The overall prognosis of DTC is good and the mortality rate is relatively low. However, the rate of disease recurrence varies widely depending on the clinicopathologic features. Patients were classified into 3 strata of risk of recurrence based on intraoperative pathological features such as residual lesions, tumor size and number, pathological subtypes, envelope vascular invasion, lymph node metastasis and extravasation, postoperative Tg levels after TSH stimulation (sTg), and molecular pathological features (Table 7). Postoperative adjuvant therapy is strongly recommended for DTC in the high-risk group; adjuvant therapy can be considered in the intermediate-risk group; and 131I thyroid clearance is generally not available in the low-risk group, but endocrine therapy should be considered.

The treatment of DTC is mainly surgical, supplemented by postoperative endocrine therapy, radionuclide therapy, and in some cases, radiation therapy, and targeted therapy. MTC is mainly surgical treatment, but in some cases, it should be supplemented by radiation therapy, targeted therapy. In the treatment of undifferentiated cancer, a few patients have the opportunity to undergo surgery, and some patients may have some effect with radiotherapy and chemotherapy, but the overall prognosis is very poor and survival time is short. It is important to note that individualization of tumor treatment is important, and each patient’s condition and complaints are different, so there is some flexibility in clinical diagnosis and treatment.

• Management of primary focus: Tumor with T grade T1 or T2 is mostly confined to one side of the For some patients with high risk factors, resection of the affected gland lobe and isthmus is recommended. For some patients with high-risk factors, total thyroidectomy is also possible. These risk factors include multifocal cancer, lymph node metastases, distant metastases, family history, and early childhood exposure to ionizing radiation. Total thyroidectomy is also indicated in some cases where postoperative nuclear therapy is considered necessary. For tumors located in the isthmus, extended isthmus resection is indicated for smaller tumors, and total thyroidectomy is considered for larger tumors or those with lymph node metastases.
  

  A subset of T1 lesions are low-risk microscopic papillary carcinomas. Because of its relatively slow progression and low lethality, conservative therapy, i.e., active surveillance and close follow-up, can be considered in addition to surgical treatment. Low-risk papillary carcinoma that can be closely monitored generally has the following characteristics: (1) the primary tumor is a single lesion, (2) the maximum diameter of the primary lesion is <1 cm, (3) the location of the primary lesion is located in the central part of the thyroid gland rather than immediately adjacent to the thyroid peritoneum or trachea, and (4) no regional lymph node metastasis has been evaluated after assessment. In addition to the above conditions, the patient should also be considered for the presence of high doses of electricity during early childhood.

History of exposure to ionizing radiation, family history of thyroid cancer, and the presence of coexisting hyperthyroidism are specific factors that should be considered. If closely monitored, re-evaluation is generally required every 6 months. If the evaluation reveals progression of the primary tumor (e.g., 2-3 mm increase in diameter, new tumor lesions, or clinically suspicious metastatic regional lymph nodes), discontinuation of conservative treatment should be considered.

therapeutic measures should be discontinued and surgical treatment should be performed.

T3 lesions with large tumors or those that have invaded the extraperitoneal muscles of the thyroid are recommended for total thyroidectomy. However, for some lesions closer to the thyroid peritoneum, which may not be large per se but have invaded the extraperitoneal muscles, excision of the affected lobe and isthmus can be performed along with excision of the invaded muscles. Specific surgical options are recommended weighing the benefits and risks of surgery.

T4 lesions that have invaded the surrounding structures are usually recommended for total thyroidectomy, and T4a lesions require resection of part of the affected structures, such as part of the larynx, along with the thyroid.

(or even the whole larynx), part of the trachea, hypopharynx, and part of the esophagus, etc., and some repair options are required. The T4b lesion is generally considered to be inoperable, but it is determined on a case-by-case basis. In general, however, T4b lesions are difficult to completely resect and have a poor prognosis, with high surgical risk and postoperative complications. Surgical treatment requires careful evaluation of the condition with a focus on whether the patient will benefit from surgery. Sometimes, palliative decompression therapy is necessary, such as tracheotomy to relieve dyspnea.

• Management of regional lymph nodes: Central zone lymph nodes (zone VI): cN1a The affected central zone should be cleared. If the lesion is on one side, it is recommended to include the affected tracheoesophageal groove and the anterior trachea. The anterior laryngeal region is also part of the central zone clearance, but the anterior laryngeal lymph nodes should be cleared.
  

Bar node metastases are rare and can be managed individually. For patients with cN0, central zone clearance may be considered if there are high-risk factors (e.g., T3 to T4 lesions, multifocal cancer, family history, history of early childhood ionizing radiation exposure, etc.). For low-risk patients with cN0 (without high-risk factors), the treatment can be individualized. The extent of central zone clearance is defined as the level of the superior border of the innominate artery at the inferior border, the level of the hyoid bone at the superior border, and the medial border of the common carotid artery at the lateral border, including the anterior trachea. The right tracheoesophageal groove requires attention to the lymphatic adipose tissue at the deep level where the laryngeal recurrent nerve is located. Central

Clearance of the laryngeal nerve and, if possible, the parathyroid glands and their blood supply should be protected, and parathyroid autotransplantation should be performed if in situ preservation of the parathyroid glands is not possible.

Lateral cervical lymph node management (zones I-V): Lateral cervical lymph node metastases in DTC are most commonly seen in zones III and IV, followed by zones II and V, and less commonly in zone I. Lateral cervical lymph node dissection is recommended to be performed therapeutically, i.e. when N1b is confirmed by preoperative evaluation or intraoperative freezing. The recommended scope of lateral neck dissection includes zones II, III, IV, and VB, with zones IIA, III, and IV being the smallest. Zone I does not require routine clearance. A schematic diagram of neck zoning and the specific divisions of each zone are shown in Figure 1 and Table 8.

Specialized lymph nodes, such as parapharyngeal lymph nodes and superior mediastinal lymph nodes, are recommended for simultaneous surgical resection when metastasis is considered on imaging.

For MTC, total thyroidectomy is recommended. In the case of MTC diagnosed after lobectomy, a total thyroidectomy is recommended. In individual cases, sporadic microscopic MTC found incidentally after lobectomy may also be considered for close observation.

MTC is more likely to have cervical lymph node metastases, and most patients present with lymph node metastases at the time of presentation. The surgical treatment of MTC should be slightly more aggressive than DTC surgery, with the aim of complete resection.

Some MTCs are hereditary medullary carcinomas and can be treated by detecting germline mutations in the RET gene.

(by genetic testing of somatic cells or blood leukocytes). In this group of patients, total thyroidectomy and cervical lymph node dissection are appropriate. In the case of MEN II patients, attention should be paid to the evaluation of the systemic situation. If there is a combination of pheochromocytoma, etc., it needs to be managed before considering thyroid surgery.

A few patients with undifferentiated cancer have small tumors at the time of presentation and may have the opportunity for surgery. The majority of patients with undifferentiated carcinoma have a large and rapidly progressing neck mass at the time of presentation and have no chance of surgery. A tracheotomy may be considered when the tumor is compressing the trachea and causing respiratory distress.

After thyroid cancer surgery, in addition to conventional rehydration, dexamethasone and neurotrophic drugs can be given as adjunctive therapy to reduce neuroedema. In patients with total thyroidectomy, parathyroid hormone and blood calcium should be checked and calcium supplements should be given to those with low calcium. Patients with injury to one laryngeal nerve often choke on food and water during the acute phase. If necessary, a tracheotomy kit should be placed at the bedside. Patients with bilateral laryngeal return nerve injury are usually treated intraoperatively with a tracheal tube and postoperative care of the tracheotomy opening. In patients with cervical lymph node dissection, postoperative attention is given to functional neck and shoulder forging.

Refinement. A postoperative adjuvant treatment plan based on pathologic staging and risk stratification should be developed and communicated to the patient.

Surgical complications are other surgically related conditions that occur during the surgical treatment of disease and have a certain probability of occurring and are not completely avoidable.

The incidence of postoperative bleeding in thyroid cancer is approximately 1 to about 2 , mostly within 24 hours after surgery. The main manifestations are increased, bloody drainage, swelling of the neck, and difficulty in breathing. If the drainage is >100 ml/h, active bleeding is considered and prompt debridement should be performed to stop the bleeding. If the patient is in respiratory distress, the airway should be controlled first, and the bedside incision can be opened in an emergency to relieve the pressure of the hematoma on the trachea first. The risk factors for postoperative bleeding in thyroid cancer include comorbid hypertension and patients taking anticoagulants or aspirin.

The probability of retrolaryngeal nerve injury in thyroid surgery is reported in the literature as 0.3 to 15.4 . Common causes of injury to the recurrent laryngeal nerve include tumor adhesion or invasion of the nerve, and the cause of surgical operation. If the tumor invades the recurrent laryngeal nerve, the tumor can be cut or the nerve can be removed together, depending on the situation. If the nerve is resected, it is recommended to perform one-stage nerve grafting or repair if possible. Injury to the laryngeal nerve on one side, postoperative paralysis of the vocal cords on the same side, hoarseness and choking on water. The surgical operation itself may damage the recurrent laryngeal nerve, and this condition cannot be completely avoided. With bilateral laryngeal nerve injury, postoperative respiratory distress can be life-threatening, and a tracheotomy should be performed at the same time as the surgery to ensure airway patency.

Supraglottic nerve injury, where the patient’s voice becomes muffled postoperatively. The supraglottic artery should be handled intraoperatively with close dissection of the thyroid gland to reduce the probability of supraglottic nerve injury.

Intraoperative neuromonitoring (IONM) techniques can help to localize the recurrent laryngeal nerve intraoperatively and can be used to detect the function of the recurrent laryngeal nerve after the specimen is lowered and to help localize the injured segment if there is nerve injury. IONM is recommended when available for secondary surgery, in cases such as large thyroid masses, and in cases where there is preoperative nerve paralysis on one side.

Fine dissection along the perineum, intraoperative exposure of the recurrent laryngeal nerve, appropriate use of energy instruments, and standardized use of IONM can reduce the probability of nerve injury.

The incidence of postoperative permanence is approximately 2to 15 , most often after total thyroidectomy. The main manifestation is postoperative hypocalcemia, with patients experiencing tingling, perioral tingling, or hand-foot twitching, which may be relieved by intravenous calcium drips. For temporary hypoparathyroidism, calcium can be given to relieve the symptoms, with the addition of osteopontin if necessary. Prophylactic dosing may be considered to reduce postoperative symptoms. In permanent hypoparathyroidism, lifelong calcium and vitamin D supplements are required. Intraoperative attention should be paid to the fine dissection along the perineurium and to the protection of the blood supply when the parathyroid glands are preserved in situ. Some staining techniques can assist in the intraoperative identification of the parathyroid glands, such as nano-carbon negative contrast.

Thyroid surgery is mostly a type I incision, with a few type II incisions involving the larynx, trachea, and esophagus. The incidence of postoperative thyroid incision infection is about 1 to 2 . Risk of incisional infection

Factors include cancer, diabetes, and immunocompromise. The signs of incisional infection include fever, cloudy drainage, redness and oozing of the incision, elevated skin temperature, and local pain with pressure. If incisional infection is suspected, antibiotic treatment should be given promptly, and the incision should be opened and changed if there is abscess accumulation. Superficial incisional infection is easy to detect, but deep incisional infection is often not easily detected early. In a very small number of patients, infection can cause life-threatening bleeding from ruptured large blood vessels in the neck.

Commonly seen after cervical lymph node dissection, it presents with a persistently high drainage volume, up to 500-1000 ml per day or even more, mostly as milky opaque fluid, also known as celiac leak. Prolonged lymphatic drainage can lead to decreased volume, electrolyte disturbance, and hypoproteinemia. When lymphatic leak occurs, drainage should be kept open. The first step is conservative treatment, usually with fasting and parenteral nutrition, and the drainage will gradually change from milky white to yellowish clear fluid in a few days, and the drainage will gradually decrease. If conservative treatment has no significant effect in 1 to 2 weeks, surgery should be considered. The surgical options are cervical thoracic duct ligation, cervical transfer tissue flap to seal the leak, or thoracoscopic ligation of the thoracic duct.

The incidence of localized effusion after thyroid surgery is approximately 1 to 6 . The greater the extent of the surgery the higher the probability of its occurrence, mainly associated with residual postoperative dead space. Retention of a drain in the operative area helps to reduce local fluid formation. Treatment includes close observation, multiple needle aspirations of the effusion, and negative pressure drainage.

Thyroid surgery can also cause some other complications, but the incidence is low, such as pneumothorax (caused by pleural rupture from cervical root surgery), Horner syndrome (cervical sympathetic chain injury), hypoglossal nerve injury causing tongue deviation, and facial nerve mandibular branch injury causing orofacial distortion. The injury to the marginal branch of the facial nerve causes a skewed angle of the mouth, etc.

Anatomical demarcation

Division

Upper boundary Lower boundary Front boundary (inner boundary) Back boundary (outer boundary)

ⅠA Mandibular union Hyoid bone Contralateral diastasis anterior ventral Ipsilateral diastasis anterior ventralⅠB Mandibular diastasis posterior ventral diastasis anterior ventral Stem hyoid muscle

IIA

Cranial base Hyoid underwater margin flat

Stem hyoid muscle Paraneoplastic plane

IIB Paramedian plane Posterior border of sternocleidomastoid muscle

< span style="font-size:1pt">

III Subglottic level Subcricoid level Subcricoid level IV Subcricoid level Clavicle

Sternocleidomastoid and trapezius muscles

External border of sternocleidomastoid muscle Posterior border of sternocleidomastoid muscle

V A

Intersection Vertex

Level of the inferior border of the cricoid cartilage

Posterior border of sternocleidomastoid muscle Anterior border of trapezius muscle

VB Inferior border of the cricoid cartilage level Clavicle

VI Hyoid bone Superior border of sternal stalk Contralateral common carotid artery Ipsilateral common carotid artery

Ⅶ Superior border of sternal stalk Superior border of common carotid artery (left) Common carotid artery

The concept of recurrence risk stratification was first introduced in the 2009 ATA Guidelines and updated in the 2015 ATA Guidelines. This recurrence risk stratification is based on intraoperative pathologic features such as degree of residual lesion, tumor size, pathologic subtype, envelope invasion, degree of vascular invasion, lymph node

metastatic features, molecular pathology, and post TSH stimulation (TSH >30 mU/L) Tg (sTg) levels and 131I post-treatment whole body scan (post-treatment whole body scan). treatment whole body scan (Rx-WBS) and other weighting factors classified patients into low, intermediate, and high risk of recurrence.

Use this stratification system to guide whether to treat patients with DTC with 131I.

PTC with all of the following: no distant metastases; all tumors seen visually were completely resected; tumors did not invade surrounding tissues; tumors were not an aggressive histologic subtype and did not invade blood vessels; if treated with 131I post-treatment whole-body imaging. No extra-bed iodine metastases; small number of lymph node metastases (e.g., cN0, but pathology reveals ≤5 micro-metastatic lymph nodes, i.e., metastases ≤0.2 cm in maximum diameter; follicular subtype of papillary thyroid carcinoma in the gland; differentiated follicular thyroid carcinoma in the gland with perineural invasion and with or without minor vascular invasion (<4); micro papillary carcinoma in the thyroid regardless of The risk stratification was low regardless of whether it was multifocal or not and whether it was associated with BRAF V600E positivity.

Either 1 of the following: microscopic tumor invasion of soft tissue outside the thyroid; invasive histology (e.g., high-cell, bootstrap, columnar cell carcinoma); papillary thyroid carcinoma with vascular invasion; systemic imaging if treated with 131I Iodine metastases in the neck; lymph node metastases (cN1, >5 metastatic lymph nodes with maximum metastasis diameter <3 cm on pathology; BRAF V600E mutation-positive intrathyroidal papillary carcinoma (1-4 cm in diameter); BRAF V600E mutation-positive multifocal thyroid carcinoma positive multifocal microscopic thyroid carcinoma combined with extraglandular infiltration.

Meets any 1 of the following: significant extraglandular infiltration; incomplete resection of the cancer; confirmed distant metastases; high postoperative Tg levels suggestive of distant metastases; combined with large lymph node metastases

metastasis (any lymph node metastasis ≧ 3cm in diameter); extensive invasion of blood vessels by follicular thyroid cancer

(>4 vascular invasion).

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• The 2015 ATA Guidelines are highly recommended for patients stratified for high risk of recurrence 131I Treatment
  

Treatment.

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• For intermediate-risk stratified patients, consider 131I treatment, but where there is microscopic thyroid exenteration
  

Moderate risk patients with small cancer foci or few lymph node metastases, small diameter of involvement and no risk factors such as highly invasive tissue subtypes or vascular invasion failed to improve after 131I treatment. span>I treatment does not improve the overall prognosis, they may not be treated with 131I.

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• In patients with low-risk stratification, it is not recommended to perform 131I treatment.
  

The current recommended indications for external radiation therapy are shown in Figure 2.

DTC

The indications for external radiation include: (1) those with significant visual residual tumor that cannot be surgically removed and cannot be controlled by radionuclide therapy alone; and (2) those with postoperative residual or recurrent lesions that do not absorb iodine.

External radiation therapy may be considered for patients who cannot be fully resected surgically, or who have recurrence. External radiation therapy is generally considered to help with local control in these patients. See Figure 3.

Comprehensive treatment is the primary treatment modality and is individualized to the patient. Radiotherapy can be used as part of a combination of preoperative and postoperative treatment. Radiotherapy alone can be used, and high-dose radiotherapy (recommended dose 60 Gy) is feasible.

For thyroid cancer with distant metastases such as lung, liver, bone or brain with clinical symptoms, surgery or 131I therapy combined with EBRT or stereotactic body radiation therapy can be considered to relieve symptoms and slow down tumor progression.

A detailed examination should be performed before radiotherapy to clarify the specific clearing of the tumor and to prepare for target area formulation: for those with hoarseness, dysphagia, and wheezing, it indicates that the tumor has invaded the thyroid body and reached the laryngeal recurrent nerve, esophagus, and trachea. Detailed examination of the neck for enlarged lymph nodes to determine whether there is regional lymph node metastasis. Laryngoscopy will be performed to determine whether there is vocal cord paralysis and whether there is invasion of the recurrent laryngeal nerve. Ultrasound and CT of the neck can be used to clarify the extent of tumor invasion and enlarged lymph nodes in the neck; CT of the lung, ultrasound of the abdomen and bone scan should be routinely examined to exclude the possibility of distant metastasis. Before postoperative radiotherapy, detailed information about the surgery, postoperative residuals, and postoperative pathological findings should be obtained.

Conformal radiotherapy or conventional radiotherapy can be used.

• intensity- modulated radiation therapy (IMRT) and three-dimensional conformal radiotherapy.
  
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  • Simulated CT localization.
    

  Selection of position: The optimal position is supine with a headrest at an appropriate angle (to ensure that the head is extended as far as possible) and a head pillow, and with the head, neck, and shoulders fixed with thermoplastic film. The C-pillow is generally used in the radiotherapy department of the Cancer Hospital of the Academy of Medical Sciences, which allows the neck to remain in the hyperextended position.

  Simulated CT scan: scan with spiral CT, all patients should be scanned with iodine contrast for enhancement, layer thickness 3 mm, upper border should include the cranial vault and lower border should include all lung tissue; upload to planning system.

• Target area development (Figure 4): There is a large controversy about target area determination. Some studies suggest that small field treatment can be used, with adequate attention to the surgeon’s external radiation to areas of high postoperative incidence, and areas that are not easily resected surgically. Some investigators believe that large-field radiation therapy should be given, with the option of treating areas of cervical lymph node drainage.
  

  The design of the target area should be specific to the type of pathology, extent of the lesion, and the presence or absence of lymph node invasion. In general, a small field is used for highly differentiated cancers, and a large field is used for poorly differentiated or undifferentiated cancers. For thyroid cancer, the upper and lower borders should be determined according to the extent of tumor invasion and the extent of lymph node metastasis, based on the principle of including the entire thyroid body and regional lymphatic drainage. For undifferentiated carcinoma, the upper border should include the upper cervical lymph nodes and the lower border should reach the level of the tracheal bifurcation to include the upper mediastinal lymph nodes.

  The current treatment field is mostly a large field, which needs to include the lymph node drainage areas in the neck and upper mediastinum.

• Tumor bed (GTVtb): includes the area of preoperative tumor invasion, as well as the extent of metastatic lymph node involvement, and should be considered for those who are not surgically For those who are not standardized, the surgical bed should be considered as GTVtb for outlining.
  
• High-risk area (CTV1): includes the thyroid area, surrounding lymph node drainage areas, and all areas with pathologically confirmed positive lymph nodes.
  
• Choice treatment area (CTV2): includes lymph node drainage areas II-VI and upper mediastinal lymph nodes without pathologic confirmation but with potential metastasis, with a low rate of metastasis in retropharyngeal lymph nodes and lymph nodes in area I. However, if lymph nodes in area II metastasize, retropharyngeal lymph nodes and lymph nodes in area I metastasize. The probability of metastasis in the retropharyngeal lymph nodes increased significantly when there were lymph node metastases in zone II, and the probability of lymph node metastases in zone Ib increased when there were large lymph node metastases in zone IIa.
  

increases and should be included in the treatment range. The lower border should be appropriately shifted downward if there are pathologically confirmed lymph node metastases in the superior mediastinum.)

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• Prescribed dose (Figure 5).
  

A. Selective treatment area (or low-risk area): 50Gy-54Gy given in general. B. Highly suspected involvement area: 59.4Gy-63Gy.

C. Positive cut edge pathology area: 63 Gy to 66 Gy. D. Naked eye residual area: 66 Gy to 70 Gy.

E. Normal tissue limits: highest dose to spinal cord ≤ 4000 cGy; average dose to parotid gland ≤ 2600 cGy; highest dose to larynx ≤ 7000 cGy (no hot spots should be present in the region of the larynx).

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• Conventional radiotherapy techniques.
  

• Positioning: same position as IMRT, recommended to use analog CT for positioning, and The field of fire is outlined on the planning system. Without the analog CT device, X-ray orthogonal images can also be used to outline the field.
  
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  • Radiographic field design.
    
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  • Two front oblique field cross-angle wedge irradiation technique: see Figure 6.
    

• Electron wire single anterior field irradiation (Figure 7, 8): according to TPS anterior neck choose the appropriate thickness of However, it should be noted that this method has a large skin reaction, so it cannot be used alone to achieve a radical dose and can be used in combination with high-energy X-rays to achieve a radical dose.
  

• Mixed X-ray and E-ray irradiation technique (Figure 9): first high-energy X-ray anterior-posterior large-field pair irradiation or single anterior field X-ray irradiation, D >

• Small bucket field irradiation technique (Figure 10): an anterior-posterior field pairing technique using high-energy X-rays, with the anterior field cervical medulla unblocked and the posterior field cervical medulla blocked, both fields irradiated daily, with a dose ratio of 4:1 in the anterior and posterior fields. The dose reference point was chosen around the anterior border of the cervical vertebral body, and at DT40Gy, the spinal cord was still within the tolerated dose range, and the thyroid, neck, and upper mediastinum all received satisfactory dose distribution. The dose distribution was satisfactory. In the final dose increase, the lower border was shifted up to the level of the thoracic notch and replaced with bilateral horizontal field pairs or two anterior oblique field wedges to achieve a total radical dose.
  

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• Radiation source: Cobalt-60 or 4-6MV high-energy X-rays, 8-15 MeV electron rays.
  
• Irradiation dose: according to the radiotherapy plan (large split plan and conventional split radiotherapy plan)
  

The irradiation dose: slightly different according to the radiotherapy protocol (macrosplit and conventional split radiotherapy protocols). According to the conventional dose fractionation: fractionated dose of 200 cGy once a day, 5 times a week, 5000 cGy in the large field, and then a reduction in the field to 6000-7000 cGy for the residual area, taking care not to exceed the tolerated spinal cord dose. Foreign treatment guidelines recommend: for those with

70 Gy is usually given for lesions with visual residual, 66 Gy for areas of microscopic residual or surgically removed tumor, 60 Gy for areas of high risk microscopic residual (including the thyroid bed, tracheoesophageal groove, and zone VI lymph node drainage area), and 54 to 7,000 cGy for areas of low risk microscopic (including uninvaded zones III-V, upper mediastinal lymph nodes) 54 to 56 Gy.

• Acute complications: 1 to 2 degree reactions are more common in about 80or more, including pharyngitis, mucositis, dry mouth, taste changes, dysphagia, painful swallowing, radiological skin
  

Pharyngitis is rare above 3 degrees, with the highest incidence of pharyngitis (<10), with the rest of the reactions <5 .

For stage IVA and stage IVB ATC, chemotherapy may be considered in addition to radiotherapy. Chemotherapy can be used in parallel with radiotherapy or given adjuvantly after radiotherapy. The drugs used include paclitaxel, anthracyclines, and platinum, as described in Table 9. When chemoradiotherapy is given concurrently, the chemotherapy regimen is recommended as a weekly regimen.

For stage IVC undifferentiated thyroid cancer, systemic chemotherapy may be considered. The recommended regimens for stage IVC undifferentiated thyroid cancer include paclitaxel combined with platinum, doxorubicin combined with doxorubicin, paclitaxel alone, and doxorubicin alone. See Table 10 for specific regimens.

It is still in the clinical research phase. For patients with thyroid cancer who have not responded to other treatments and whose disease is still progressing, participation in clinical studies related to immunotherapy is recommended.

According to current clinical findings, targeted therapies may prolong progression-free survival, but most do not improve overall survival. Once targeted therapy is initiated, the disease may progress at an accelerated rate. Therefore, it is recommended to strictly control the indications for targeted therapy. In particular, for DTC, it is recommended to consider targeted therapy if surgical treatment and 131I therapy have failed and the disease is still progressing significantly.

Note AUC, area under the concentration-time curve; IV, intravenous drip

Note: AUC, area under the concentration-time curve; IV, intravenous drip

Thyroid cancer belongs to the category of “gall tumor” in Chinese medicine. Modern research, combined with ancient medical knowledge of this disease, all agree that emotional factors are the main cause of the disease, in addition to deficiency, phlegm, stasis, heat, toxicity, and diet. The clinical picture is a mixture of deficiency and actuality, with multiple factors causing the disease together.

Inhibit tumor progression and control the disease as an adjuvant and end-stage supportive treatment. The second is to opt for pure TCM treatment without surgery or radiotherapy.

Population: Patients in the perioperative period, during radiotherapy, targeted therapy, post-treatment recovery, and in advanced stages.

Treatment: oral tonics, Chinese patent medicines, Chinese patent preparations, other Chinese medical methods

(external application, acupuncture, etc.)

Indications: Congenital weakness or damage to the righteous qi after surgery or radiotherapy.

Representative formulas: Bajhen Tang, Angelica Sinensis Blood Tonic Soup, Ten Perfect Tonic Soup, Tonic Zhong Yi Qi Soup plus

Decrease.

Indications: Commonly seen after radiotherapy or in vegetative deficiency. Chinese herbal tonics: Zhi Bai Di Huang Wan plus reduction

Indications: Commonly seen in bone marrow suppression or vegetative deficiency after radiotherapy. Representative tonics: Liu Wei Di Huang Wan plus or minus.

Indications: Depressed or irritable mood, good at resting, distension and pain in the chest and abdomen. Chinese herbal soup: Seaweed Yuhu Tang or Hanxia Houpu Tang with reduction.

Thyroid cancer, especially DTC, has a good prognosis, low mortality, and a long survival. It requires a multidisciplinary, standardized and comprehensive treatment process, including surgery, pathology, diagnostic imaging, nuclear medicine, radiotherapy, endocrinology, medical oncology, etc., and should be individualized and precise for different patients or different stages of treatment for the same patient.

Treatment and follow-up of thyroid cancer should be surgery-led. The patient’s condition will vary, and a comprehensive treatment plan will be developed in consultation with nuclear medicine, endocrinology, radiotherapy, and medical oncology.

• For patients with low-risk differentiated thyroid cancer, surgery + postoperative exogenous thyroxine replacement therapy or TSH suppression therapy is sufficient.
  
• For patients with distant metastatic high-risk differentiated thyroid cancer, surgery + postoperative 131I therapy + postoperative TSH suppression therapy is the main combined treatment modality.
  
• For localized lesions that are not surgically resectable, local radiofrequency ablation or external radiotherapy can be considered.
  

• Neck ultrasound should be performed periodically during DTC follow-up to assess the status of the thyroid bed and lymph nodes in the central and lateral neck areas. The first postoperative ultrasound examination is recommended at 3 months postoperatively for high-risk patients and 6 months postoperatively for intermediate and low-risk patients. If suspicious lesions are found, the examination interval can be shortened as appropriate. Ultrasound-guided puncture biopsy and/or puncture eluate Tg testing is indicated for suspicious lymph nodes.
  
• DTC patients undergoing surgery and 131131 span>I thyroid clearance therapy, Dx-WBS can be applied selectively at follow-up depending on the risk of recurrence.
  

  1) Patients with DTC at low to moderate risk of recurrence who have Dx-WBS that does not suggest 131I uptake outside the thyroid bed and who have a non-abnormal neck ultrasound and basal serum Tg levels at follow-up

  (in TSH suppressed state) are not high, no Dx-WBS is required.

  (ii) In patients with DTC at moderate to high risk of recurrence, Dx-WBS applied during long-term follow-up may be valuable in detecting tumor lesions, with a recommended interval of 6 to 12 months between examinations. If patients have progressively elevated Tg levels during follow-up, or if DTC recurrence is suspected, Dx-WBS is feasible.

• CT and MRI are not routinely performed in DTC follow-up. CT or MRI of the cervical thorax should be performed when: (i) the lymph node recurrence is extensive and cannot be accurately described by ultrasound; (ii) the metastatic lesion may invade the upper respiratory and gastrointestinal tracts and further evaluation of the extent of invasion is needed; (iii) the serum Tg level is elevated (>10ng/ml) or TgAb is elevated in high-risk patients. If Dx-WBS is negative, iodine-containing contrast should be avoided if follow-up 131I therapy is possible. If an enhanced CT scan with iodine contrast is performed, 131I therapy is recommended 4 to 8 weeks after the examination.
  

Trial administration of 3.7-7.4GBq (100-200mCi)131I; if DTC is detected by Dx-WBS after treatment lesions or reduced serum Tg levels after Dx-WBS, repeat 131I therapy; otherwise, discontinue 131I therapy and focus on TSH suppression.

Postoperative thyroid function follow-up is consistent with DTC but does not require TSH suppression therapy. Serum calcitonin and CEA are the more specific biochemical markers for MTC and are mandatory for follow-up review. For patients whose serum calcitonin and CEA levels return to normal after surgery, the follow-up period can be referred to the follow-up of low-risk DTC; for patients whose serum calcitonin and CEA do not fall into the normal range but are at lower levels, the follow-up of high-risk DTC can be referred to; for patients whose biochemical indicators are still at high levels, close follow-up should be performed, and it is recommended that ultrasound be repeated in 3 to 6 months, and that the serum calcitonin and CEA be reviewed according to the serum calcitonin and CEA levels.

The magnitude of the rise in serum calcitonin and CEA, combined with CT or MRI, should be used to determine the extent of the tumor, and PET-CT should be performed if necessary.

Attachments

Thyroid Cancer Treatment Guidelines (2022 Edition) Validation Expert Group

(in surname stroke order)

Team leaders: Liu Shaoyan, Xu Zhenzang

Members:Wang Ping, Wang Yu, Zhu Yiming, Sun Hui, Yang Ankui, He Xiaohui, Lin Yansong, Yi Junlin, Luo Dehong, Fang Jugao, Shi Bingyin, Qin Jianwu, Gao Ming, Guo Liang, Huang Tao, Ge Minghua, Lu Hazhen, Liao Quan