Surgeon’s Checklist #1
Intraoperative Gross Extrathyroid / Extranodal Disease
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Table 11. Risk Stratification System with Proposed Modifications (ATA 2009)
Risk Level
ATA Low Risk
- Papillary thyroid cancer (with all of the following):
- No local or distant metastases,
- All macroscopic tumor has been resected,
- No tumor invasion of loco-regional tissues or structures,
- The tumor does not have aggressive histology (e.g. tall cell, hobnail variant, columnar cell carcinoma),
- If I131 is given, there are no RAI-avid metastatic foci outside the thyroid bed on the first post-treatment whole-body RAI scan,
- No vascular invasion,
- Clinical N0 or ≤ 5 pathologic N1 micrometastases (< 0.2 cm in largest dimension).*
- Intrathyroidal, encapsulated follicular thyroid variant of papillary thyroid cancer.*
- Intrathyroidal, well-differentiated follicular thyroid cancer with capsular invasion and no or minimal (< 4 foci) vascular invasion.*
- Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including BRAFV600E mutated (if known).*
ATA Intermediate Risk
- Microscopic invasion of tumor into the perithyroidal soft tissues.
- RAI-avid metastatic foci in the neck on the first post-treatment whole-body RAI scan.
- Aggressive histology (e.g. tall cell, hobnail variant, columnar cell carcinoma).
- Papillary thyroid cancer with vascular invasion.
- Clinical N1 or > 5 pathologic N1 with all involved lymph nodes < 3 cm in largest dimension.*
- Multifocal papillary microcarcinoma with ETE and BRAFV600E mutated (if known).*
ATA High Risk
- Macroscopic invasion of tumor into the perithyroidal soft tissues (gross ETE).
- Incomplete tumor resection.
- Distant metastases.
- Postoperative serum thyroglobulin suggestive of distant metastases.
- Pathologic N1 with any metastatic lymph node ≥ 3 cm in largest dimension.*
- Follicular thyroid cancer with extensive vascular invasion (> 4 foci of vascular invasion).*
* Proposed modifications, not present in the original 2009 initial risk stratification system.
The publisher for this copyrighted material is Mary Ann Liebert, Inc. publishers.
Table 5. AJCC Staging of Differentiated Thyroid Cancer (Disease Specific Mortality)
Age at Diagnosis
Younger than 55 Years
| T | N | M | Stage Group |
|---|---|---|---|
| Any T | Any N | M0 | I |
| Any T | Any N | M1 | II |
55 Years or Older
| T | N | M | Stage Group |
|---|---|---|---|
| T1 | N0 / NX | M0 | I |
| T1 | N1 | M0 | II |
| T2 | N0 / NX | M0 | I |
| T2 | N1 | M0 | II |
| T3a / T3b | Any N | M0 | II |
| T4a | Any N | M0 | III |
| T4b | Any N | M0 | IV A |
| Any T | Any N | M1 | IV B |
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