👉The modern view of risk stratification begins with the identification of a suspicious nodule (peri-diagnostic period) and continues through the phases of diagnosis, treatment, adjuvant therapy, and follow-up.
👉From a practical standpoint, postoperatively, we use
the eighth edition of the American Joint Committee on
Cancer/tumor node metastasis (AJCC/TNM) staging
system to predict disease-specific mortality and the
American Thyroid Association (ATA) risk stratification
system to predict the risk of recurrent or persistent disease.
👉These initial risk estimates are then modified over time using the descriptions from the ATA guidelines to define the patients response to therapy at any point during follow-up, as excellent (no evidence of persistent / recurrent disease), biochemically incomplete [abnormal thyroglobulin (Tg) or rising Tg antibodies in the absence of identifiable structural disease], structurally incomplete (structural evidence of persistent / recurrent disease), or indeterminate (nonspecific findings that cannot be confidently classified as benign or malignant).
👉These modified risk estimates are then used to plan
👉Recently, the move toward deferred intervention
(active surveillance) of very low-risk thyroid cancers
and a more minimalistic approach to thyroid surgery has expanded the risk-stratification horizon to include not only the intraoperative and postoperative time periods but also the peri-diagnostic time frame that begins with the detection of a suspicious thyroid nodule.
👉In this peri-diagnostic period, it is important to
identify low-risk thyroid cancers that may be eligible for either an active surveillance management approach (with or without cytological confirmation) or for a minimalistic
surgical intervention, such as thyroid lobectomy without neck dissection.
👉Conversely, it is equally important to identify, in the peri-diagnostic period, those patients who would be most likely to benefit from more aggressive initial interventions that could include total thyroidectomy, with or without prophylactic or therapeutic neck dissection, radioactive iodine treatment,
external beam radiation, or upfront systemic therapy.
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