甲狀腺癌2021.v3（英文）-NCCN腫瘤臨床實踐指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)ThyroidCarcinomaersionOctoberNCCNGuidelinesforPatients?availableat/patientsVersion3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:28:48AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion3.2021ThyroidCarcinomaIndex*RobertI.Haddad,MD/Chair?Dana?Farber/BrighamandWomen’serCenter*LindsayBischoff,MD/Vice?ChaireVanderbilt?IngramCancerCenterDouglassBall,MDeTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsVictorBernet,MDeMayoClinicCancerCenterErikBlomain,MD,PhD§￥StanfordCancerInstituteNaifaLamkiBusaidy,MDeTheUniversityofTexaserCenterMichaelCampbell,MDeUCDavisComprehensiveCancerCenterPaxtonDickson,MD?St.JudeChildren’sResearchHospital/TheUniversityofTennesseeHealthScienceCenterQuan?YangDuh,MD?UCSFHelenDillerFamilyComprehensiveCancerCenterHormozEhya,MD≠FoxChaseCancerCenterWhitneyS.Goldner,MDeFred&PamelaBuffettCancerCenterTheresaGuo,MDζUCSanDiegoMooresCancerCenterNCCNGuidelinesPanelDisclosuresMeganHaymart,MDTeUniversityofMichiganRogelCancerCenterShelbyHolt,MD?UTSouthwesternSimmonsComprehensiveCancerCenterJasonP.Hunt,MD?HuntsmanCancerInstituteattheUniversityofUtahAndreiIagaru,MDФtanfordCancerInstituteFouadKandeel,MD,PhDeCityofHopeNationalMedicalCenterDominickM.Lamonica,MDTФellParkComprehensiveCancerCenterStephanieMarkovina,MD,PhD§SitemanCancerCenteratBarnes?JewishHospitalandWashingtonUniversitySchoolofMedicineBryanMcIver,MD,PhDeMoffittCancerCenterChristopherD.Raeburn,MD?UniversityofColoradoCancerCenterRodRezaee,MD?ζCaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteJohnA.Ridge,MD,PhD?FoxChaseCancerCenterContinueMaraY.Roth,MDeFredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceRandallP.Scheri,MD?DukeCancerInstituteJatinP.Shah,MD,PhD?MemorialSloanKetteringCancerCenterJenniferA.Sipos,MDeTheOhioStateUniversityComprehensiveCancerCenter?JamesCancerHospitalandSoloveResearchInstituteRebeccaSippel,MD?UniversityofWisconsinCarboneCancerCenterCordSturgeon,MD?RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversitThomasN.Wang,MD,PhD?O'NealComprehensiveCancerCenteratUABLoriJ.Wirth,MD?MassachusettsGeneralHospitalCancerCenterRichardJ.Wong,MD?MemorialSloanKetteringCancerCenterMichaelYeh,MDUCLAJonssonComprehensiveCancerCenterSusanDarlow,PhDDottieShead,MSCarlyJ.Cassara,MSceT?EndocrinologyInternaleT?MedicaloncologyNuclearOtolaryngologyPathology￥Patientadvocacy§Radiation/Radiationoncology?Surgery/Surgicaloncology*WritingCommitteeMemberVersion3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.dCarcinomaPanelMembersSummaryoftheGuidelinesUpdatesThyroidCarcinomaNoduleEvaluation(THYR?1)PapillaryCarcinomaFNAResults,DiagnosticProcedures,PreoperativeorIntraoperativeDecision?MakingCriteria,PrimarydCarcinomaPanelMembersSummaryoftheGuidelinesUpdatesThyroidCarcinomaNoduleEvaluation(THYR?1)PapillaryCarcinomaFNAResults,DiagnosticProcedures,PreoperativeorIntraoperativeDecision?MakingCriteria,PrimaryTreatment(PAP?1)ceduresPrimaryTreatmentFOLLnomaeatmentHRTMedullaryThyroidCarcinomaClinicalPresentation,DiagnosticProcedures,PrimaryTreatment(MEDU?1)GermlineMutationofRETProto?oncogene(MEDU?3)idCarcinomaIndexdNCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.AnaplasticCarcinomaFNAorCoreBiopsyFinding,DiagnosticProcedures,EstablishGoalsofTherapy,Stage(ANAP?1)SystemicTherapyforAnaplasticThyroidCarcinoma(ANAP?A)ofTSHSuppressionTHYRAaseInhibitorTherapyinAdvancedThyroidCarcinomaTHYRBciplesofRadiationandRadioactiveIodineTherapyTHYRCTheNCCNGuidelines?areastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatment.AnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancestodetermineanypatientscareortreatment.TheNationalComprehensiveCancerNetwork?(NCCN?)makesnorepresentationsorwarrantiesofanykindregardingtheircontent,useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.TheNCCNGuidelinesarecopyrightedbyNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2021.Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.ContinuedVersion3.2021,Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:28:48AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion3.2021ThyroidCarcinomadexUpdatesinVersion3.2021oftheNCCNGuidelinesforThyroidCarcinomafromVersion2.2021include:PAP?9?UnderConsidersystemictherapybullet,added:Cabozantinib(category1)ifprogressionafterlenvatiniband/orsorafenib.?Modifiedfootnotehh:Commerciallyavailablesmallmoleculekinaseinhibitors(suchasaxitinib,everolimus,pazopanib,sunitinib,vandetanib,vemurafenib[BRAFpositive],ordabrafenib[BRAFpositive],orcabozantinib[allarecategory2A])canbeconsideredifclinicaltrialsarenotavailableorappropriate.PAP?10?Added:Cabozantinib(category1)ifprogressionafterlenvatiniband/orsorafenibtotreatmentofbonemetastases?Added:Cabozantinib(category1)ifprogressionafterlenvatiniband/orsorafenibtotreatmentofCNSmetastasesFOLL?8?UnderConsidersystemictherapybullet,added:Cabozantinibifprogressionafterlenvatiniband/orsorafenib.?Modifiedfootnoteee:Commerciallyavailablesmallmoleculekinaseinhibitors(suchasaxitinib,everolimus,pazopanib,sunitinib,vandetanib,vemurafenib[BRAFpositive],ordabrafenib[BRAFpositive],orcabozantinib[allarecategory2A])canbeconsideredifclinicaltrialsarenotavailableorappropriate.FOLL?9?Added:Cabozantinibifprogressionafterlenvatiniband/orsorafenibtotreatmentofbonemetastases?Added:Cabozantinibifprogressionafterlenvatiniband/orsorafenibtotreatmentofCNSmetastasesHURT?8?UnderConsidersystemictherapybullet,added:Cabozantinibifprogressionafterlenvatiniband/orsorafenib.?Modifiedfootnoteff:Commerciallyavailablesmallmoleculekinaseinhibitors(suchasaxitinib,everolimus,pazopanib,sunitinib,vandetanib,vemurafenib[BRAFpositive],ordabrafenib[BRAFpositive],orcabozantinib[allarecategory2A])canbeconsideredifclinicaltrialsarenotavailableorappropriate.HURT?9?Added:Cabozantinibifprogressionafterlenvatiniband/orsorafenibtotreatmentofbonemetastases?Added:Cabozantinibifprogressionafterlenvatiniband/orsorafenibtotreatmentofCNSmetastasesUpdatesinVersion2.2021oftheNCCNGuidelinesforThyroidCarcinomafromVersion1.2021include:Discussion?TheDiscussionsectionhasbeenupdatedtoreflectthechangesinthealgorithm.PrintedbyMinTangon3/14/20227:28:48AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion3.2021ThyroidCarcinomadexUpdatesinVersion1.2021oftheNCCNGuidelinesforThyroidCarcinomafromVersion2.2020include:ThyroidCarcinomaGeneral?Algorithmsdescribingworkupforthyroidnoduleknownorsuspected,Bethesdal,andBethesdallwereremovedfromtheguidelines.ThisinformationwaspreviouslynotedonpagesTHYR?1andTHYR?2.THYR?1?Changed:Carcinomaorsuspiciousforcarcinoma(BethesdaVandorVl)?Bottombranch,added:ConsidertoRepeatFNA.THYR?2?CombinedbranchesforAUS/FLUS(BethesdaIII)orFollicularneoplasm(BethesdaIV).?AddedamiddlebranchforMoleculardiagnostics,notinformative.Undertreatment,addedoptions:NodulesurveillanceorConsiderlobectomyortotalthyroidectomyinselectsituationsfordefinitivediagnosis/treatment.?Footnoteb,added:Ifmoleculardiagnosticsaretechnicallyinadequateornotdone,thenrepeatFNA.?Footnotei,changed:"lobectomy"to"surgery."PapillaryCarcinoma(Note:Changeslistedbelowhavebeenmadethroughouttheguidelinesubtypes[FollicularandHürthleCellCarcinoma]whereappropriateforconsistency)PAP?1?Removedfootnote:ThereisapotentialroleforlobectomywithorwithoutfrozensectionifFNAissuspiciousbutnotdiagnosticforpapillarycarcinoma.?Diagnosticprocedures,changed:pConsiderassessmentevaluationofvocalcordmobility(ultrasound,mirrorindirectlaryngoscopy,orfiberopticlaryngoscopy)(alsoappliestoFOLL?1)pStronglyconsiderFNAforsuspiciouslateralnecknodes?Footnoteb,modified:Vocalcordmobilityshouldmaybeexaminedinpatientsifclinicalconcernforinvolvement,includingthosewithabnormalvoice,surgicalhistoryinvolvingtherecurrentlaryngealorvagusnerves,invasivedisease,orbulkydiseaseofthecentralneck.Evaluationisimperativeinthosewithvoicechanges.(Thischangewasmadeconsistentlythroughoutwhereappropriate.)?Changed"cervicallymphnodemetastases"to"lateralcervicallymphnodemetastases."PAP?2?CombinedpreviouspagesPAP?2andPAP?3.?Toppathway:Macroscopicmultifocaldisease(>1cm)movedtomiddlepathway?Middlepathway,deleted:Tumor1?4cmindiameterdeleted?Footnotef,changed:(<5involvednodeswithnometastasis>5>2mminlargestdimension).?Footnoteh,modified:Measurementofthyroglobulinandantithyroglobulinantibodiesmaybeusefulforobtainingapostoperativebaseline;however,datatointerpretTgandTgAbinthesettingofanintactthyroidlobearelacking.?Footnoteu:removed(category2B)?Removedfootnote:Maybeusefulforobtainingapostoperativebaseline.Therearenotenoughdatatoprovidefurtherrecommendations.PAP?3?Changed:SuspectedorproveninadequateRAIuptakeabsent.?Changed:AdequateRAIuptakepresentorNoRAIimagingperformed.?Footnotel,added:Forcontraindicationstowithdrawal,thyrotropinalfamaybeusedasanalternative.PAP?4?RAIselectivelyrecommended(ifanypresent),added:Detectableanti-Tgantibodies.?Changed:PostoperativeunstimulatedTg<5–<10ng/mL?Changed:RAIablationisnotrequiredinpatientswithclassicPTCwhohaveT1b/T2(1–4cm)N0orNXaand/orN0bdisease.?Footnoter,added:ie,poorlydifferentiated,tallcell,columnarcell,hobnailvariants,diffusesclerosing,andinsular.Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.ContinuedUPDATES?Footnotejj,added:Denosumabandintravenousbisphosphonatescanbeassociatedwithseverehypocalcemia;patientswithhypoparathyroidismandvitaminDdeficiencyareatincreasedriskofhypocalcemia.Discontinuingdenosumabcancausereboundradiotherapy?Footnotejj,added:Denosumabandintravenousbisphosphonatescanbeassociatedwithseverehypocalcemia;patientswithhypoparathyroidismandvitaminDdeficiencyareatincreasedriskofhypocalcemia.Discontinuingdenosumabcancausereboundradiotherapy,and/orresectioninselectcases.NCCNGuidelinesVersion3.2021ThyroidCarcinomadexUpdatesinVersion1.2021oftheNCCNGuidelinesforThyroidCarcinomafromVersion2.2020include:PAP?5?Modified:Considerpretreatmentneckimagingiodine?123wholebodydiagnosticimagingwithTSHstimulation(category2B)\?Removedfootnotev:Alternatively,low?doseiodine?131(1–3mCi)maybeused.PAP?6?Modified:Considerpretreatmentradioiodinediagnosticimaging(iodine?123oriodine?131)withTSHstimulation.PAP?7?Footnotex,modified:Long-termultrasoundfollow-upisnotrequired.Asubgroupoflow?riskpatientsmayonlyrequireanultrasoundifthereisareasonablesuspicionforrecurrence.PAP?9?Modified:Foradvanced,progressive,orthreateningdisease,genomictestingtoidentifyactionablemutations(includingALK,NTRK,andRETgenefusions),DNAmismatchrepair(dMMR),microsatelliteinstability(MSI),andtumormutationalburdenwholebrainradiotherapyorstereotacticradiosurgeryimage?guided?Modified:Forwholebrainradiotherapyorstereotacticradiosurgeryimage?guidedatypicalvertebralfractures.FollicularCarcinomaFOLL?1?Addedanewfootnote:Diseasemonitoringispreferredinmostcircumstances.However,therearecertainclinicalscenariosinwhichcompletionofthyroidectomymaybeappropriate.(AlsoforHURT?1)MedullaryCarcinomaMEDU?1?DiagnosticProcedures:pRemoved:ConsidergeneticcounselingpModified:ScreenforgermlineRETproto?oncogenemutations(exons10,11,13–16);geneticcounselingmaybeindicated.pAddedanewfootnote:Priortogermlinetesting,allpatientsshouldbeofferedgeneticcounselingeitherbytheirphysicianorageneticcounselor.MEDU?2?Modified:ScreenforgermlineRETproto?oncogenemutations(exons10,11,13–16);geneticcounselingmaybeindicated.MEDU?3?Modified:ConsiderneckCTwithcontrastifindicated.AnaplasticCarcinomaANAP?2?Treatmentforresectabledisease,added:pEBRT/IMRTwithchemotherapywhenclinicallyappropriatepFootnoteadded:SeePrinciplesofRadiationandRAITherapy(THYR-C).?Treatmentforunresectable,added:pConsidermolecularlytargetedneoadjuvanttherapyforborderlineresectablediseasewhensafetodoso.pNewfootnote:Regimensthatmaybeusedforneoadjuvanttherapyincludedabrafenib/trametinibforBRAFV600Emutations;selpercatiniborpralsetinibforRET-fusionpositivetumors;andlarotrectiniborentrectinibforpatientswithNTRKgenefusion-positivetumors.ANAP?3?Treatment,added:Considertracheostomy.ANAP?A(2of3)?Lenvatinibandcorrespondingreferencewereremovedfromtheguideline.Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?ConsidernodulesurveillanceiflowriskorpatientpreferenceasrecommendedbytheATAorTI?RADSg?Considermoleculardiagnosticsb(SeeTHYR?2)?ConsidernodulesurveillanceasrecommendedbytheATAorTI?RADSg(ifBethesdaIIIon2or?ConsidernodulesurveillanceiflowriskorpatientpreferenceasrecommendedbytheATAorTI?RADSg?Considermoleculardiagnosticsb(SeeTHYR?2)?ConsidernodulesurveillanceasrecommendedbytheATAorTI?RADSg(ifBethesdaIIIon2ormoreoccasions)NCCNGuidelinesVersion3.2021ThyroidCarcinomaIndexFNARESULTSCarcinomaorsuspiciousforcarcinoma(BethesdaVorVl)PapillaryorsuspiciousforpapillaryMedullaryorsuspiciousformedullaryAnaplasticorsuspiciousforanaplasticTREATMENTeSeePrimaryTreatment(PAP?1)SeePrimaryTreatment(MEDU?1)SeePrimaryTreatment(ANAP?1)DiagnosticcategoriesforFNAresultsreflectNCIstateofthescienceconference,theBethesdaClassification.CibasESandAliSZ.Thyroid2017;27:1341?1346.https://www.ncbi./pubmed/29091573.Cytologyreportsshouldbeinterpretedinlightofterminologyusedbylocalcytopathologists.Follicularorneoplasma,bHüneoplasma,b(BethesdaIV)Atypiaofundeterminedsignificance/Follicularlesionofsignificancebsignificanceb,c(AUS/FLUS)(BethesdaIII)Highclinicaland/orradiographicmalignancydsuspicionmalignancydHighclinicaland/orradiographicmalignancydsuspicionmalignancydYesYesSeePAP?1SeeFOLL?1SeeSeePAP?1SeeFOLL?1SeeHüRT?1Considerlobectomyortotalthyroidectomyf?Considermoleculardiagnosticsb(SeeTHYR?2)??Considermoleculardiagnosticsb(SeeTHYR?2)Considerlobectomyortotalthyroidectomyffordefinitivediagnosis/treatmentSeePAP?1?Considerdiagnosticlobectomy?ConsiderrepeatFNAh?ConsiderdiagnosticlobectomyaAlternativeterm:SuspiciousforfollicularorHürthlecellneoplasm.Estimatedriskofmalignancyis15%–40%.Numbersmayvarybyinstitutionorcytopathologist.bThediagnosisoffollicularcarcinomaorHürthlecellcarcinomarequiresevidenceofeithervascularorcapsularinvasion,whichcannotbedeterminedbyFNA.Moleculardiagnosticsmaybeusefultoallowreclassificationoffollicularlesions(ie,follicularneoplasm,AUS,FLUS)aseithermoreorlesslikelytobebenignormalignantbasedonthegeneticprofile.Ifmoleculartestingsuggestspapillarythyroidcarcinoma,especiallyinthecaseofBRAFV600E,seePAP?1.Ifmoleculartesting,inconjunctionwithclinicalandultrasoundfeatures,predictsariskofmalignancycomparabletotheriskofmalignancyseenwithabenignFNAcytology(approximately5%orless),considernodulesurveillance.Molecularmarkersshouldbeinterpretedwithcautionandinthecontextofclinical,radiographic,andcytologicfeaturesofeachindividualpatient.Ifmoleculardiagnosticsaretechnicallyinadequateornotdone,thenrepeatFNA.cEstimatedriskofmalignancyis6%–18%withoutNIFTPand10%–30%withnoninvasivefollicularthyroidneoplasmwithpapillary?likenuclearfeatures(NIFTP).dBasedonrapidgrowthofnodule,imaging,physicalexam,age,clinicalhistoryofradiation,andfamilyhistory.eTheorderofthetreatmentoptionsdoesnotindicatepreference.fTotalthyroidectomymaybeconsideredforHürthlecellneoplasm(BethesdaIV),historyofradiationexposure,orcontralaterallobelesions.gTI?RADS(/article/S1546?1440(17)30186?2/pdf)orATA(/pmc/articles/PMC4739132/pdf/thy.2015.0020.pdf).hConsidersecondopinionpathology.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.and/orConsidermoleculardiagnosticsbPrintedbyMinTangon3/14/20227:28:48AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.and/orConsidermoleculardiagnosticsbNCCNGuidelinesVersion3.2021ThyroidCarcinomaIndexMOLECULARDIAGNOSTICRESULTSTREATMENTiAUS/FLUSc(BethesdaIII)orFollicular(BethesdaIV(BethesdaIV)bRepeatFNARepeatFNAindicatebenignlesionbMolecularindicatebenignlesionbMoleculardiagnosticsnotinformativeMoleculardiagnosticssuggestiveofmalignancyNodulesurveillancegNodulesurveillancegorConsiderlobectomyortotalthyroidectomyinselectsituationsfordefinitivediagnosis/treatmentConsiderlobectomyortotalthyroidectomyfordefinitivediagnosis/treatmentNodulesurveillanceNodulesurveillancegDiagnosticcategoriesforFNAresultsreflectNCIstateofthescienceconference,theBethesdaClassification.CibasESandAliSZ.Thyroid2017;27:1341?1346./pubmed/29091573.Cytologyreportsshouldbeinterpretedinlightofterminologyusedbylocalcytopathologists.aAlternativeterm:Suspiciousforfollicularneoplasm.Estimatedriskofmalignancyis15%–40%.Numbersmayvarybyinstitutionorcytopathologist.bThediagnosisoffollicularcarcinomaorHürthlecellcarcinomarequiresevidenceofeithervascularorcapsularinvasion,whichcannotbedeterminedbyFNA.Moleculardiagnosticsmaybeusefultoallowreclassificationoffollicularlesions(ie,follicularneoplasm,AUS,FLUS)aseithermoreorlesslikelytobebenignormalignantbasedonthegeneticprofile.Ifmoleculartestingsuggestspapillarythyroidcarcinoma,especiallyinthecaseofBRAFV600E,seePAP?1.Ifmoleculartesting,inconjunctionwithclinicalandultrasoundfeatures,predictsariskofmalignancycomparabletotheriskofmalignancyseenwithabenignFNAcytology(approximately5%orless),considernodulesurveillance.Molecularmarkersshouldbeinterpretedwithcautionandinthecontextofclinical,radiographic,andcytologicfeaturesofeachindividualpatient.Ifmoleculardiagnosticsaretechnicallyinadequateornotdone,thenrepeatFNA.cEstimatedriskofmalignancyis6%–18%withoutNIFTPand10%–30%withNIFTP.gTI?RADS(/article/S1546?1440(17)30186?2/pdf)orATA(/pmc/articles/PMC4739132/pdf/thy.2015.0020.pdf).iClinicalriskfactors,sonographicpatterns,andpatientpreferencecanhelpdeterminewhethernodulesurveillanceorsurgeryisappropriate.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version3.2021,10/15/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?Considerassessmentofvocalcordmobility(ultrasound,mirrorindirectlaryngoscopy,orfiberopticlaryngoscopy)b?FNAforsuspiciouslateralnecknodescPrintedbyMinTangon3/14/20227:28:48AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensive?Considerassessmentofvocalcordmobility(ultrasound,mirrorindirectlaryngoscopy,orfiberopticlaryngoscopy)b?FNAforsuspiciouslateralnecknodescNCCNGuidelinesVersion3.2021ThyroidCarcinoma–PapillaryCarcinomadexFNARESULTSPapillarycarcinomaorsuspiciousforpapillarycarcinoma≥1cm<1cmDIAGNOSTICPROCEDURES?Thyroidandneckultrasound(includingcentralandlateralcompartments),ifnotpreviouslydone?CT/MRIwithcontrastforvocalcordparesisalocallyvocalcordparesisaThyroidandneckultrasound(includingcentralandlateralcompartments),ifnotpreviousl