Differentiated thyroid carcinoma: defining new paradigms for the post-operative management

The demography of differentiated thyroid cancers (DTCs) has changed considerably since the 1990s, when the vast majority of these tumors were clinically evident at the time of diagnosis, and many were associated with regional lymph-node involvement. Today's DTCs are more likely to be small, localized, asymptomatic papillary forms that have been discovered incidentally, during neck imaging procedure performed for other reasons or during postoperative assessment of a gland removed for benign nodular goiter. The tools available for diagnosing, treating, and monitoring DTCs have also changed and their diagnostic capacities have increased. For these reasons, DTC treatment and follow-up paradigms are being revised to ensure more appropriate, cost-effective management of the current generation of DTCs. This review will examine some of the key issues in this area, including the assessment of risks for disease recurrence and thyroid cancer-related death, indications for postoperative ablation of the thyroid remnant with radioactive iodine and TSH-suppressive doses of levothyroxine, the pros, cons, and rationales for use of various follow-up tools (serum thyroglobulin assays, neck ultrasound, 18FDG-positron emission tomography, whole-body 131I scintigraphy), and temporal strategies for maximizing their efficacy. An algorithm will be presented for individualized, risk-tailored management of DTC patients