甲状腺癌2021.v3（英文）-NCCN肿瘤临床实践指南

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‑ChairðVanderbilt‑IngramCancerCenterDouglassBall,MDðTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsVictorBernet,MDðMayoClinicCancerCenterErikBlomain,MD,PhD§¥StanfordCancerInstituteNaifaLamkiBusaidy,MDðTheUniversityofTexaserCenterMichaelCampbell,MDðUCDavisComprehensiveCancerCenterPaxtonDickson,MD¶St.JudeChildren’sResearchHospital/TheUniversityofTennesseeHealthScienceCenterQuan‑YangDuh,MD¶UCSFHelenDillerFamilyComprehensiveCancerCenterHormozEhya,MD≠FoxChaseCancerCenterWhitneyS.Goldner,MDðFred&PamelaBuffettCancerCenterTheresaGuo,MDζUCSanDiegoMooresCancerCenterNCCNGuidelinesPanelDisclosuresMeganHaymart,MDÞðUniversityofMichiganRogelCancerCenterShelbyHolt,MD¶UTSouthwesternSimmonsComprehensiveCancerCenterJasonP.Hunt,MD¶HuntsmanCancerInstituteattheUniversityofUtahAndreiIagaru,MDФtanfordCancerInstituteFouadKandeel,MD,PhDðCityofHopeNationalMedicalCenterDominickM.Lamonica,MDÞФellParkComprehensiveCancerCenterStephanieMarkovina,MD,PhD§SitemanCancerCenteratBarnes‑JewishHospitalandWashingtonUniversitySchoolofMedicineBryanMcIver,MD,PhDðMoffittCancerCenterChristopherD.Raeburn,MD¶UniversityofColoradoCancerCenterRodRezaee,MD¶ζCaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteJohnA.Ridge,MD,PhD¶FoxChaseCancerCenterContinueMaraY.Roth,MDðFredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceRandallP.Scheri,MD¶DukeCancerInstituteJatinP.Shah,MD,PhD¶MemorialSloanKetteringCancerCenterJenniferA.Sipos,MDðTheOhioStateUniversityComprehensiveCancerCenter‑JamesCancerHospitalandSoloveResearchInstituteRebeccaSippel,MD¶UniversityofWisconsinCarboneCancerCenterCordSturgeon,MD¶RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversitThomasN.Wang,MD,PhD¶O'NealComprehensiveCancerCenteratUABLoriJ.Wirth,MD†MassachusettsGeneralHospitalCancerCenterRichardJ.Wong,MD¶MemorialSloanKetteringCancerCenterMichaelYeh,MDUCLAJonssonComprehensiveCancerCenterSusanDarlow,PhDDottieShead,MSCarlyJ.Cassara,MScðÞ†EndocrinologyInternalðÞ†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