\u200b<\/sup><\/span> <\/li><\/ol>\n<\/div><\/details><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">It is important that a post therapy whole body scan (with or without SPECT\/CT) is performed after RAI administration to assist in disease staging and document the RAI avidity of any structural lesion.<span id=\"61633260-17c5-4bab-8ad2-f74d3ff480f1\" data-items=\"[&quot;1669419985&quot;,&quot;1160858975&quot;,&quot;3102056739&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b1,3,7\u200b<\/sup><\/span> If there is a satisfactory response to RAI-avid disease, treatment may be repeated after 6\u201312 months. However, it is important that characteristics of RAI refractory disease are identified and if present, <a href=\"https:\/\/tiro.expert\/rai-in-diagnosis-therapy-for-initial-long-term-management-of-thyroid-cancer\/#5-role-of-rai-therapy-administered-activity\">no further RAI therapy is administered<\/a>.<\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Characteristics of RAI Refractory Disease<\/summary><div class=\"gb-accordion-text\">\n<p class=\"wp-block-paragraph\">The following clinical scenarios provide strong evidence that a patient with structurally identifiable metastatic disease has radioactive iodine refractory differentiated thyroid carcinoma provided the imaging is done with appropriate TSH stimulation, iodine preparation, and imaging techniques (including current scanner technology, appropriate iodine [I<sup>123<\/sup>, I<sup>131<\/sup> or I<sup>124<\/sup>] administered activity and imaging time after iodine administration). These scenarios include: (i) absence of initial RAI uptake in the malignant\/metastatic tissue (i.e. no uptake outside the thyroid bed at first therapeutic WBS); (ii) tumour tissue no longer able to concentrate RAI after previous evidence of RAI avid disease; (iii) RAI uptake in some lesions but not in others; and (iv) progression of metastatic disease (as defined by RECIST) despite significant RAI uptake within 6\u201312 months.<span id=\"02276ca9-9024-4ac1-9b31-cf465ba4be3b\" data-items=\"[&quot;1669419985&quot;,&quot;454795586&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b1,4\u200b<\/sup><\/span> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">NCCN<span id=\"4cebd248-6ecc-4430-aca9-710a7e4e8d1b\" data-items=\"[&quot;1160858975&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b3\u200b<\/sup><\/span> and JAES<span id=\"e4fb74c9-5291-4ddf-b4b1-ce4b26265a18\" data-items=\"[&quot;3102056739&quot;]\" data-has-children=\"true\" class=\"abt-citation\" contenteditable=\"false\"><sup>\u200b7\u200b<\/sup><\/span> do not specifically define RAI refractory disease other than being not amenable to RAI therapy. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">ESMO<span id=\"37941960-518a-42db-87c4-133f315c3483\" data-items=\"[&quot;454795586&quot;]\" class=\"abt-citation\" data-has-children=\"true\" contenteditable=\"false\"><sup>\u200b4\u200b<\/sup><\/span> also highlights controversy about additional potential criteria, including presence of high FDG uptake, aggressive histology and persistence of disease after multiple RAI treatment courses.<\/p>\n<\/div><\/details><\/div>\n\n\n\n<div id=\"edu-6\" class=\"wp-block-group edu-info tw-rounded has-white-background-color has-background tw-shadow\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"wp-block-paragraph\">Supplemental Educational Content<\/p>\n\n\n\n<div class=\"wp-block-genesis-blocks-gb-accordion lecture gb-block-accordion\"><details><summary class=\"gb-accordion-title\">Cabozantinib for Radioiodine-refractory Differentiated Thyroid Cancer<\/summary><div class=\"gb-accordion-text\">\n<h6 class=\"tw-eyebrow tw-heading-border-bottom wp-block-heading\">Presenter: Steven Sherman, MD<\/h6>\n\n\n\n<ul class=\"is-style-tw-border-inner wp-block-list\"><li><strong><a href=\"https:\/\/www.youtube.com\/watch?v=vAh2JSuMVd0&amp;t=636s\">10:36<\/a> Patterns of RAI Refractory DTC<\/strong><\/li><li><strong><a href=\"https:\/\/www.youtube.com\/watch?v=vAh2JSuMVd0&amp;t=1385s\">23:05<\/a> Cabozantinib&#8217;s Targeting Potential<\/strong><br>Using radioactive iodine (RAI) resistance pathways as a framework for reference, Dr. Steven Sherman highlights Cabozantinib\u2019s potential clinical benefits in patients who develop RAI refractory disease.&nbsp;<\/li><li><strong><a href=\"https:\/\/www.youtube.com\/watch?v=vAh2JSuMVd0&amp;t=2532s\">42:12<\/a> Cabozantinib Conclusions<\/strong><br>Dr. Steven Sherman provides an overview of conclusions from a phase III randomized trial of Cabozantinib versus placebo, alluding to directions for future research.<\/li><\/ul>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link\" href=\"https:\/\/youtu.be\/QH2e9GjcMOU\"><i class=\"fab fa-fw fa-youtube\"><\/i> Watch this session<\/a><\/div>\n<\/div>\n<\/div><\/details><\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-media-text alignwide is-stacked-on-mobile is-vertically-aligned-center is-image-fill tw-mt-9 alignfull is-style-tw-shadow tw-rounded has-violet-08-color has-subtle-background-background-color has-text-color has-background tw-media-bottom tw-stretched-link\" style=\"grid-template-columns:30% auto\"><figure class=\"wp-block-media-text__media\" style=\"background-image:url(https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-1024x683.jpg);background-position:67% 52%\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"683\" src=\"https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-1024x683.jpg\" alt=\"selective focus photography of people sitting on chairs while writing on notebooks\" class=\"wp-image-2444 size-full\" srcset=\"https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-1024x683.jpg 1024w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-300x200.jpg 300w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-768x512.jpg 768w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-1536x1024.jpg 1536w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-600x400.jpg 600w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi-1200x800.jpg 1200w, https:\/\/tiro.expert\/wp-content\/uploads\/2021\/05\/hb6uwq0i4mi.jpg 1600w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure><div class=\"wp-block-media-text__content\">\n<h2 class=\"wp-block-heading has-violet-08-color has-text-color\">Add TIROxMDS Webinars to Your Calendar<\/h2>\n\n\n\n<p class=\"has-violet-08-color has-text-color wp-block-paragraph\"><strong>In 2 quick steps, you can add our entire schedule of upcoming webinars to your calendar today!<\/strong> That way, you will never miss our upcoming lectures, presentations and case-based studies. Every Friday at 8:00 AM ET, we cover a new topic from published research.<\/p>\n\n\n\n<a title=\"Add to Calendar\" class=\"addeventstc\" data-id=\"wo408159\" href=\"https:\/\/www.addevent.com\/calendar\/wo408159\" target=\"_blank\" rel=\"nofollow noopener\">Add to Calendar<\/a>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group alignfull tw-mt-9\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-group alignfull tw-mt-9\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 class=\"wp-block-heading has-text-align-center tw-mb-6 tw-sm-text-left tw-heading-border-bottom has-violet-color has-text-color has-h-3-font-size\">Upcoming Webinars<\/h2>\n\n\n\n\n\n\n\n\n\n\n\n<div class=\"wp-block-columns alignwide tw-mt-8 tiroxmds-grid tw-cols-rounded tw-cols-stack-md tw-cols-card tw-cols-card-white is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-h-5-font-size\">Ari Wassner, MD<\/h3>\n\n\n\n<p class=\"has-text-align-left tw-mt-1 tw-text-uppercase tw-letter-spacing-tight has-violet-04-color has-text-color wp-block-paragraph\" style=\"font-size:10px\"><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong>Guest Presenter<\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<p class=\"tw-eyebrow tw-letter-spacing-tight has-violet-05-color has-text-color has-small-font-size wp-block-paragraph\"><i class=\"fas fa-fw fa-presentation-screen\"><\/i> <strong>Journal Club<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><strong><strong><strong><strong>Thyroid Function After Hemithyroidectomy in Children<\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date wp-block-paragraph\">Nov. 13, 2026<\/p>\n\n\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-h-5-font-size\">Gabriela Brenta, MD<\/h3>\n\n\n\n<p class=\"has-text-align-left tw-mt-1 tw-text-uppercase tw-letter-spacing-tight has-violet-04-color has-text-color wp-block-paragraph\" style=\"font-size:10px\"><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong>Guest Presenter<\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<p class=\"tw-eyebrow tw-letter-spacing-tight has-violet-05-color has-text-color has-small-font-size wp-block-paragraph\"><i class=\"fas fa-fw fa-presentation-screen\"><\/i> <strong>Journal Club<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><strong><strong><strong><strong>ATA 2026 Guidelines for Thyroid Disease in Preconception, Pregnancy &amp; Post Partum<\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date wp-block-paragraph\">Nov. 20, 2026<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/evt.to\/r2zbrqhwblsp\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fas fa-fw fa-user-check\"><\/i> RSVP<\/a><\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column has-accent-background-color has-background is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-violet-04-color has-text-color has-h-5-font-size\">No Webinar<\/h3>\n\n\n\n<p class=\"has-background-color has-text-color has-small-font-size wp-block-paragraph\"><strong><strong>Due to Thanksgiving (US Holiday).<\/strong><\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date has-violet-05-color has-text-color wp-block-paragraph\">Nov. 27, 2026<\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns alignwide tw-mt-8 tiroxmds-grid tw-cols-rounded tw-cols-stack-md tw-cols-card tw-cols-card-white is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-h-5-font-size\">Marika Russell, MD<\/h3>\n\n\n\n<p class=\"has-text-align-left tw-mt-1 tw-text-uppercase tw-letter-spacing-tight has-violet-04-color has-text-color wp-block-paragraph\" style=\"font-size:10px\"><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong>Guest Presenter<\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<p class=\"tw-eyebrow tw-letter-spacing-tight has-violet-05-color has-text-color has-small-font-size wp-block-paragraph\"><i class=\"fas fa-fw fa-presentation-screen\"><\/i> <strong>Journal Club<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><strong><strong><strong><strong>Scholarly Dialogue on Risk to the Recurrent Laryngeal Nerve with Thermal Ablation Procedures: A Reflection on Empirical Practices.<\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date wp-block-paragraph\">Dec. 4, 2026<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/evt.to\/8qxr8bgvhxjm\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fas fa-fw fa-user-check\"><\/i> RSVP<\/a><\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-h-5-font-size\">Michael Tuttle, MD<\/h3>\n\n\n\n<p class=\"has-text-align-left tw-mt-1 tw-text-uppercase tw-letter-spacing-tight has-violet-04-color has-text-color wp-block-paragraph\" style=\"font-size:10px\"><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong>Moderator<\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<p class=\"tw-eyebrow tw-letter-spacing-tight has-violet-05-color has-text-color has-small-font-size wp-block-paragraph\"><i class=\"fas fa-fw fa-comments\"><\/i> <strong>Tumor Board<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><strong><strong><strong><strong>Cases presen<\/strong><\/strong><\/strong>ted by Dr. Andy Bauer<\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date wp-block-paragraph\">Dec. 11, 2026<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/evt.to\/9td6xgn8slvc\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fas fa-fw fa-user-check\"><\/i> RSVP<\/a><\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading tw-mb-1 has-h-5-font-size\">Johnson Thomas, MD<\/h3>\n\n\n\n<p class=\"has-text-align-left tw-mt-1 tw-text-uppercase tw-letter-spacing-tight has-violet-04-color has-text-color wp-block-paragraph\" style=\"font-size:10px\"><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong><strong>Guest Presenter<\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<p class=\"tw-eyebrow tw-letter-spacing-tight has-violet-05-color has-text-color has-small-font-size wp-block-paragraph\"><i class=\"fas fa-fw fa-presentation-screen\"><\/i> <strong>Journal Club<\/strong><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><strong><strong><strong><strong>Artificial Intelligence Applications in Thyroid Cancer Diagnosis: 2026 Update<\/strong><\/strong><\/strong><\/strong><\/p>\n\n\n\n<div class=\"wp-block-group event-actions\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"date wp-block-paragraph\">Dec. 18, 2026<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/evt.to\/ngl44hcwp9cn\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fas fa-fw fa-user-check\"><\/i> RSVP<\/a><\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-media-text alignwide has-media-on-the-right is-stacked-on-mobile is-vertically-aligned-center is-image-fill tw-mt-9 alignfull is-style-tw-shadow tw-rounded tw-media-bottom tw-stretched-link\" style=\"grid-template-columns:auto 49%\"><div class=\"wp-block-media-text__content\">\n<h2 class=\"wp-block-heading has-text-align-center has-violet-08-color has-text-color\">Watch Past Videos<\/h2>\n\n\n\n<p class=\"has-text-align-center has-violet-08-color has-text-color wp-block-paragraph\">We record and post all prior educational webinars to our YouTube channel.<\/p>\n\n\n\n<div class=\"wp-block-buttons is-horizontal is-content-justification-center is-layout-flex wp-container-core-buttons-is-layout-cbcdc57d wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-outline is-style-outline--2\"><a class=\"wp-block-button__link has-violet-color has-white-background-color has-text-color has-background has-link-color has-border-color wp-element-button\" href=\"https:\/\/youtube.com\/playlist?list=PLKIn9wjqDMOm0DCLhGQN77tnT4MPo_Rcg\" style=\"border-color:#5b47da;border-width:3px;border-radius:100px\" target=\"_blank\" rel=\"noreferrer noopener\">Watch now<\/a><\/div>\n<\/div>\n<\/div><figure class=\"wp-block-media-text__media\" style=\"background-image:url(https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1024x683.jpg);background-position:55% 34%\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"683\" src=\"https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1024x683.jpg\" alt=\"Focused businessman wear headphones study online watching webinar\" class=\"wp-image-1180 size-full\" srcset=\"https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1024x683.jpg 1024w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-300x200.jpg 300w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-768x512.jpg 768w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1536x1024.jpg 1536w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-scaled.jpg 2048w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-600x400.jpg 600w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1200x800.jpg 1200w, https:\/\/tiro.expert\/wp-content\/uploads\/2020\/06\/iStock-1203044233-watch-video-1980x1320.jpg 1980w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure><\/div>\n\n\n\n<div class=\"wp-block-group tw-rounded has-blush-light-purple-gradient-background has-background\"><div class=\"wp-block-group__inner-container is-layout-constrained wp-block-group-is-layout-constrained\">\n<h2 class=\"wp-block-heading\">\u00cates-vous de langue maternelle fran\u00e7aise?<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Notre conseil consultatif international a cr\u00e9\u00e9 une version portable de TIRO.<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/tiro.expert\/wp-content\/uploads\/2021\/04\/TIRO.expert-Traduction-en-francais-des-recommandations.docx.pdf\" target=\"_blank\" rel=\"noreferrer noopener\"><i class=\"fas fa-fw fa-cloud-arrow-down\"><\/i> t\u00e9l\u00e9charger le PDF<\/a><\/div>\n<\/div>\n<\/div><\/div>\n\n\n\n<section aria-label=\"Bibliography\" class=\"wp-block-abt-bibliography abt-bibliography\" role=\"region\"><h3 class=\"abt-bibliography__heading\">References<\/h3><ol class=\"abt-bibliography__body\" data-entryspacing=\"1\" data-maxoffset=\"3\" data-linespacing=\"1\" data-second-field-align=\"flush\"><li id=\"1669419985\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">1. <\/div><div class=\"csl-right-inline\">Haugen B, Alexander E, Bible K, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. <i>Thyroid<\/i>. 2016;26(1):1-133. doi:<a href=\"https:\/\/doi.org\/10.1089\/thy.2015.0020\">10.1089\/thy.2015.0020<\/a><\/div>\n  <\/div>\n<\/li><li id=\"1464913474\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">2. <\/div><div class=\"csl-right-inline\">Tufano R, Clayman G, Heller K, et al. Management of recurrent\/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance. <i>Thyroid<\/i>. 2015;25(1):15-27. doi:<a href=\"https:\/\/doi.org\/10.1089\/thy.2014.0098\">10.1089\/thy.2014.0098<\/a><\/div>\n  <\/div>\n<\/li><li id=\"1160858975\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">3. <\/div><div class=\"csl-right-inline\">Haddad RI, Nasr C, Bischoff L, et al. NCCN Guidelines Insights: Thyroid Carcinoma, Version 2.2018. <i>J Natl Compr Canc Netw<\/i>. Published online December 2018:1429-1440. doi:<a href=\"https:\/\/doi.org\/10.6004\/jnccn.2018.0089\">10.6004\/jnccn.2018.0089<\/a><\/div>\n  <\/div>\n<\/li><li id=\"454795586\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">4. <\/div><div class=\"csl-right-inline\">Filetti S, Durante C, Hartl D, et al. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up\u2020. <i>Ann Oncol<\/i>. 2019;30(12):1856-1883. doi:<a href=\"https:\/\/doi.org\/10.1093\/annonc\/mdz400\">10.1093\/annonc\/mdz400<\/a><\/div>\n  <\/div>\n<\/li><li id=\"609125014\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">5. <\/div><div class=\"csl-right-inline\">Sugitani I, Ito Y, Takeuchi D, et al. Indications and Strategy for Active Surveillance of Adult Low-Risk Papillary Thyroid Microcarcinoma: Consensus Statements from the Japan Association of Endocrine Surgery Task Force on Management for Papillary Thyroid Microcarcinoma. <i>Thyroid<\/i>. 2021;31(2):183-192. doi:<a href=\"https:\/\/doi.org\/10.1089\/thy.2020.0330\">10.1089\/thy.2020.0330<\/a><\/div>\n  <\/div>\n<\/li><li id=\"677630845\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">6. <\/div><div class=\"csl-right-inline\">Patel K, Yip L, Lubitz C, et al. Executive Summary of the American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. <i>Ann Surg<\/i>. 2020;271(3):399-410. doi:<a href=\"https:\/\/doi.org\/10.1097\/SLA.0000000000003735\">10.1097\/SLA.0000000000003735<\/a><\/div>\n  <\/div>\n<\/li><li id=\"3102056739\">  <div class=\"csl-entry\">\n    <div class=\"csl-left-margin\">7. <\/div><div class=\"csl-right-inline\">Ito Y, Onoda N, Okamoto T. The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer. <i>Endocr J<\/i>. 2020;67(7):669-717. doi:<a href=\"https:\/\/doi.org\/10.1507\/endocrj.EJ20-0025\">10.1507\/endocrj.EJ20-0025<\/a><\/div>\n  <\/div>\n<\/li><\/ol><\/section>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Definiciones de las recomendaciones de manejo Enfermedad persistente: enfermedad que queda despu\u00e9s de la cirug\u00eda inicial debido a una resecci\u00f3n inferior a R0 del tumor primario y\/o enfermedad de los ganglios linf\u00e1ticos regionales. Enfermedad recurrente: una bioqu\u00edmica y\/o la identificaci\u00f3n de una nueva enfermedad estructural en un paciente que se cre\u00eda libre de enfermedad. Recurrencia local: evidencia de c\u00e1ncer de tiroides en el lecho tiroideo....<\/p>","protected":false},"author":1,"featured_media":2315,"parent":4458,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"templates\/template-cover.php","meta":{"_acf_changed":false,"inline_featured_image":false,"_uag_custom_page_level_css":"","footnotes":""},"class_list":["post-1761","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO Pro 5.0.5 - aioseo.com -->\n\t<meta name=\"description\" content=\"In patients with advanced or recurrent differentiated thyroid cancer, different treatments might be available based on anatomic site and extent of disease.\" \/>\n\t<meta name=\"robots\" content=\"nosnippet, max-image-preview:large, max-video-preview:-1\" \/>\n\t<meta name=\"google-site-verification\" content=\"dgn_KNbWOqdQMThGOuzuLswqwKwBsjcS82PzbL7RTr4\" \/>\n\t<meta name=\"msvalidate.01\" content=\"665B47E811A7F57E1C97131210D3FD3A\" \/>\n\t<meta name=\"keywords\" content=\"persistent thyroid cancer,recurrent thyroid cancer,recurrent thyroid cancer in lymph nodes,recurrent thyroid cancer after total thyroidectomy,recurrent thyroid cancer ultrasound,managing recurrent thyroid cancer,rai for recurrent thyroid cancer,persistent papillary thyroid cancer,persistent follicular thyroid cancer,tsh suppression for persistent thyroid cancer,papillary thyroid carcinoma treatment guidelines,thyroid cancer guidelines\" \/>\n\t<link rel=\"canonical\" href=\"https:\/\/tiro.expert\/es\/recommendations\/dtc\/recurrent-persistent-disease\/\" \/>\n\t\t<meta name=\"generator\" content=\"All in One SEO Pro (AIOSEO) 5.0.5\" \/>\n\t\t<script type=\"application\/ld+json\" class=\"aioseo-schema\">\n\t\t\t{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/dtc\\\/recurrent-persistent-disease\\\/#breadcrumblist\",\"itemListElement\":[{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/#listItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/tiro.expert\\\/es\\\/\",\"nextItem\":{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/#listItem\",\"name\":\"Care Recommendations\"}},{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/#listItem\",\"position\":2,\"name\":\"Care Recommendations\",\"item\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/\",\"nextItem\":{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/dtc\\\/#listItem\",\"name\":\"Differentiated Thyroid Cancer\"},\"previousItem\":{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/#listItem\",\"name\":\"Home\"}},{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/dtc\\\/#listItem\",\"position\":3,\"name\":\"Differentiated Thyroid Cancer\",\"item\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/dtc\\\/\",\"nextItem\":{\"@type\":\"ListItem\",\"@id\":\"https:\\\/\\\/tiro.expert\\\/es\\\/recommendations\\\/dtc\\\/recurrent-persistent-disease\\\/#listItem\",\"name\":\"Recurrent &#038; 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