Current trends in the management of well differentiated papillary thyroid carcinoma

Clinical members of the American Thyroid Association were surveyed in regard to their diagnostic assessment, treatment, and long term assessment of differentiated papillary thyroid carcinoma. For a 39-yr-old female with a 2-cm solitary nodule and no history of radiation (index patient), respondents were asked to provide their preferences for diagnostic evaluation, treatment assuming a papillary carcinoma was focal, and follow-up. Of 408 surveys mailed, 233 (57.1%) were analyzed. Diagnostic studies included thyroid scan (56%), fine needle aspiration (96%), total serum T-4 (49%), and third generation TSH (56%). Treatment included surgery (99%), with 86% preferring near-total/total thyroidectomy. After surgery, 61% recommended I-131 ablation; long term therapy using L-T-4 alone was recommended by 97%, with most preferring suppression to a target TSH level of less than 0.01 mu IU/mL (22%), 0.01-0.05 (38%), or 0.06-0.50 (32%). For variations from the index patient, respondents' treatment were not different for a history of radiation, age of either 16 or 60 yr, nodule size of 1.5 cm, male sex, the presence of less than 1-cm multiple foci in the contralateral lobe, or capsular invasion of the nodule. Treatment and follow-up did change if there was blood vessel invasion or distant metastasis. In summary, our survey indicated consensus on diagnostic assessment of the index patient by fine needle aspiration and management by surgery and I-131 therapy. However, management varied widely for the ablative dose of I-131, the target TSH level after ablation, and the frequency and type of follow up.