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    Home > Active Ingredient News > Endocrine System > Professor Qing Su: Interpretation of "Management of Patients with Undifferentiated Thyroid Carcinoma: 2021 ATA Guidelines" | 2021CDEF

    Professor Qing Su: Interpretation of "Management of Patients with Undifferentiated Thyroid Carcinoma: 2021 ATA Guidelines" | 2021CDEF

    • Last Update: 2021-06-01
    • Source: Internet
    • Author: User
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    Edited by Yimaitong, please do not reprint without authorization.

    Guide: On May 21st, the "2021 Frontier Advances in Endocrine and Metabolic Diseases Forum (CDEF)" co-sponsored by the Chinese National Health Association and the Chinese Society of Geriatric Healthcare and Medical Research was held in Tianjin.

    Professor Qing Su from Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine gave a wonderful speech on the topic of "Management of Patients with Undifferentiated Thyroid Carcinoma (ATC): Interpretation of the 2021 ATA Guidelines".
    Yimaitong edited it for teachers.
    Check out learning.

     Professor Qing Su Professor Qing Su's profile: Director of the Department of Endocrinology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Doctor of Medicine, Chief Physician, Doctoral Supervisor; Member of the Standing Committee of Diabetes Branch of Chinese Medical Association; Deputy Chairman of Diabetes Branch of Shanghai Medical Association; 6 projects funded by the National Natural Science Foundation of China, more than 200 papers have been published, of which more than 50 papers are included in SCI as the first author or corresponding author.
    The guidelines include diagnosis of ATC, initial evaluation, establishment of treatment goals, and treatment of focal diseases (Surgery, radiotherapy, targeted/systemic therapy, nursing care during active treatment), treatment of advanced/metastatic diseases, selection of palliative care, monitoring and long-term follow-up, including ethical issues at the end of life.

    A total of 31 recommendations and 16 good practice statements were made.

     Strength of Recommendation and Grade of Evidence Follow the Grading System for Quality of Evidence and Strength of Recommendation (GRADE) to establish the strength of recommendation and evidence.

     Strength of recommendation: ➤strong recommendation ➤conditional recommendation.
    Level of evidence: high, medium, low, very low.
    Definition of terms According to the 8th edition of the American Joint Committee on Cancer (AJCC) Tumor-lymph node-distant metastasis (TNM) staging, all ATCs belong to stage IV.1.
    Definition of terms: TNM stage ➤IVA stage (T1-T3a, N0, M0): the tumor is limited to the thyroid, and there is no lymph node metastasis (N0) and distant metastasis (M0) ➤IVB stage (T3b, T4, ≥ N1, M0): The primary tumor invades the thyroid gland or penetrates the thyroid capsule (T3b, T4), and/or there is limited lymph node metastasis (≥N1), but no distant metastasis (M0) ➤IVC stage ( Any T, Any N, M1): The tumor has distant metastasis 2.
    Definition of terms: extent of resection ➤R0: Complete tumor resection, no residual tumor lesions at the edge under microscopic examination ➤R1: Complete resection visible to the naked eye Tumor, but there are still small residual lesions at the margin of surgical resection (removal margin included under microscopy) ➤R2: gross residual lesions are visible to the naked eye (including resection lesions under microscopy) 3.
    Definition of terms: adjuvant treatment and neoadjuvant treatment ➤adjuvant treatment (Adjuvant therapy): If radiotherapy, systemic therapy or combined therapy with therapeutic purposes is performed after surgery, it is called adjuvant therapy.

    ➤Neoadjuvant therapy: If the above treatment is performed before surgery, it is called neoadjuvant therapy.

     4.
    Term definition: oligometastatic disease (oligometastatic disease) with a few (usually 1-5) large metastases is called oligometastatic cancer.

     The definition, epidemiology, prognosis and risk factors of ATC 1.
    The definition of ATC is a rapidly progressing thyroid malignant tumor composed of undifferentiated thyroid follicular epithelial cells.
    2.
    Epidemiology of ATC ➤ ATC accounts for worldwide Compared with 1.
    3%-9.
    8% of thyroid cancer, the median is 3.
    6%; ➤American ATC accounted for 1.
    7% of all thyroid cancers; ➤decreased proportion.(It is not the decrease in the incidence of ATC, but the increase in the detection rate of non-ATC thyroid cancer, mainly papillary cancer) 3.
    The prognosis is very poor: ➤Median survival time of 5 months; ➤1 year survival rate of 20%;➤ Rarely live for 2 years; ➤China's 10-year survival rate is 3% (Mainland China) 4.
    ATC risk factors ➤Low education level (OR 1.
    42); ➤B blood type (OR 2.
    41); ➤Goiter (OR 25- 33); Obesity (OR 1.
    93); TERT gene promoter C228T (OR 68).

    31 Recommendations and 16 Good Practice Statement Guidelines Recommendation 1: Fine needle aspiration cytology (FNAC) is very important for the initial diagnosis of ATC, but a core biopsy (core biopsy) may be necessary for the diagnosis and is a molecular Provide sufficient tissue specimens for testing.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 2: Biopsy must be used to confirm the diagnosis before surgical resection.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 3: The routine surgical pathology of excised specimens should focus on confirming the diagnosis of ATC, recording the scope of the disease, confirming any combined differentiated thyroid cancer (DTC) and/or other pathologies Type of existence.

    At the same time, the proportion of ATC in the entire tumor should be recorded.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 4: Once ATC is diagnosed, BRAFV600E mutation should be detected as soon as possible through IHC and confirmed by molecular testing as soon as possible.

    (Recommendation level: strong; quality of evidence: medium) Guideline recommendation 5: When ATC is diagnosed, molecular expression profiling should be performed as soon as possible to inform the decision to use targeted therapy, especially for mutation-specific therapies approved by the FDA.
    Case.

    (Recommendation level: strong; quality of evidence: medium) Table 1 IHC Marker Guidelines Recommendation 6: Initial imaging tumor staging should include tomographic images, especially enhanced CT (or MRI) of the neck, chest, abdomen, and pelvis; if available Allowed, FDG PET/CT is feasible; if there are relevant clinical indications, cranio-enhanced imaging should also be performed (MRI is preferred).

    (Recommendation level: strong; quality of evidence: medium) Good practice statement 1: If there are clinical indications for biopsy of suspicious metastatic lesions, the initial management of ATC should not be delayed due to waiting for the biopsy.

    Good practice statement 2: All important appointments and assessments required before the initial treatment of ATC should be prioritized and completed as soon as possible.

    Guideline recommendation 7: Every patient with ATC should be assessed for the vocal cords at the first visit, and then assessed in a timely manner based on changes in symptoms.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 8: Before establishing "treatment goals" or conducting treatment discussions with patients, comprehensive disease-specific multidisciplinary participation should be achieved; those involved in management decision-making should include experience in treating ATC Rich experts.

    (Recommendation level: strong; quality of evidence: weak) Good practice statement 3: The patient must have the ability to understand and make decisions to agree to treatment or make specific medical decisions; when the patient is worried about the above-mentioned ability decline or impairment, the spirit should be provided in time Health and/or clinical ethics information to assess barriers that affect the patient’s ability.

    Good Practice Statement 4: Patients should be encouraged to draft advance instructions, which designate a commissioned decision maker, list emergency treatments acceptable or rejected under cardiopulmonary failure (code status), and other end-of-life options, such as life-sustaining treatment orders (Physician Orders for Life Sustaining Treatment, POLST) and medical order (Medical Orders for Scope of Treatment, MOST) form, etc.
    ; it is also necessary to discuss with the patient the possibility of do not resuscitate (DNR).

    Good practice statement 5: The "treatment goals" should be discussed with the patient as soon as possible; when discussing with the multidisciplinary team, a frank dialogue must be held, which includes full disclosure of the potential risks and benefits of various treatment options, and updates from time to time, including these How the plan affects the life of the patient; the treatment options discussed should include all end-of-life options, such as hospice care and palliative care; the patient’s personal wishes should guide clinical management.

    Guideline Recommendation 9: At every stage of patient management, the treatment team should have experts in palliative care to help patients relieve pain and control symptoms, and solve psychological and spiritual problems.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 10: The treatment team should encourage hospice care for ATC patients who refuse cancer treatment to extend their life but still need to control symptoms and relieve pain during the remaining time of the disease.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 11: At all stages of palliative care and hospice care for ATC patients, clinicians should understand the patient’s family situation and how it affects patient decision-making.

    (Level of recommendation: strong; quality of evidence: weak) Guideline recommendation 12: For patients with limited ATC (stage IVA/IVB) and expectable R0/R1 resection, we strongly recommend surgical resection.

    (Recommendation level: strong; quality of evidence: weak) Guideline Recommendation 13: Considering the poor prognosis of ATC, radical resection (including resection of larynx, trachea, esophagus, and/or resection of large vessels or mediastinum) is generally not recommended.
    The multidisciplinary team considers to carry out very selectively after thorough discussion, and at the same time, radical resection can also be considered when new information based on gene mutations and effective targeted treatments are used.

    (Recommendation level: strong; quality of evidence: weak) Good Practice Voice 6: If surgery is performed, intraoperative frozen section and pathological diagnosis may be an aid to surgical decision-making.

    Guideline recommendation 14: After R0 or R1 resection, it is recommended that if the patient is in good condition, has no evidence of metastatic disease, and has a positive willingness to treat, standard segmented intensity-modulated radiotherapy (IMRT) and simultaneous systemic therapy should be performed.

    (Recommendation level: strong; quality of evidence: weak) Good Practice Statement 8: Start radiation therapy no later than 6 weeks after surgery.

    Good practice statement 9: When deciding on active multimodal treatment, the patient’s treatment goals, treatment-related medical and mental health, potential treatment toxicity, economic concerns, and strong social support should be considered.

    Good practice statement 10: If the subsequent chemoradiotherapy is expected to have sufficient efficacy, cytotoxic chemotherapy can be initiated within 1 week after surgery.

    Guideline recommendation 15: For patients who have undergone R2 resection, or whose cancer is unresectable but have no metastatic lesions and are in good condition and are willing to actively treat, standard segmented IMRT and systemic therapy should be provided; for BRAFV600E mutant ATC patients, At this time, combined treatment with BRAF/MEK inhibitors can be considered.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 16: For patients whose lesions were unresectable at the initial evaluation, radiotherapy and/or systemic therapy (chemotherapy or combined with BRAF/MEK inhibitors) make it possible for the tumor to be resected, It is recommended to reconsider surgical resection.

    Good practice statement 11: For patients in poor condition, palliative care or preventive (no residual lesions) local and regional radiotherapy is recommended to be better than high-dose radiotherapy.

    Guideline recommendation 17: IMRT is recommended for patients who have received radiotherapy due to unresectable thyroid cancer, or who are undergoing surgery.

    (Recommendation level: strong; quality of evidence: weak) Guideline Recommendation 18: For patients who are aimed at radical radiotherapy, cytotoxic chemotherapy containing taxanes (paclitaxel or docetaxel) is recommended, with or without combination Combination of anthracyclines (doxorubicin) or platinum drugs (cisplatin or carboplatin).

    (Recommendation level: strong; quality of evidence: weak) Guideline Recommendation 19: For patients with unresectable or advanced ATC who expect active treatment, early initiation of cytotoxic chemotherapy is recommended as the initial treatment and possible bridging approach (bridging approach) , Until the detection result of gene mutation and/or mutation-specific treatment is obtained.

    (Recommendation level: conditional; quality of evidence: low) Guideline recommendation 20: For patients with BRAFV600E mutations in IVC stage and unresectable IVB stage ATC, if radiotherapy is refused, if possible, the initiation of BRAF/MEK inhibitors (Dala The treatment of fenib plus trametinib is superior to other systemic treatments.

    (Recommendation level: strong; quality of evidence: weak) Guideline Recommendation 21: For patients with stage IVB ATC with BRAFV600E mutation and unresectable tumor but radiotherapy, chemotherapy or neoadjuvant therapy (dalafenib/trametinib) can be the initial Alternative to treatment.

    (Recommendation level: conditional; quality of evidence: weak) Guideline recommendation 22: ATC patients without BRAF mutations, if the burden of metastatic lesions is low, should consider concurrent radiotherapy and chemotherapy to try to maintain the patient's airway.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 23: For patients with IVC stage ATC with NTRK or RET fusion, it is recommended to start TRK inhibitor [Larotrectinib or entrectinib] or RET inhibitor [selpercatinib or pralsetinib, if possible, is best performed in clinical trials.

    (Recommendation level: conditional; quality of evidence: very weak) Guideline recommendation 24: For patients with IVC stage ATC who overexpress programmed death receptor-ligand 1 (PD-L1), there are no other targeted therapies to choose from Consider choosing checkpoint (PD-L1, PD1) inhibitors as the first-line treatment, or preferably as a later treatment in clinical trials.

    (Recommendation level: conditional; quality of evidence: weak) Guideline Recommendation 25: When patients with metastatic ATC have no other treatment options, including unable to enter clinical trials, cytotoxic chemotherapy is recommended, including paclitaxel drugs and/or cyclic drugs, Or paclitaxel combined with or without cisplatin or carboplatin.

    (Recommendation level: conditional; quality of evidence: weak) Good Practice Statement 14: As the prognosis of metastatic and progressive ATC is extremely poor, the best supportive treatment (hospice care) should also be discussed as one of the options.

    Guideline Recommendation 26: For ATC patients considering treatment, it is recommended to perform cranial MRI to assess the presence of brain metastases at the time of diagnosis, as part of the initial staging, and to evaluate when other symptoms cause concern.

    (Recommendation level: strong; quality of evidence: weak) Guideline Recommendation 27: For ATC patients with symptoms or signs of neurological brain compression, dexamethasone (4-16 mg/d) is recommended.

    (Level of recommendation: strong; quality of evidence: weak) Guideline recommendation 28: Patients with ATC with brain metastases should be referred to the Department of Neurosurgery/Radiation Oncology.

    (Recommendation level: strong; quality of evidence: weak) Good Practice Statement 15: Patients with brain metastases who drive a motor vehicle or are in a situation that may endanger themselves or others may think that they are at higher risk, and therefore should receive appropriate counseling guidelines Recommendation 29: Palliative radiotherapy is recommended for ATC patients with symptomatic or threatening bone metastases but no structural damage or spinal cord compression that requires surgical treatment.

    (Level of recommendation: strong; quality of evidence: weak) Guideline recommendation 30: For ATC patients whose bone metastases cause structural damage to the weight-bearing area or threaten spinal cord compression, orthopedic fixation is recommended before palliative radiotherapy.

    (Recommendation level: strong; quality of evidence: weak) Guideline recommendation 31: For ATC patients with bone metastases, it is recommended to inject bisphosphonates regularly or subcutaneously inject RANK ligand inhibitors.

    (Recommendation level: conditional; quality of evidence: weak) Good Practice Statement 16: For patients with oligometastasis and receiving systemic therapy, local tumor-oriented therapy can be considered to delay the need to change other systemic therapies.

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