What are the ATA treatment guidelines for thyroid cancer during pregnancy?

Updated: Jun 24, 2020
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Answer

American Thyroid Association (ATA) guidelines on management of thyroid disease during pregnancy and the postpartum include the following recommendations on thyroid nodules and cancer in these patients [9] :

  • For women with suppressed serum thyroid-stimulating hormone (TSH) levels that persist beyond 16 weeks gestation, fine-needle aspiration (FNA) of a clinically relevant thyroid nodule may be deferred until after pregnancy. At that time, if serum TSH remains suppressed, a radionuclide scan to evaluate nodule function can be performed if the woman is not breastfeeding
  • There is insufficient evidence to recommend for or against routine measurement of serum calcitonin in pregnant women with thyroid nodules.
  • Thyroid nodule FNA is generally recommended for newly detected nodules in pregnant women with a nonsuppressed TSH. Determination of which nodules require FNA should be based on the nodule's sonographic pattern. The decision whether to perform FNA during gestation or early postpartum may be influenced by the clinical assessment of cancer risk or by patient preference.
  • Radionuclide scintigraphy or radioiodine uptake determination should not be performed during pregnancy.
  • Pregnant women with cytologically benign thyroid nodules do not require special surveillance strategies during pregnancy and should be managed according to the ATA guidelines for adults iwth thyroid nodules and differentiated thyroid cancer.
  • Pregnant women with cytologically indeterminate nodules, in the absence of cytologically malignant lymph nodes or other signs of metastatic disease, do not routinely require surgery while pregnant.
  • Surgery may be considered during pregnancy if there is clinical suspicion of an aggressive behavior in cytologically indeterminate nodules.
  • Molecular testing is not recommended for evaluation of cytologically indeterminate nodules during pregnancy.
  • Papillary thyroid cancer detected in early pregnancy should be monitored sonographically. If it grows substantially before 24–26 weeks gestation, or if cytologically malignant cervical lymph nodes are present, surgery should be considered during pregnancy. However, if the disease remains stable by midgestation, or if it is diagnosed in the second half of pregnancy, surgery may be deferred until after delivery.
  • The impact of pregnancy on newly diagnosed medullary carcinoma or anaplastic cancer is unknown. However, a delay in treatment is likely to adversely affect outcome, so surgery should be strongly considered, after assessment of all clinical factors.

Recommendations for subsequent pregnancy in women with thyroid cancer include the following:

  • Pregnancy should be deferred for 6 months after a woman has received therapeutic radioactive iodine ( 131I) treatment.
  • In women with thyroid cancer who become pregnant, the TSH goal should remain the same as determined preconception. TSH should be monitored approximately every 4 weeks until 16–20 weeks of gestation, and at least once between 26 and 32 weeks of gestation.
  •  Women with previously treated differentiated thyroid cancer who have undetectable serum thyroglobulin (Tg) levels (in the absence of Tg autoantibodies)and are classified as having no biochemical or structural evidence of disease prior to pregnancy do not require ultrasound and Tg monitoring during pregnancy.
  • Women diagnosed with papillary thyroid microcarcinoma who are under active surveillance shuld have ultrasound monitoring of their thyroid performed each trimester during pregnancy.

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