Management of Anaplastic Thyroid Cancer Clinical Practice Guidelines (ATA, 2021)

American Thyroid Association (ATA)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 30, 2021

Guidelines for the management of patients with anaplastic thyroid cancer (ATC) were published in March 2021 by the American Thyroid Association (ATA) in Thyroid.[1]

Surgical Management of ATC

For patients with confined (stage IVA/IVB) ATC in whom R0/R1 resection is anticipated, surgical resection is strongly recommended. Radical resection is generally not recommended, given the poor prognosis of ATC, and should be considered only very selectively.

Radiotherapy and Systemic Chemotherapy for Locoregionally Confined ATC

After R0/R1 resection, patients with good performance status (PS) and no evidence of metastatic disease who wish an aggressive approach should be offered standard fractionation intensity-modulated radiation therapy (IMRT) with concurrent systemic therapy.

Patients who have undergone R2 resection or have unresectable but nonmetastatic disease with good PS and who wish an aggressive approach should be offered standard fractionation IMRT with systemic therapy. In BRAF V600E–mutated ATC, combined BRAF/MEK inhibitors can be considered.

For patients whose disease was unresectable during initial evaluation but was rendered potentially resectable by radiotherapy (RT) and/or systemic therapy, surgical resection should be reconsidered.

For patients who are to receive RT for unresectable thyroid cancer or in the postoperative setting, IMRT is recommended.

For patients treated with definitive-intention RT, cytotoxic chemotherapy involving a taxane, with or without an anthracycline or a platin, is recommended.

Systemic Therapy for Locally Advanced Unresectable and/or Metastatic ATC

For patients with unresectable or advanced disease who wish aggressive therapy, early initiation of cytotoxic chemotherapy is suggested as an initial and potentially bridging approach until mutational interrogation results and/or mutationally specified therapies might be available.

For patients with BRAF V600E–mutated stage IVC disease or unresectable stage IVB disease who decline RT, BRAF/MEK inhibitors are recommended over other systemic therapies if available.

For patients with BRAF V600E–mutated unresectable stage IVB disease in which RT is feasible, chemoradiotherapy and neoadjuvant dabrafenib-trametinib are alternatives to initial therapy.

For patients without BRAF mutation, RT with concurrent chemotherapy should be considered in an effort to maintain the airway in patients with a low burden of metastatic disease.

For stage IVC ATC patients with NTRK or RET fusion, a TRK inhibitor or a RET inhibitor is suggested if available, preferably in the context of a clinical trial.

For stage IVC ATC patients with high programmed death ligand 1 (PD-L1) expression, checkpoint inhibitors can be considered as first-line therapy in the absence of other targetable alterations or as later-line therapy, preferably in the context of a clinical trial.

For patients with metastatic ATC who lack other therapeutic options (including clinical trials), cytotoxic chemotherapy including a taxane and/or an anthracycline or a taxane with or without cisplatin or carboplatin is suggested.

Approaches to Brain and Bone Metastases

For patients considering therapy, magnetic resonance imaging (MRI) of the brain is recommended to assess for brain metastases as a part of initial staging and when symptoms prompt concern.

For patients with neurologic brain-compressive symptoms or signs, dexamethasone 4-16 mg/day is recommended.

ATC patients with brain metastases should be referred to neurosurgery/radiation oncology.

For patients with symptomatic or threatening bone metastases but without structural compromise or threatened spinal cord compression in need of surgical remediation, palliative RT is recommended.

For patients with bone metastasis causing structural compromise in a weightbearing region or threatening spinal cord compression, orthopedic fixation is recommended before palliative RT.

For patients with bone metastasis, periodic intravenous bisphosphonate infusion or subcutaneous administration of a RANK ligand inhibitor is suggested.

For more information, please go to Thyroid Cancer and Thyroid Cancer Treatment Protocols.

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