American Thyroid Association pediatric thyroid cancer risk levels and postoperative management in children with papillary thyroid carcinoma

ATA pediatric risk level*	Definition	Initial postoperative staging^¶	TSH goal^Δ	Surveillance of patients with no evidence of disease^◊
Low	Disease grossly confined to the thyroid with N0/Nx disease or patients with incidental N1a disease (microscopic metastasis to a small number [<5] of central neck lymph nodes)	Nonstimulated Tg(ie, measured while taking levothyroxine)^§	0.5 to 1.0 mIU/L	Ultrasound at 6 months postoperatively and then annually for 5 years. Tg^§ while on LT4 every 3 to 6 months for 2 years and then annually.
Intermediate	Extrathyroidal extension or extensive N1a or minimal N1b disease (6 to 10 lymph nodes with metastases)	TSH-stimulated Tg^§ and diagnostic 123-I scan in most patients	0.1 to 0.5 mIU/L	Ultrasound at 6 months postoperatively, every 6 to 12 months for 5 years, and then less frequently. Tg^§ on LT4 every 3 to 6 months for 3 years and then annually. Consider TSH-stimulated Tg^§ – diagnostic 123-I scan in 1 to 2 years in patients treated with 131-I.
High	Regionally extensive disease (extensive N1b, >10 lymph nodes with metastases or nodes >3 cm in size) or locally invasive disease (T4 tumors), with or without distant metastasis	TSH-stimulated Tg^§ and diagnostic 123-I scan in all patients	<0.1 mIU/L	Ultrasound at 6 months postoperatively, every 6 to 12 months for 5 years, and then less frequently. Tg^§ while on LT4 every 3 to 6 months for 3 years and then annually. TSH-stimulated Tg^§ ± diagnostic 123-I scan in 1 to 2 years in patients treated with 131-I.

ATA: American Thyroid Association; TSH: thyroid-stimulating hormone; Tg: thyroglobulin; mIU: milli-international units; LT4: levothyroxine; 123-I: iodine 123 (radioactive iodine); 131-I: iodine 131 (radioactive iodine); T4: localized tumor extension beyond the thyroid capsule, as defined by the American Joint Committee on Cancer classification system; TgAb: thyroglobulin antibody; M1: distant metastasis, as defined by the American Joint Committee on Cancer classification system.
* Risk levels defined by the ATA Task Force for Pediatric Thyroid Cancer. "Risk" is defined as the likelihood of having persistent cervical neck disease and/or distant metastases after initial total thyroidectomy with lymph node dissection by a high-volume thyroid surgeon. Risk does not refer to the risk for mortality, which is extremely low in the pediatric population.
¶ Initial postoperative staging that is done within 12 weeks after surgery.
Δ These are initial targets for TSH suppression and should be adapted to the patient's known or suspected disease status; in ATA Pediatric Intermediate- and High-risk patients who have no evidence of disease after 3 to 5 years of follow-up, the TSH can be allowed to rise to the low-normal range.
◊ Postoperative surveillance implies studies done at 6 months after the initial surgery and beyond in patients who are believed to be disease free; the intensity of follow-up and extent of diagnostic studies are determined by initial postoperative staging, current disease status, and whether or not 131-I was given for treatment; it may not necessarily apply to patients with known or suspected residual disease or follicular thyroid cancer.
§ Assumes a negative TgAb; in TgAb-positive patients, consideration can be given (except in patients with T4 or M1 disease) to deferred postoperative staging to allow time for TgAb clearance.

Adapted with permission from: Francis GL, Waguespack SG, Bauer AJ, et al. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2015; 25:716. Copyright © 2015 Mary Ann Liebert. The publisher for this copyrighted material is Mary Ann Liebert, Inc. publishers.

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American Thyroid Association pediatric thyroid cancer risk levels and postoperative management in children with papillary thyroid carcinoma