cd /tmp/workspace/attachments/8a2d428c-b1a9-4deb-be14-76e09e34e831/ && python3 -c " import pypdf r=pypdf.PdfReader('ATA DTC 2025.pdf') print(len(r.pages)) t=''.join((p.extract_text() or '')+'\n=====PAGE=====\n' for p in r.pages) open('/tmp/workspace/dtc.txt','w').write(t) print(len(t)) "

cd /tmp/workspace && python3 -c " t=open('dtc.txt').read().split('=====PAGE=====') for i in [0,1,2,3]: print('--- PAGE',i+1); print(t[i][:3500]) "

cd /tmp/workspace && python3 -c " t=open('dtc.txt').read().split('=====PAGE=====') print(t[1][3400:]); print('-----P3'); print(t[2][:6000]); "

Which topic should I go deep on first?

Which block should I build first? (The blocks are: 1 DATA framework, pathology and NIFTP; 2 Genetics; 3 Pre-op work-up and active surveillance; 4 Surgery; 5 Voice and parathyroid protection; 6 Post-op risk stratification; 7 Radioiodine; 8 TSH suppression and follow-up; 9 Recurrent and metastatic disease; 10 RAI-refractory disease and systemic therapy)

cd /tmp/workspace && python3 - <<'E' import re t=open('dtc.txt').read() pages=t.split('=====PAGE=====') # find recommendation markers for m in re.finditer(r'RECOMMENDATION\s*\d+',t): pass print(len(re.findall(r'RECOMMENDATION',t))) i=t.find('RECOMMENDATION') print(t[i-300:i+1500]) E

ls -la /tmp/workspace/ /tmp/workspace/attachments/*/ 2>&1 | head -30

~/attachments

mkdir -p /tmp/workspace/dtc-notes && cd /tmp/workspace/dtc-notes && python3 - <<'E' import pypdf,re r=pypdf.PdfReader('/tmp/workspace/attachments/8a2d428c-b1a9-4deb-be14-76e09e34e831/ATA DTC 2025.pdf') pages=[(p.extract_text() or '') for p in r.pages] open('pages.txt','w').write('\n=====PAGE=====\n'.join(pages)) t='\n'.join(pages) print(len(pages),len(t)) print(len(re.findall(r'RECOMMENDATION',t)), len(re.findall(r'Recommendation',t))) i=t.find('RECOMMENDATION'); print(t[i-200:i+1200]) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re t=open('pages.txt').read() t=t.replace('=====PAGE=====','') t=re.sub(r'Downloaded by .*?only\.','',t,flags=re.S) t=re.sub(r'\d{3} RINGEL AND SOSA, ET AL\.|ATA DTC GUIDELINES \d{3}','',t) t=t.replace('/uniFB01','fi').replace('/uniFB02','fl').replace('/H17039','').replace('/uniFB00','ff').replace('/uniFB03','ffi') ms=list(re.finditer(r'RECOMMENDATIONS?\s*(\d+)',t)) print(len(ms)) out=[] for k,m in enumerate(ms): end=ms[k+1].start() if k+1<len(ms) else len(t) seg=t[m.end():end] # cut at quality tag q=re.search(r'\((?:Strong|Conditional|Good Practice|Weak|Insufficient)[^)]*\)?',seg) if q: seg=seg[:q.end()] else: seg=seg[:1500] seg=re.sub(r'\s+',' ',seg) out.append((m.group(1),seg)) open('recs.txt','w').write('\n\n'.join(f'R{n}: {s}' for n,s in out)) print(sum(len(s) for n,s in out)) for n,s in out[:30]: print(f'R{n}: {s}\n') E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re t=open('pages.txt').read().replace('=====PAGE=====','') t=re.sub(r'Downloaded by .*?only\.','',t,flags=re.S) t=re.sub(r'\d{3} RINGEL AND SOSA, ET AL\.|ATA DIFFERENTIATED THYROID CANCER GUIDELINES \d{3}','',t) for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H17039',''),('/uniFB00','ff'),('/uniFB03','ffi'),('/H11005','='),('/H11021','<'),('/H11022','>')]: t=t.replace(a,b) ms=list(re.finditer(r'RECOMMENDATIONS?\s*(\d+)',t)) tag=re.compile(r'\((?:Strong|Conditional|Good Practice|Weak|Insufficient)[^)]*\)',re.I) out=[] for k,m in enumerate(ms): end=ms[k+1].start() if k+1<len(ms) else len(t) seg=t[m.end():end][:3500] tags=list(tag.finditer(seg)) seg=seg[:tags[-1].end()] if tags else seg[:1200] seg=re.sub(r'\s+',' ',seg) seg=re.sub(r'\(Strong recommendation, [^)]*\)','(Strong)',seg) seg=re.sub(r'\(Conditional recommendation, [^)]*\)','(Cond)',seg) seg=re.sub(r'\(Good Practice Statement\)','(GPS)',seg) out.append(f'R{m.group(1)}: {seg}') open('recs2.txt','w').write('\n\n'.join(out)) print(sum(map(len,out))) print('\n\n'.join(out[1:2]+out[6:7]+out[10:11]+out[14:16])) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' t=open('recs2.txt').read().split('\n\n') print(len(t)) import re for x in t[7:10]+t[16:30]: print(x[:1500]);print() E

cd /tmp/workspace/dtc-notes && python3 - <<'E' t=open('recs2.txt').read().split('\n\n') for x in t[30:46]: print(x[:1500]);print() E

cd /tmp/workspace/dtc-notes && python3 - <<'E' t=open('recs2.txt').read().split('\n\n') for x in t[45:65]: print(x[:1300]);print() E

cd /tmp/workspace/dtc-notes && python3 - <<'E' t=open('recs2.txt').read().split('\n\n') for x in t[65:84]: print(x[:1300]);print() E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re t=open('pages.txt').read() pg=t.split('=====PAGE=====') for i,p in enumerate(pg): for m in re.finditer(r'Table (\d+)\.',p): print(i+1,m.group(0),p[m.start():m.start()+90].replace('\n',' ')) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>=')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return s for i in [7]: print('=== P',i); print(c(pg[i-1])[:3500]) for i in [41,42]: print('=== P',i); print(c(pg[i-1])[:6000]) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>=')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return s for i in [45,60]: print('=== P',i); print(c(pg[i-1])[:5500]) for i,p in enumerate(pg): if 'Risk Stratification' in p and ('Low' in p) and 'Table' in p and 36<=i+1<=40: print('RSS page',i+1) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) t=c('\n'.join(pg)) def show(pat,n=2200,k=1,off=0): ms=[m for m in re.finditer(pat,t)] print('###',pat,len(ms)) for m in ms[:k]: print(t[max(0,m.start()-off):m.start()+n]);print() show(r'Table 4\. Syndromes Associated',1800) show(r'Table 5\. Extent of Initial',1500) show(r'[Ii]ntermediate-high risk',1800,3) show(r'Table 2\. Pathological Diagnostic Criteria',900) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) t=c('\n'.join(pg)) def show(pat,n=2200,k=1,off=0): ms=[m for m in re.finditer(pat,t)] print('###',pat,len(ms)) for m in ms[:k]: print(t[max(0,m.start()-off):m.start()+n]);print() show(r'How is radioiodine-refractory DTC classified|How is radioiodine-refractory DTC classi',2500,2) show(r'RECOMMENDATION 45',200) show(r'Recommendation 45 ',200,1) show(r'TSH suppression.{0,40}(0\.1|0\.5)',900,3) show(r'RECOMMENDATION 46',2200,1) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) for i in range(36,40): s=c(pg[i-1]) print('=== P',i,len(s)) if re.search(r'(Low|low)[- ]intermediate',s): print(s[:5500]) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) t=c('\n'.join(pg)) for m in list(re.finditer(r'(?i)low-intermediate',t))[:40]: pass idx=[m.start() for m in re.finditer(r'(?i)Low-intermediate',t)] print(len(idx), idx[:15]) # find the RSS text: "ATA Low" etc for pat in [r'ATA Risk of Recurrence (Estimates|categories)',r'Low risk\.',r'High risk\. ',r'Intermediate-high\.']: for m in list(re.finditer(pat,t))[:2]: print('##',pat,m.start(), t[m.start():m.start()+700]);print() E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) t=c('\n'.join(pg)) print(t[266800:270800]) print('-----') print(t[272600:275400]) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import re pg=open('pages.txt').read().split('=====PAGE=====') def c(s): for a,b in [('/uniFB01','fi'),('/uniFB02','fl'),('/H11005','='),('/H11021','<'),('/H11022','>'),('/H11350','<='),('/H11349','>='),('/H17039','')]: s=s.replace(a,b) s=re.sub(r'Downloaded by .*?only\.','',s,flags=re.S) return re.sub(r'\s+',' ',s) for i,p in enumerate(pg): s=c(p) for m in re.finditer(r'FIG\. 2\.',s): print(i+1, s[m.start():m.start()+1800]);print() t=c('\n'.join(pg)) m=re.search(r'RECOMMENDATION 81',t); print(t[m.start()+1300:m.start()+2300]) E

cd /tmp/workspace/dtc-notes && python3 - <<'E' import pypdf r=pypdf.PdfReader('/tmp/workspace/attachments/8a2d428c-b1a9-4deb-be14-76e09e34e831/ATA DTC 2025.pdf') p=r.pages[7] for i,im in enumerate(p.images): open(f'p8_{i}.{im.name.split(".")[-1]}','wb').write(im.data); print(im.name,len(im.data)) E ls -la

mkdir -p /tmp/workspace/dtc-notes/output && cat > /tmp/workspace/dtc-notes/build.py <<'PYEOF' import re, os, matplotlib from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.units import mm from reportlab.lib.styles import ParagraphStyle from reportlab.platypus import BaseDocTemplate, PageTemplate, Frame, Paragraph, Spacer, Table, TableStyle, KeepTogether, PageBreak from reportlab.pdfbase import pdfmetrics from reportlab.pdfbase.ttfonts import TTFont fd=os.path.join(matplotlib.get_data_path(),'fonts','ttf') pdfmetrics.registerFont(TTFont('DV',fd+'/DejaVuSans.ttf')) pdfmetrics.registerFont(TTFont('DVB',fd+'/DejaVuSans-Bold.ttf')) pdfmetrics.registerFont(TTFont('DVI',fd+'/DejaVuSans-Oblique.ttf')) pdfmetrics.registerFont(TTFont('DVBI',fd+'/DejaVuSans-BoldOblique.ttf')) pdfmetrics.registerFontFamily('DV',normal='DV',bold='DVB',italic='DVI',boldItalic='DVBI') def esc(s): s=re.sub(r'&(?!amp;|lt;|gt;)','&amp;',s) return re.sub(r'<(?![/a-zA-Z])','&lt;',s) B=ParagraphStyle('b',fontName='DV',fontSize=8.6,leading=11.8) SM=ParagraphStyle('sm',parent=B,fontSize=8,leading=10.5) H=ParagraphStyle('h',fontName='DVB',fontSize=15,leading=19,textColor=colors.white) SUB=ParagraphStyle('sub',parent=B,fontName='DVB',fontSize=9.5,leading=12,spaceBefore=6,spaceAfter=2) ST=ParagraphStyle('st',parent=B,fontName='DVI',fontSize=8.8,leading=12.2) def P(t,s=B): return Paragraph(esc(t),s) W=A4[0]-28*mm def box(title,items,bg,fg,bullets=True): rows=[[P('<b>'+title+'</b>',ParagraphStyle('t',parent=B,textColor=colors.white,fontName='DVB'))]] t=Table(rows,colWidths=[W]) t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),fg),('TOPPADDING',(0,0),(-1,-1),2),('BOTTOMPADDING',(0,0),(-1,-1),2)])) body=[[P(('• ' if bullets else '')+i)] for i in items] b=Table(body,colWidths=[W]) b.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),bg),('TOPPADDING',(0,0),(-1,-1),1.5),('BOTTOMPADDING',(0,0),(-1,-1),1.5),('LEFTPADDING',(0,0),(-1,-1),6),('BOX',(0,0),(-1,-1),0.6,fg)])) return KeepTogether([t,b,Spacer(1,4)]) def chapter(num,title,color,story,rows,numbers,mnem,traps): out=[] ban=Table([[P(f'CHAPTER {num}: {title}',H)]],colWidths=[W]) ban.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),color),('TOPPADDING',(0,0),(-1,-1),7),('BOTTOMPADDING',(0,0),(-1,-1),7),('LEFTPADDING',(0,0),(-1,-1),8)])) out.append(ban); out.append(Spacer(1,4)) sb=Table([[P('<b>THE STORY:</b> '+story,ST)]],colWidths=[W]) sb.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),colors.HexColor('#FFF8E1')),('BOX',(0,0),(-1,-1),0.8,colors.HexColor('#F9A825')),('LEFTPADDING',(0,0),(-1,-1),7),('RIGHTPADDING',(0,0),(-1,-1),7),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)])) out.append(sb); out.append(Spacer(1,5)) data=[[P('<b>Rec</b>',SM),P('<b>What to remember</b>',SM)]]+[[P('<b>'+r+'</b>',SM),P(t,SM)] for r,t in rows] tb=Table(data,colWidths=[17*mm,W-17*mm],repeatRows=1) tb.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),colors.HexColor('#E0E0E0')),('GRID',(0,0),(-1,-1),0.3,colors.HexColor('#9E9E9E')),('VALIGN',(0,0),(-1,-1),'TOP'),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,colors.HexColor('#F5F9FF')]),('TOPPADDING',(0,0),(-1,-1),2),('BOTTOMPADDING',(0,0),(-1,-1),2)])) out.append(tb); out.append(Spacer(1,5)) if numbers: out.append(box('NUMBERS TO TATTOO ON YOUR BRAIN',numbers,colors.HexColor('#E8F5E9'),colors.HexColor('#2E7D32'))) if mnem: out.append(box('MEMORY HOOKS',mnem,colors.HexColor('#F3E5F5'),colors.HexColor('#6A1B9A'))) if traps: out.append(box('EXAM TRAPS (do not fall in!)',traps,colors.HexColor('#FFEBEE'),colors.HexColor('#C62828'))) out.append(PageBreak()) return out story=[] # COVER cov=Table([[P('2025 ATA DTC GUIDELINES',ParagraphStyle('c1',fontName='DVB',fontSize=24,leading=29,textColor=colors.white))],[P('The Thyroid Town Memory Palace',ParagraphStyle('c2',fontName='DVB',fontSize=15,leading=20,textColor=colors.HexColor('#FFE082')))],[P('All 84 recommendations (R1 to R84), key tables and numbers, turned into stories, hooks and drills. Source: Ringel, Sosa et al., Thyroid 2025 (the PDF you uploaded).',ParagraphStyle('c3',fontName='DV',fontSize=10,leading=14,textColor=colors.white))]],colWidths=[W]) cov.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),colors.HexColor('#1A237E')),('LEFTPADDING',(0,0),(-1,-1),12),('TOPPADDING',(0,0),(-1,-1),9),('BOTTOMPADDING',(0,0),(-1,-1),9)])) story+=[cov,Spacer(1,8)] story.append(box('HOW TO USE THIS SHEET',[ 'Each chapter = a short <b>story</b> (the logic), a <b>table</b> of the recommendations, <b>numbers</b>, <b>memory hooks</b> and <b>exam traps</b>.', 'Read the story first, cover the table, and try to rebuild the rules from it. Finish with the <b>Recall Arena</b> at the end.', 'Evidence labels used in the guideline: <b>Strong</b> (do it), <b>Conditional</b> (consider it, individualise), <b>GPS</b> = Good Practice Statement (expert consensus). Wording like <i>should</i> usually means Strong or GPS; <i>may be considered</i> means Conditional.', 'The guideline has <b>84</b> numbered recommendations (not 80). R81 to R84 cover pregnancy and survivorship.'],colors.HexColor('#E3F2FD'),colors.HexColor('#1565C0'))) story.append(box('THE BIG PICTURE IN 60 SECONDS',[ '<b>DTC</b> = papillary + follicular + oncocytic (Hurthle) carcinoma = more than <b>90%</b> of thyroid cancers. Excellent prognosis for most.', 'US incidence peaked in <b>2015 (14.9 per 100,000)</b> then fell, because small nodules under 1 cm are no longer biopsied without abnormal nodes or invasion (less overdiagnosis). 44,020 new US cases estimated in 2024.', '<b>DATA framework</b> = <b>D</b>iagnosis, risk/benefit <b>A</b>ssessment, <b>T</b>reatment decisions, response <b>A</b>ssessment. It is used at first diagnosis AND again at any recurrence.', 'Philosophy: <b>de-escalate the low risk, escalate the high risk</b>. Less surgery, less RAI, less suppression, less follow-up for low risk. More of everything, plus targeted drugs, for high risk or poor response.', 'Patient journey in one line: <b>Stage (US) - Operate - Re-stratify (risk + response) - RAI if indicated - TSH target - Tg and US follow-up - Systemic therapy only if RAI-refractory and progressing.</b>'],colors.HexColor('#FFF3E0'),colors.HexColor('#E65100'))) story.append(box('THE HERO OF OUR STORY',[ 'Meet <b>Mira</b>, 38, a teacher who finds a thyroid lump. Her journey through the 11 chapters is the journey of the guideline. Every chapter begins with where Mira is on the map.'],colors.HexColor('#E8EAF6'),colors.HexColor('#283593'),bullets=False)) story.append(PageBreak()) story+=chapter(1,'WHAT IS IT? Pathology and NIFTP','#00695C' and colors.HexColor('#00695C'), 'Mira\'s biopsy comes back as a tumor with PTC-like nuclei, but it is fully encapsulated, with no invasion. The pathologist smiles: it is <b>NIFTP</b>, the "tumor that dropped the C-word". Mira needs the operation she needs, but not the extra RAI and completion surgery that a true cancer might bring.', [('R1','NIFTP, Follicular Tumor of Uncertain Malignant Potential and Hyalinizing Trabecular Tumor have <b>very low malignant potential (lower than the lowest-risk DTC)</b>. Do NOT routinely give completion thyroidectomy / lymphadenectomy / RAI. Best monitoring approach is uncertain (GPS).'), ('R27','Pathology report must carry more than staging: margins, <b>vascular invasion and number of vessels</b>, number of nodes examined and involved, <b>size of the largest nodal metastasis</b>, <b>extranodal extension</b>. Report unfavourable subtypes and syndromic subtypes (GPS).'), ('Table 2','<b>NIFTP criteria:</b> encapsulation/demarcation; follicular pattern (no papillae, no psammoma bodies, under 30% solid/trabecular/insular); PTC nuclear features; no capsular or vascular invasion; no necrosis; under 3 mitoses per 10 HPF.'), ('Subtypes','<b>Unfavourable:</b> tall cell, columnar cell, hobnail PTC; widely invasive FTC and OTC; high-grade follicular-derived non-ATC. <b>Favourable:</b> IEFVPTC with minimal invasion, minimally invasive FTC.'), ('Genes','<b>RAS and RET fusions</b> = tend to respond to RAI. <b>BRAF V600E, TERT promoter, TP53</b> = more RAI resistance. BRAF V600E plus TERT or TP53 = loss of iodine avidity and poor outcomes.')], ['DTC &gt; 90% of thyroid cancers; US incidence 14.9 per 100,000 (2015 peak)','NIFTP mitoses: under 3 per 10 HPF'], ['<b>NIFTP = E-F-N-I-N-M</b>: Encapsulated, Follicular pattern, Nuclei of PTC, Invasion none, Necrosis none, Mitoses under 3.','<b>RAS and RET = RAI Responders; BRAF + TERT + TP53 = the Bad Boys</b> (Bad, Terrible, Poor).'], ['NIFTP is NOT routinely followed by completion surgery or RAI.','The nodal size that matters in the pathology report is the <b>largest metastatic focus</b>, not the largest node removed.']) story+=chapter(2,'THE FAMILY SECRET: Genetics (R2 to R6)','#4527A0' and colors.HexColor('#4527A0'), 'Mira\'s mother had thyroid cancer, her aunt had breast cancer, and her cousin has macrocephaly. The genetic counsellor opens a family tree and plays detective: which syndrome hides in this pedigree?', [('R2','<b>Offer germline testing</b> if: (A) suspicion of <b>Cowden/PHTS</b> (DTC + non-thyroid tumors/features); (B) FNMTC diagnosed in childhood or families with paediatric DTC: assess <b>DICER1</b>; (C) <b>cribriform-morular carcinoma (APC)</b>; (D) other tumor combinations (Carney complex, Werner syndrome). All Conditional.'), ('R3','<b>Non-syndromic FNMTC</b>: no evidence that germline testing helps. Non-thyroid cancers in the family may drive the decision.'), ('R4','FNMTC family history = careful history and neck exam at routine check-ups. <b>Ultrasound screening may be considered</b> in first-degree relatives when <b>3 or more</b> relatives (first or second degree) have NMTC. Also consider with 2 affected if young onset or small family. Start age unknown; weigh against overtreatment (Conditional, very low certainty).'), ('R5','Tumor (somatic) genomic testing can accidentally reveal a <b>germline</b> variant. If relevant: clinical correlation, family history, refer to genetic counselling.'), ('R6','<b>High-volume surgeon</b> (more than 25 to 50 thyroidectomies per year) = fewer complications and better outcomes (Strong).'), ('Table 4','<b>PTEN (Cowden/PHTS):</b> FTC > PTC, lifetime thyroid risk 3 to 10%; breast, endometrial cancers, goiter, macrocephaly. <b>APC (FAP):</b> cribriform-morular PTC, up to 12%; colon polyposis, CHRPE, desmoids. <b>DICER1:</b> PTC, FTC, PDTC; pleuropulmonary blastoma, cystic nephroma, ovarian sex-cord tumors. <b>PRKAR1A (Carney):</b> skin pigmentation, myxomas, schwannomas. <b>WRN (Werner):</b> premature aging, cataracts, diabetes.')], ['FNMTC clinical diagnosis: 3 or more affected relatives','Surgeon volume threshold: more than 25 to 50 per year','Cowden thyroid lifetime risk 3 to 10%; FAP up to 12%'], ['<b>"Pete And Dicer Can Wear"</b> = PTEN, APC, DICER1, Carney (PRKAR1A), Werner (WRN) = the 5 syndromes in Table 4.','Cowden = <b>C</b>ancer of breast + <b>O</b>ver-sized head (macrocephaly) + thyroid FTC. FAP = colon polyps + cribriform-morular PTC.'], ['Non-syndromic FNMTC does NOT get routine germline testing (R3).','Ultrasound screening of relatives is "may be considered", Conditional, very low certainty.']) story+=chapter(3,'BEFORE THE KNIFE: Pre-op work-up and Active Surveillance (R7 to R14)','#EF6C00' and colors.HexColor('#EF6C00'), 'Mira\'s nodule is a 7 mm PTC, cT1aN0M0. Her team asks: do we operate at all? First the sonographer maps every neck compartment. Then the "watch or cut" conversation begins. Her neighbour Raj has a bulky nodal mass and gets a CT with contrast instead.', [('R7','<b>Pre-op neck ultrasound for ALL</b> (central + lateral nodes + gross ETE) when cytology/molecular result is malignant (Strong). FNA suspicious nodes <b>greater than 8 to 10 mm in smallest diameter</b> if it changes management (Strong). FNA-Tg washout optional (Conditional), hard to interpret with the thyroid in place.'), ('R8','<b>CT/MRI with IV contrast</b> of neck + mediastinum for suspected advanced disease: gross ETE, bulky/invasive nodes, aerodigestive or thoracic involvement (Strong). Chest/abdomen/pelvis imaging only if it changes surgery (GPS). <b>Routine pre-op FDG-PET: NOT recommended</b> (Strong).'), ('R9','<b>No routine pre-op Tg or TgAb</b> (Conditional).'), ('R10','<b>No routine pre-op genomic testing</b> of confirmed DTC; if known, may inform extent of surgery.'), ('R11','<b>Active surveillance (AS)</b> may be offered for some <b>cT1aN0M0 PTC</b> with shared decision-making. <b>US-guided percutaneous ablation</b> is an alternative for selected cT1aN0M0 (Conditional).'), ('R12','AS monitoring tool = <b>neck ultrasound</b> of thyroid and ALL nodal compartments, <b>every 6 months for 1 to 2 years, then yearly</b>. Team must be skilled in neck US (GPS). No routine CT.'), ('R13','During AS: <b>no routine Tg / TgAb</b> (GPS).'), ('R14','<b>Convert to surgery</b> if: new biopsy-proven node mets, growth by <b>3 mm or more</b>, distant mets, extrathyroidal extension, posterior growth, patient anxiety, inability to follow up, or patient preference (GPS).')], ['Node FNA size threshold: more than 8 to 10 mm (shortest diameter)','AS ultrasound: every 6 months x 1 to 2 years, then annually','Growth trigger: 3 mm or more'], ['<b>Surgery triggers: "New Giants Don\'t Eat Pizza At Funerals, Please"</b> = New nodal mets, Growth 3 mm, Distant mets, Extrathyroidal extension, Posterior growth, Anxiety, Follow-up impossible, Preference.','<b>No PET, No Tg, No genes</b> before surgery (routinely). Three "No"s = R8 (PET), R9, R10.'], ['AS applies only to <b>cT1a</b> (1 cm or less) N0M0 PTC. Not to recurrence (that is called "monitoring").','Pre-op CT uses IV contrast; iodine load worry is handled by the team, the guideline recommends contrast for advanced disease.']) story+=chapter(4,'THE SURGEON\'S MENU: Extent of surgery (R15 to R20)','#AD1457' and colors.HexColor('#AD1457'), 'Think of a restaurant menu where portion size matches hunger. Small tumor = small portion (lobectomy). Big, invasive or nodal disease = full banquet (total thyroidectomy plus node dissection). The chef (surgeon) also decides whether to peek into the central neck "just in case". The guideline says: usually don\'t.', [('R15A','<b>cT1 (2 cm or less), no gross ETE, cN0M0 = LOBECTOMY</b> unless bilateral cancers or another reason to remove the other lobe (Strong).'), ('R15B','<b>cT2N0M0 (over 2 to 4 cm), unilateral low risk:</b> lobectomy may be preferred (lower side effects); total thyroidectomy acceptable for RAI, follow-up, suspicious contralateral nodularity or preference. Counsel about conversion/completion (Conditional).'), ('R15C','<b>Over 4 cm (cT3a), any size with gross ETE (cT3b/T4), cN1 or cM1 = TOTAL thyroidectomy</b> with removal of all gross disease/nodes (Strong).'), ('Table 5','cT1N0 unilateral: lobectomy. cT1 multifocal bilateral: total. cT2 unilateral: lobectomy OR total. cT2 bilateral: total. cT3-4 or cN1 or cM1: total.'), ('R16','<b>Completion thyroidectomy</b> after lobectomy may be considered to treat persistent primary tumor, enable RAI, or enhance follow-up when postoperative risk is higher (consider RLN function). Extensive vascular invasion (FTC, OTC, PTC) and high-risk variants (tall cell, hobnail, diffuse sclerosing, widely invasive FTC/OTC, PDTC) may justify it. Same logic for OTC (Conditional).'), ('R17','<b>Thyroglossal duct carcinoma (TGDCa):</b> <b>Sistrunk</b> (tumor/cyst + central hyoid bone) (Conditional). Add thyroidectomy if suspicious thyroid nodularity or larger tumor/older patient. <b>Sistrunk + total thyroidectomy for advanced disease</b> (gross extension, nodal or distant mets) (Strong).'), ('R18','Completion thyroidectomy after Sistrunk if higher-risk features, <b>Delphian/prelaryngeal node metastasis</b>, suspicious nodularity, or larger tumor (Conditional).'), ('R19','<b>No prophylactic central neck dissection</b> for small, noninvasive cT1-T2 cN0 PTC and most FTC (Strong). <b>May consider</b> for T3/T4 PTC or when it will change further therapy (Conditional).'), ('R20','<b>cN1a</b> (central) = therapeutic central dissection (<b>Level VI + upper Level VII</b>) (Strong). <b>cN1b</b> (lateral) = ipsilateral central dissection too (Conditional). Lateral dissection <b>Levels IIa, III, IV, Vb</b> for biopsy-proven/obvious lateral nodes (Strong).')], ['Lobectomy: 2 cm or less (cT1). Gray zone: over 2 to 4 cm. Total: over 4 cm, ETE, N1, M1','Central compartment = Level VI + upper VII. Lateral = IIa, III, IV, Vb'], ['<b>"2-4-Total"</b>: up to 2 cm lobectomy, 2 to 4 cm either, beyond 4 cm total.','Lateral levels: <b>"2a-3-4-5b"</b> (counting up the neck, skipping 1, 5a and 2b).','<b>Sistrunk = Hyoid centre</b>: "Sis-trunk takes the trunk of the hyoid".'], ['Prophylactic central dissection is NOT routine in cN0 T1-T2 PTC (Strong "should not").','A cN1b neck needs the lateral dissection AND the ipsilateral central dissection (Conditional for the central part).']) story+=chapter(5,'PROTECT THE VOICE AND THE CALCIUM (R21 to R27)','#00838F' and colors.HexColor('#00838F'), 'Mira sings in a choir. Before surgery the surgeon listens to her voice, and if anything is hoarse, a camera goes down. In the theatre the surgeon treats the recurrent laryngeal nerve like a fragile violin string, and the parathyroid glands like four precious rice grains that must keep their blood supply.', [('R21','Informed consent includes nerve and parathyroid injury risk; share findings with anaesthesia (GPS).'), ('R22','<b>Voice assessment for EVERY patient pre-op</b> (patient description + clinician assessment) (Strong). <b>Laryngeal exam if:</b> pre-op dysphonia; prior neck or upper chest surgery risking RLN/vagus; known cancer with posterior ETE or extensive central/jugular nodes (Strong).'), ('R23','<b>Visually identify the RLN</b> (GPS). Intra-operative nerve monitoring <b>may</b> be used, especially total or reoperative surgery. EBSLN identification/monitoring <b>may</b> help voice. After first lobectomy, <b>stimulate vagus/proximal RLN before removing the other lobe</b> to avoid bilateral injury (GPS).'), ('R24','Preserve parathyroids and their blood supply. If devascularised or removed: <b>autotransplant into nearby muscle after frozen section confirms parathyroid</b> (GPS). After total thyroidectomy/central dissection: <b>PTH-directed calcium + vitamin D supplementation</b> beats serial calcium observation alone (Strong).'), ('R25','<b>No routine drain</b>: longer stay, more infection, no fewer hematomas (Conditional, High certainty).'), ('R26','Assess voice post-op; formal laryngeal exam if abnormal; communicate operative findings to the care team; <b>speech-language pathologist/voice specialist</b> referral for known RLN injury (GPS).')], [], ['<b>"Voice First, Look Second"</b>: everyone gets a voice check (R22A); only the at-risk get a laryngeal camera (R22B: dysphonia, previous surgery, posterior ETE/bulky nodes).','<b>"Test the first, before the second"</b>: stimulate the nerve after the first lobe before taking the second.'], ['R25 is the only recommendation in this chapter with HIGH certainty evidence: no drain.','Nerve monitoring is "may be performed", not mandatory. Visual identification of the RLN is the must-do.']) # Chapter 6 with table of risk rs=[('R28','<b>Use the 2025 ATA Risk Stratification System</b> (histology + node number, with AJCC stage, post-op imaging, Tg/TgAb) to estimate structural recurrence risk (Strong). <b>Routine post-op molecular profiling NOT recommended</b>, but can refine risk if available (Conditional).'), ('R29','<b>Use the ATA Response Criteria</b> after surgery together with risk estimates (Strong). First assessment <b>within 3 months</b> of resection. Four categories: excellent, indeterminate, biochemical incomplete, structural incomplete.'), ('R30','<b>Tg 6 to 12 weeks after total thyroidectomy</b>, on LT4 or TSH-stimulated (Strong). After lobectomy: one Tg with normal TSH, cutoff uncertain (GPS). Tg nadir median 12 weeks.'), ('R31','<b>Ultrasound is the preferred imaging</b> (Strong). If post-op Tg is above the excellent range or TgAb present: US or cross-sectional imaging <b>before RAI</b> (GPS). <b>US at 6 to 12 months</b> after initial therapy, then by risk (GPS). Nodes <b>under 8 to 10 mm</b> can be watched unless they grow or threaten vital structures (Conditional). Nodes <b>8 to 10 mm or more</b>: FNA cytology + Tg washout if it changes management (GPS). Rising Tg with negative neck US: cross-sectional imaging of lungs and bone (lung and bone are the main distant sites to screen).')] story+=chapter(6,'HOW BAD WAS IT? Risk and response after surgery (R28 to R31)','#37474F' and colors.HexColor('#37474F'), 'Mira\'s operation is done. Now a weather forecast is issued: the <b>risk of structural recurrence</b> (the forecast, based on what was found) and later the <b>response to therapy</b> (what actually happened). Forecast first, then reality check. Doctors update the forecast as reality arrives (dynamic risk).', rs, ['<b>ATA 2025 risk of structural recurrence:</b> LOW under 10%; LOW-INTERMEDIATE 10 to 15%; INTERMEDIATE-HIGH 16 to 30% (at least 16%); HIGH over 30%.','<b>Tg thresholds WITH total thyroidectomy + RAI:</b> excellent = nonstimulated Tg under 0.2 (or stimulated under 1) + negative imaging; indeterminate = 0.2 to 1 nonstimulated or 1 to 10 stimulated; biochemical incomplete = over 1 nonstimulated or over 10 stimulated, or rising TgAb.','<b>WITHOUT RAI:</b> excellent under 2.5; indeterminate 2.5 to 5; biochemical incomplete over 5 (nonstimulated).','Re-classification: many initially intermediate/high patients become low risk after an excellent response; response-based systems explain 62 to 84% of outcome variance.'], ['<b>Risk ladder "10-15-30"</b>: under 10, 10 to 15, 16 to 30, over 30.','<b>Tg ladder with RAI: "0.2 - 1 - 10"; without RAI: "2.5 - 5".</b> Think: RAI burns remnant, so Tg should be nearly zero; without RAI the remnant still makes some Tg.'], ['Rising TgAb with negative imaging = <b>biochemical incomplete</b>. Stable or declining TgAb = <b>indeterminate</b>.','FNA threshold 8 to 10 mm applies to both pre-op and post-op nodes. Under that size, watch.']) # risk table story page rt=[[P('<b>Category</b>',SM),P('<b>Risk</b>',SM),P('<b>PTC features (Fig. 2 of the guideline)</b>',SM)], [P('<b>HIGH</b>',SM),P('over 30%',SM),P('T3a + microscopic ETE, T3b or T4; OR any T with: poorly differentiated/high grade, gross incomplete resection (R2), cN1 with node 3 cm or larger, extranodal extension, distant metastasis (M1). FTC/OTC: also widely invasive, or encapsulated angioinvasive with 4 or more vessels.',SM)], [P('<b>INTERMEDIATE-HIGH</b>',SM),P('16 to 30%',SM),P('T1, T2, T3a with any of: bilateral multifocality over 1 cm, clinically evident lateral nodes (cN1b) under 3 cm, 2 or more low-intermediate factors, aggressive histology, vascular invasion. (FTC/OTC: cN1b under 3 cm or 2+ low-intermediate factors.)',SM)], [P('<b>LOW-INTERMEDIATE</b>',SM),P('10 to 15%',SM),P('T3a or T1-T2 with any of: unilateral multifocality, microscopic ETE, cN1a or pN1a with nodes over 2 mm or more than 5 nodes, negative margins or microscopic positive posterior margin (R1). (FTC/OTC: limited vascular invasion under 4 vessels.)',SM)], [P('<b>LOW</b>',SM),P('under 10%',SM),P('T1 and T2 (4 cm or less), unifocal, pN0a/cN0 or pN1a (5 or fewer nodes, all 2 mm or less), negative margins or microscopic anterior margin only (R1). (FTC/OTC: minimally invasive, capsular invasion only.)',SM)]] rtab=Table(rt,colWidths=[32*mm,20*mm,W-52*mm]) rtab.setStyle(TableStyle([('GRID',(0,0),(-1,-1),0.3,colors.grey),('VALIGN',(0,0),(-1,-1),'TOP'),('BACKGROUND',(0,1),(-1,1),colors.HexColor('#FFCDD2')),('BACKGROUND',(0,2),(-1,2),colors.HexColor('#FFE0B2')),('BACKGROUND',(0,3),(-1,3),colors.HexColor('#FFF9C4')),('BACKGROUND',(0,4),(-1,4),colors.HexColor('#C8E6C9')),('BACKGROUND',(0,0),(-1,0),colors.HexColor('#E0E0E0'))])) resp=[[P('<b>Response</b>',SM),P('<b>TT + RAI</b>',SM),P('<b>TT, no RAI</b>',SM),P('<b>TSH goal</b>',SM)], [P('Excellent',SM),P('Tg under 0.2 (stim under 1) + negative imaging',SM),P('Tg under 2.5',SM),P('Normal range',SM)], [P('Indeterminate',SM),P('Nonspecific imaging, Tg 0.2 to 1 (stim 1 to 10), stable/declining TgAb',SM),P('Nonspecific imaging, Tg 2.5 to 5, stable/declining TgAb',SM),P('Normal range',SM)], [P('Biochemical incomplete',SM),P('Tg over 1 (stim over 10) or rising TgAb, imaging negative',SM),P('Tg over 5 or rising TgAb, imaging negative',SM),P('Below normal (weigh AF, osteoporosis)',SM)], [P('Structural incomplete',SM),P('Imaging or biopsy-proven disease',SM),P('Imaging or biopsy-proven disease',SM),P('Below normal (weigh AF, osteoporosis)',SM)]] rsp=Table(resp,colWidths=[30*mm,52*mm,45*mm,W-127*mm]) rsp.setStyle(TableStyle([('GRID',(0,0),(-1,-1),0.3,colors.grey),('VALIGN',(0,0),(-1,-1),'TOP'),('BACKGROUND',(0,0),(-1,0),colors.HexColor('#E0E0E0')),('BACKGROUND',(0,1),(-1,1),colors.HexColor('#C8E6C9')),('BACKGROUND',(0,2),(-1,2),colors.HexColor('#FFF9C4')),('BACKGROUND',(0,3),(-1,3),colors.HexColor('#FFE0B2')),('BACKGROUND',(0,4),(-1,4),colors.HexColor('#FFCDD2'))])) # remove last pagebreak of chapter 6 then append tables story.pop() story+=[Spacer(1,4),P('<b>TABLE: 2025 ATA Risk of Structural Recurrence (PTC wording)</b>',SUB),rtab,Spacer(1,8),P('<b>TABLE: Response to therapy after initial treatment (Table 9)</b>',SUB),rsp,Spacer(1,4),P('Hemithyroidectomy: excellent response = normal/low-risk contralateral lobe nodules (or benign biopsy) and no abnormal nodes on imaging; Tg cutoffs for lobectomy are uncertain.',SM),PageBreak()] story+=chapter(7,'THE RADIOACTIVE SUPERHERO: RAI (R32 to R44)','#F9A825' and colors.HexColor('#F57F17'), 'RAI is a superhero that only visits towns that are dangerous. For a low-risk town (Mira) he stays home. For a high-risk town or one with distant mets he comes with a bigger cape (dose). Before he arrives, the town must be "hungry for iodine": high TSH, low-iodine diet, and no other iodine sources. Afterwards he leaves a scan (post-therapy WBS) as a calling card.', [('R32','<b>Low risk: NO routine remnant ablation</b> (Strong, High certainty). <b>Low-intermediate and intermediate-high:</b> adjuvant RAI <b>may be considered</b> (Conditional). <b>High risk: RAI recommended</b> (Strong). <b>Distant mets at diagnosis: RAI recommended</b> (Strong).'), ('R33','<b>OTC:</b> data limited; if no empiric RAI, a diagnostic WBS can test iodine avidity (Conditional, very low certainty).'), ('R34','<b>rhTSH preferred over thyroid hormone withdrawal</b> for ablation/adjuvant RAI (Strong). rhTSH for anyone with comorbidity precluding withdrawal. If withdrawing: <b>LT4 off for 3 to 4 weeks</b>; if 4 weeks or more consider <b>LT3</b> bridge and stop LT3 at least 2 weeks. <b>Target TSH over 30 mIU/L</b>. Known distant mets: either method.'), ('R35','<b>Low-iodine diet for about 1 to 2 weeks</b> before RAI (GPS).'), ('R36','Diagnostic 123I or low-dose 131I WBS <b>may be considered</b> pre-treatment (Conditional).'), ('R37','<b>Post-therapy scan should be done</b> after every RAI treatment (Strong).'), ('R38','<b>SPECT/CT</b> may be added to diagnostic or post-treatment WBS to localise uptake and separate benign from malignant foci (Conditional).'), ('R39','Give oral + written radiation safety instructions to protect family and public (GPS).'), ('R40','Counsel: acute/chronic <b>salivary gland</b> damage, <b>lacrimal duct stenosis</b>, small second-cancer risk. Hydration; dental care for xerostomia (caries); <b>surgery for nasolacrimal obstruction (epiphora)</b> (GPS).'), ('R41','<b>Second primary malignancy</b> risk after RAI is small; no extra screening (GPS).'), ('R42','Baseline <b>CBC and renal function</b> before therapeutic RAI (GPS).'), ('R43','Women: negative pregnancy test; <b>avoid pregnancy at least 6 months</b> after RAI. <b>No RAI while nursing</b>; defer until breastfeeding/pumping stopped <b>at least 3 months</b>. Men with cumulative over <b>14.8 GBq (400 mCi)</b>: infertility counselling. RAI has not been shown to impair female fertility (GPS).'), ('R44','<b>EBRT</b> adjuvant: select high-risk locoregional features (aggressive histology, gross ETE, positive margins, visceral/soft tissue invasion), especially if salvage surgery would not be possible. May improve locoregional control, <b>no overall survival data</b>, real toxicity. EBRT +/- chemo for gross residual or unresectable disease in select patients (Conditional).')], ['<b>Table 10 - activity by risk:</b> Low: none (if used 1.1 to 1.85 GBq = 30 to 50 mCi). Intermediate: consider 1.1 to 3.7 GBq (30 to 100 mCi). High: 3.7 to 5.55 GBq (100 to 150 mCi). Distant mets: 3.7 to 7.4 GBq (100 to 200 mCi) or dosimetry.','Above 7.4 GBq (200 mCi): dosimetry recommended.','TSH over 30 mIU/L; LT4 off 3 to 4 weeks; LT3 off 2 weeks; low-iodine diet 1 to 2 weeks; avoid pregnancy 6 months; stop breastfeeding 3 months; male infertility over 400 mCi.','<b>Trials:</b> ESTIMABL2 (low risk: event-free 95.6% no RAI vs 95.9% RAI = noninferior). HiLo (1.1 GBq vs 3.7 GBq: similar recurrence).'], ['<b>Dose ladder "30-100-150-200":</b> low 30 to 50, intermediate up to 100, high 100 to 150, metastatic up to 200 mCi.','<b>"Hungry Thyroid" rule:</b> TSH over 30 + low iodine 1 to 2 weeks + rhTSH preferred.','<b>Sixes and threes:</b> 6 months no pregnancy, 3 months post breastfeeding.'], ['Low-risk: remnant ablation is NOT routine, and if RAI is used the dose is LOW (30 to 50 mCi).','The post-therapy scan is Strong; the pre-therapy diagnostic scan is only Conditional.','RAI second-cancer risk: counsel, but NO additional screening.']) story+=chapter(8,'THE LONG ROAD: TSH, Tg and ultrasound follow-up (R45 to R51)','#1565C0' and colors.HexColor('#1565C0'), 'A year after surgery, Mira returns for check-ups. Her team asks three questions: how hard should we push her TSH down? Is her Tg quiet? Does she still need ultrasounds? As years pass with excellent results, her follow-up gets lighter, until after 10 to 15 years she is declared in <b>complete remission</b>.', [('R45','Individualise TSH suppression to benefits vs risks; <b>high-risk disease benefits more</b> (Conditional). Goals follow Table 9: normal range for excellent/indeterminate; below normal for biochemical/structural incomplete (weigh atrial fibrillation, osteoporosis).'), ('R46','<b>No long-term TSH suppression</b> for low or intermediate risk with no biochemical/structural recurrence (Conditional). Re-evaluate the TSH goal over time (GPS).'), ('R47','Tg assay calibrated to <b>BCR457</b>; <b>measure TgAb with EVERY Tg</b> (GPS). Tg on LT4 after total thyroidectomy (Strong; better predictive value after RAI). Early follow-up Tg <b>every 6 to 12 months</b>, more often in intermediate-high/high risk. Not routine after lobectomy. TgAb interferes with IMA/RIA; LC-MS/MS has low sensitivity; trend TgAb with the same assay; <b>imaging is primary</b> when TgAb present.'), ('R48','<b>De-escalate in low-risk DTC with sustained excellent response:</b> total thyroidectomy +/- RAI: stop routine US at 5 to 8 years, then biochemical markers every 1 to 2 years; after <b>10 to 15 years</b> of sustained excellent response no routine biochemical monitoring = <b>complete remission</b>. Lobectomy: if initial US negative, US every 1 to 3 years for 5 to 8 years.'), ('R49','<b>No surveillance WBS</b> after lobectomy or total thyroidectomy without RAI (GPS). No routine diagnostic WBS in low and low-intermediate risk with excellent response. Intermediate-high/high risk: diagnostic WBS (123I or low-activity 131I, +/- SPECT-CT) if clinical suspicion.'), ('R50','<b>FDG-PET/CT</b>: high-risk patients with elevated Tg, OTC or aggressive histology, or negative RAI imaging; also prognostic and for response to systemic/local therapy (Conditional).'), ('R51','<b>Dynamic (ongoing) risk stratification</b> combined with the initial risk guides timing and type of imaging (GPS).'), ('Table 11','Low risk, excellent response. <b>Total thyroidectomy + RAI:</b> Tg under 0.2 with undetectable TgAb, TSH normal, US every 1 to 3 years for 5 to 8 years then stop. <b>Total thyroidectomy, no RAI:</b> Tg under 2.5, same US schedule. <b>Hemithyroidectomy:</b> one Tg post-op, TSH normal, US every 1 to 3 years for 5 to 8 years. Restart imaging if rising Tg, new TgAb, concerning exam or symptoms.')], ['Tg every 6 to 12 months early on; US 6 to 12 months after initial therapy','De-escalation clock: stop US at 5 to 8 years; remission at 10 to 15 years','Assay standard: BCR457; Tg functional sensitivity 0.1 ng/mL'], ['<b>"5-8 ultrasound goodbye, 10-15 remission hi"</b>.','<b>TgAb rule: "No Tg without TgAb"</b>: an undetectable Tg means little when antibodies exist.','TSH tune: <b>Excellent/Indeterminate = Normal; Incomplete = Low.</b>'], ['Complete remission statements for 10 to 15 years apply to LOW-risk with sustained excellent response (GPS).','De-escalation data come mainly from PTC; OTC may spread locally, so ultrasound beyond year 1 is reasonable.']) story+=chapter(9,'WHEN IT COMES BACK: Recurrence and metastases (R52 to R60)','#6D4C41' and colors.HexColor('#6D4C41'), 'Five years on, Mira\'s Tg rises and a 12 mm node appears. The team opens the toolbox: re-operate, ablate with ethanol or RFA, give RAI, or use beam radiation. For lung or bone mets, RAI dosing gets serious and numbers matter. Finally, a key vocabulary test: is the tumor truly RAI-refractory?', [('R52','Reoperation decision depends on prior surgery, size and site, growth pace, patient factors. <b>Percutaneous ethanol ablation</b> or <b>RFA</b> are alternatives, best in patients at high risk from reoperation.'), ('R53','RAI for isolated cervical node mets <b>only after local therapy or when local therapy is not feasible</b> (Conditional); benefit limited.'), ('R54','<b>EBRT (IMRT, stereotactic)</b> for unresectable locoregional recurrence, extranodal extension or soft tissue involvement. SBRT for isolated mets, not for resectable nodes.'), ('R55','Empiric 131I <b>over 5.5 GBq (150 mCi)</b> should be avoided in patients <b>over 70 or with renal failure</b>; dosimetry first (Strong). Dosimetry-guided RAI may be considered when over 5.5 GBq. rhTSH or withdrawal both usable for metastatic disease.'), ('R56','<b>Lung micro/macro-nodules:</b> empiric <b>3.7 to 7.4 GBq (100 to 200 mCi)</b>, or <b>3.7 to 5.55 GBq (100 to 150 mCi) if over 70</b>; or dosimetry limiting whole-body retention to <b>2.96 GBq (80 mCi) at 48 hours</b> with <b>200 cGy to bone marrow</b>. Repeat while it concentrates RAI and responds.'), ('R57','<b>Iodine-avid bone mets: RAI associated with better survival, so use it</b> (Strong). 3.7 to 7.4 GBq (100 to 200 mCi) or dosimetry.'), ('R58','<b>Tg-positive, scan-negative:</b> if no structural disease and stimulated Tg <b>under 10</b> (withdrawal) or <b>under 5</b> (rhTSH): just LT4 and watch. If Tg high or rapidly rising and imaging negative: empiric 100 to 200 mCi may be considered; repeat only if objective tumor reduction.'), ('R59','<b>RAIR cannot be diagnosed unless the patient received an ablative/treatment dose.</b> Strong criteria: (i) <b>no uptake on post-therapy scan</b> despite imaging-visible disease, or (ii) <b>progression under 6 months</b> after RAI that showed uptake. RAIR patients get <b>no more empiric RAI</b> (GPS).'), ('R60','Asymptomatic, stable or minimally progressive RAIR (or significant comorbidity): <b>TSH-suppressive LT4 + imaging every 3 to 12 months</b>. No routine molecular testing unless systemic therapy or redifferentiation planned.')], ['RAI >5.5 GBq (150 mCi): dosimetry if over 70 or renal failure','Lung mets: 100 to 200 mCi; over 70: 100 to 150 mCi; retention limit 80 mCi at 48 h, marrow 200 cGy','Scan-negative Tg cutoffs: stimulated Tg under 10 (withdrawal) or under 5 (rhTSH)','RAIR progression window: under 6 months'], ['<b>"80-48-200"</b>: 80 mCi retained at 48 hours, 200 cGy marrow.','<b>RAIR = "Rejected, Absent uptake, or Quick progression (under 6 months)"</b>.','<b>70 and 5.5</b>: patients over 70, doses over 5.5 GBq - think dosimetry.'], ['You cannot call a tumor RAIR without having given a real treatment dose.','Bone mets with iodine avidity: RAI is Strong. Brain mets: different story (see Chapter 10).']) story+=chapter(10,'THE TARGETED ERA: RAI-refractory DTC and systemic therapy (R61 to R80)','#B71C1C' and colors.HexColor('#B71C1C'), 'Mira\'s cousin Dev has progressive RAIR lung metastases. The oncologist first asks the genes what they want: "Which driver are you?" If a driver is found (NTRK, RET, ALK), a matching key opens the lock in first line. If no driver, the broad weapon is lenvatinib. If lenvatinib fails, cabozantinib steps in. Along the way, supportive care keeps the patient on treatment.', [('R61','<b>Tissue-based biomarker testing BEFORE systemic therapy</b> for progressive RAIR DTC (Strong).'), ('R62','No actionable driver: <b>MKI lenvatinib or sorafenib</b>; <b>lenvatinib usually preferred first-line</b> (Strong).'), ('R63','<b>Symptomatic</b> RAIR where local therapy is unsuitable: start MKI <b>without delay</b> (Strong). <b>Asymptomatic</b> but progressing over prior 12 to 14 months: start earlier if efficacy is the priority; delay and monitor if quality of life is the priority (GPS).'), ('R64','<b>Lenvatinib start dose 24 mg once daily</b> for most (Strong, High certainty); lower dose in selected patients. Dose holds and reductions are key tools (GPS).'), ('R65','MKI patients seen at baseline and <b>at least every 2 weeks for the first 2 months</b>, then every 1 to 2 months (GPS). Prevent and treat adverse events early ("prehabilitation").'), ('R66','<b>Second-line: cabozantinib</b> for RAIR without actionable driver after prior MKI progression or intolerance (Strong, High certainty).'), ('R67 to R69','<b>NTRK fusion = NTRK inhibitor first line. RET fusion = RET inhibitor first line. ALK fusion = ALK inhibitor first line</b> (all Strong).'), ('R70','<b>BRAF V600E:</b> BRAF-directed therapy may be first line if poor candidate for lenvatinib (Conditional); <b>recommended after progression on or intolerance to MKI</b> (Strong); <b>NOT for non-V600 BRAF alterations</b> (Strong). Dabrafenib + trametinib was not superior to dabrafenib alone in DTC, so dabrafenib alone may be considered.'), ('R71','Other actionable targets: <b>clinical trial or first-line lenvatinib</b> (Conditional).'), ('R72','At progression on targeted therapy: <b>re-biopsy (tumor/core) for NGS</b> to find resistance mechanisms (GPS); tissue preferred over ctDNA (Conditional). Third-line options: trial, or lenvatinib/cabozantinib/sorafenib not yet used.'), ('R73','<b>Immunotherapy</b> only in select cases: <b>high tumor mutational burden or mismatch repair deficient</b> (Conditional).'), ('R74','<b>Redifferentiation</b> by MAPK blockade in selected progressive RAIR with targetable mutations (trial encouraged). <b>Adjuvant redifferentiation in non-gene-selected high-risk DTC: NOT recommended</b> (Strong).'), ('R75','<b>Cytotoxic chemotherapy</b> only for rapidly progressive, symptomatic or threatening disease not controllable otherwise; trial preferred.'), ('R76','<b>Oligometastatic (2 to 5 lesions):</b> focal ablative treatment may be considered, ideally multidisciplinary.'), ('R77','Symptomatic site: <b>local treatment</b> (surgery, radiotherapy, percutaneous thermo-ablation).'), ('R78','Symptomatic or multiple <b>bone mets: bone-modifying agent</b> (Strong). <b>Every 3 months</b> dosing may reduce adverse events (osteonecrosis of the jaw) but may raise skeletal events (Conditional).'), ('R79','<b>Brain mets:</b> resection and/or SBRT are the mainstays. If RAI-avid, give RAI only after <b>SBRT + glucocorticoids</b> to blunt TSH-induced tumor swelling and inflammation (GPS).'), ('R80','Counsel about <b>clinical trials</b> (clinicaltrials.gov) (GPS).')], ['Lenvatinib 24 mg daily; visits every 2 weeks for first 2 months','Oligometastatic = 2 to 5 lesions','Bone agent every 3 months may lower jaw osteonecrosis risk'], ['<b>Driver rule "NRA = go targeted first line"</b>: NTRK, RET, ALK. BRAF is the special child: first line only if lenvatinib is a poor choice, but definitely after MKI failure.','<b>"1st Lenva, 2nd Cabo"</b> for no-driver disease.','<b>Brain mets order: Shoot (SBRT) + Steroid, THEN RAI</b>.','<b>Drug examples</b> (from general knowledge, not read in your PDF): NTRK larotrectinib/entrectinib; RET selpercatinib/pralsetinib; ALK alectinib or similar; BRAF dabrafenib (+/- trametinib).'], ['Do not give BRAF V600-directed drugs for non-V600 BRAF changes.','Adjuvant redifferentiation in unselected high-risk patients is a Strong recommendation AGAINST.','Biopsy beats ctDNA at progression.']) story+=chapter(11,'LIFE AROUND THE CANCER: Pregnancy and survivorship (R81 to R84)','#2E7D32' and colors.HexColor('#2E7D32'), 'Years later Mira is pregnant. Her team balances two lives: usually the surgery can wait until after delivery, the baby gets no X-rays, and the TSH is checked often. Beyond biology, her team also asks about money worries and the emotional weight of being a cancer survivor.', [('R81A','Most pregnant patients: <b>surgery can wait until after delivery</b>; if needed, do it in the <b>second trimester</b> (Conditional).'), ('R81B','Neck <b>ultrasound at least once in early second trimester</b>; MRI if cross-sectional imaging is needed; <b>avoid ionising radiation</b> except exceptional cases.'), ('R81C','<b>TSH goal = same as pre-conception</b>; may relax suppression if LT4 excess harms pregnancy. <b>TSH about every 4 weeks until 16 to 20 weeks, and at least once between 26 and 32 weeks</b> (GPS).'), ('R81D','Incomplete response: monitor with neck US and Tg. Excellent/indeterminate: monitor as in non-pregnant patients.'), ('R82','Inform patients of <b>long-term side effects</b> of treatment and arrange monitoring/referral (GPS).'), ('R83','Discuss <b>financial burden</b> and available resources (GPS).'), ('R84','Offer <b>psychosocial support</b> and be ready to manage the psychological impact (GPS).')], ['TSH every 4 weeks until 16 to 20 weeks; once at 26 to 32 weeks','Surgery in pregnancy, if unavoidable: second trimester'], ['<b>Pregnancy = "Wait, Watch, Weigh, no X-ray"</b>: wait for surgery, watch with US/MRI, weigh the TSH dose.'], ['hCG weakly stimulates the TSH receptor, one reason pregnancy might stimulate DTC growth.']) # Strong list sl=[('R6','Refer to a high-volume surgeon'),('R7A,B','Pre-op neck US for all; FNA nodes over 8 to 10 mm'),('R8','CT/MRI with contrast for advanced disease; no routine pre-op PET'),('R15A,C','Lobectomy for cT1N0M0; total thyroidectomy for over 4 cm, ETE, N1, M1'),('R17C','Sistrunk + total thyroidectomy for advanced TGDCa'),('R19A','No prophylactic central dissection in cT1-T2 cN0 PTC and most FTC'),('R20A,C','Therapeutic central (cN1a) and lateral dissection'),('R22','Pre-op voice assessment for all; laryngeal exam for those at risk'),('R24B','PTH-directed calcium and vitamin D supplementation'),('R28, R29','Use 2025 ATA risk system and response criteria'),('R30A','Tg 6 to 12 weeks after total thyroidectomy'),('R31A','US is the preferred imaging'),('R32A,C,D','No RAI for low risk; RAI for high risk and for distant mets'),('R34A','rhTSH preferred'),('R37','Post-therapy scan'),('R47B','Tg monitoring after total thyroidectomy'),('R55A','Avoid empiric RAI over 150 mCi if over 70 or renal failure'),('R57A','RAI for iodine-avid bone mets'),('R61','Biomarker testing before systemic therapy'),('R62','Lenvatinib (or sorafenib) first line without driver'),('R63A','Start MKI without delay if symptomatic'),('R64A','Lenvatinib 24 mg start'),('R66','Cabozantinib second line'),('R67-R69','NTRK, RET, ALK inhibitors first line'),('R70B,C','BRAF therapy after MKI failure; not for non-V600'),('R74B','No adjuvant redifferentiation in unselected patients'),('R78A','Bone-modifying agent for symptomatic/multiple bone mets')] sd=[[P('<b>Rec</b>',SM),P('<b>STRONG recommendation: the non-negotiables</b>',SM)]]+[[P('<b>'+a+'</b>',SM),P(b,SM)] for a,b in sl] stb=Table(sd,colWidths=[24*mm,W-24*mm],repeatRows=1) stb.setStyle(TableStyle([('GRID',(0,0),(-1,-1),0.3,colors.grey),('BACKGROUND',(0,0),(-1,0),colors.HexColor('#FFCDD2')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,colors.HexColor('#FFF3F3')]),('VALIGN',(0,0),(-1,-1),'TOP')])) story+=[P('<font size="14"><b>THE STRONG-RECOMMENDATION LIST (high-yield for exams)</b></font>',B),Spacer(1,4),stb,Spacer(1,6)] story.append(box('"NO" LIST: things the guideline says NOT to do routinely',[ 'No routine pre-op PET (R8), Tg/TgAb (R9) or genomic testing (R10).','No prophylactic central neck dissection in cT1-T2 cN0 PTC (R19A).','No routine drain (R25).','No remnant ablation in low risk (R32A).','No routine post-op molecular profiling (R28B).','No long-term TSH suppression in low/intermediate risk without recurrence (R46).','No surveillance WBS after lobectomy or total thyroidectomy without RAI (R49A).','No extra screening for second cancers after RAI (R41).','No more empiric RAI in RAIR disease (R59B).','No BRAF V600 drugs for non-V600 alterations (R70C).','No adjuvant redifferentiation in unselected high-risk patients (R74B).','No RAI while breastfeeding (R43B); no ionising imaging in pregnancy (R81B).'],colors.HexColor('#FFEBEE'),colors.HexColor('#C62828'))) story.append(PageBreak()) qa=[('What does DATA stand for?','Diagnosis, risk/benefit Assessment, Treatment decisions, response Assessment.'), ('Percent of thyroid cancers that are DTC?','More than 90% (papillary, follicular, oncocytic).'), ('Is NIFTP routinely followed by completion thyroidectomy or RAI?','No (R1).'), ('NIFTP mitotic count limit?','Under 3 per 10 high-power fields.'), ('Which syndrome: DTC + breast/endometrial cancer + macrocephaly?','Cowden / PTEN hamartoma tumor syndrome.'), ('Gene linked to cribriform-morular thyroid carcinoma?','APC (FAP).'), ('How many affected relatives define clinical FNMTC?','3 or more.'), ('Minimum surgeon volume suggested?','More than 25 to 50 thyroidectomies per year.'), ('Node size to FNA?','8 to 10 mm or more (smallest diameter).'), ('Is pre-op FDG-PET routine?','No (Strong).'), ('Active surveillance eligibility?','Some cT1aN0M0 PTC.'), ('AS ultrasound schedule?','Every 6 months for 1 to 2 years, then yearly.'), ('Growth that triggers surgery during AS?','3 mm or more (plus nodes, distant mets, ETE, posterior growth, anxiety, no follow-up, preference).'), ('Initial surgery for cT1N0M0 (2 cm or less)?','Lobectomy (Strong).'), ('Initial surgery for tumor over 4 cm or gross ETE or cN1 or cM1?','Total thyroidectomy (Strong).'), ('Operation for thyroglossal duct carcinoma?','Sistrunk; add total thyroidectomy if advanced or suspicious thyroid disease.'), ('Prophylactic central dissection for cT1-T2 cN0 PTC?','No (Strong).'), ('Levels in central neck dissection?','Level VI and upper Level VII.'), ('Levels in lateral neck dissection?','IIa, III, IV and Vb.'), ('Who needs pre-op laryngeal exam?','Dysphonia, prior neck/upper chest surgery, posterior ETE or bulky central/jugular nodes.'), ('What to do with a devascularised parathyroid?','Frozen section then autotransplant into muscle.'), ('Is a drain recommended?','No (High certainty).'), ('ATA 2025 risk categories and recurrence rates?','Low under 10%; low-intermediate 10 to 15%; intermediate-high 16 to 30%; high over 30%.'), ('When is the first Tg after total thyroidectomy?','6 to 12 weeks.'), ('Excellent response Tg after total thyroidectomy + RAI?','Nonstimulated under 0.2 (stimulated under 1) with negative imaging.'), ('Excellent response Tg without RAI?','Under 2.5.'), ('RAI for low-risk DTC?','Not routine; if used, 30 to 50 mCi.'), ('RAI for high-risk DTC dose?','100 to 150 mCi (3.7 to 5.55 GBq).'), ('RAI for distant metastases dose?','100 to 200 mCi (3.7 to 7.4 GBq) or dosimetry.'), ('Preferred RAI preparation?','rhTSH (Strong).'), ('TSH target before RAI after withdrawal?','Over 30 mIU/L; LT4 off 3 to 4 weeks.'), ('Low-iodine diet duration?','About 1 to 2 weeks.'), ('Avoid pregnancy after RAI for how long? Breastfeeding gap?','6 months; at least 3 months after stopping breastfeeding.'), ('Male fertility counselling threshold?','Cumulative RAI over 14.8 GBq (400 mCi).'), ('Baseline tests before RAI?','CBC and renal function.'), ('Tg assay standard and companion test?','BCR457; TgAb with every Tg.'), ('When can routine ultrasound stop in low-risk with excellent response?','After 5 to 8 years (total thyroidectomy); then biochemical marker every 1 to 2 years.'), ('When is a low-risk patient in complete remission?','Sustained excellent response for 10 to 15 years.'), ('Dose limit for RAI in elderly/renal failure patients?','Avoid empiric over 150 mCi (5.5 GBq); use dosimetry.'), ('Lung mets RAI dosimetry limits?','80 mCi whole-body retention at 48 h; 200 cGy to bone marrow.'), ('When is a tumor RAIR?','No uptake on post-therapy scan with visible disease, or progression under 6 months after RAI with uptake; must have had a treatment dose.'), ('First-line systemic therapy without driver? Second line?','Lenvatinib (or sorafenib); cabozantinib.'), ('Lenvatinib starting dose?','24 mg once daily.'), ('Which fusions get targeted first-line therapy (Strong)?','NTRK, RET, ALK.'), ('BRAF V600E place in therapy?','Recommended after MKI failure; first line only if poor lenvatinib candidate; not non-V600.'), ('Immunotherapy in DTC?','Select cases: high TMB or mismatch repair deficiency.'), ('Oligometastatic definition and approach?','2 to 5 lesions; focal ablative treatment.'), ('Bone mets treatment?','Bone-modifying agent; every 3 months may lower jaw osteonecrosis risk.'), ('Brain mets order of therapy?','Resection/SBRT; if RAI-avid give SBRT + steroids before RAI.'), ('TSH monitoring in pregnancy?','Every 4 weeks until 16 to 20 weeks, once at 26 to 32 weeks.')] story.append(P('<font size="15"><b>THE RECALL ARENA: cover the right column and answer</b></font>',B)) story.append(Spacer(1,4)) qd=[[P('<b>#</b>',SM),P('<b>Question</b>',SM),P('<b>Answer</b>',SM)]]+[[P(str(i+1),SM),P(q,SM),P(a,SM)] for i,(q,a) in enumerate(qa)] qt=Table(qd,colWidths=[8*mm,(W-8*mm)*0.5,(W-8*mm)*0.5],repeatRows=1) qt.setStyle(TableStyle([('GRID',(0,0),(-1,-1),0.3,colors.grey),('BACKGROUND',(0,0),(-1,0),colors.HexColor('#C5CAE9')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,colors.HexColor('#F3F4FB')]),('VALIGN',(0,0),(-1,-1),'TOP'),('BACKGROUND',(2,1),(2,-1),colors.HexColor('#F1F8E9'))])) story.append(qt) story.append(Spacer(1,6)) story.append(P('Source: 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer (Ringel, Sosa et al., Thyroid 2025), as provided in your PDF. The stories, mnemonics and the drug examples marked as general knowledge are study aids added here, not text from the guideline. Always confirm clinical decisions against the full guideline.',SM)) def foot(c,d): c.saveState(); c.setFont('DV',7.5); c.setFillColor(colors.grey) c.drawString(14*mm,8*mm,'2025 ATA DTC Memory Palace'); c.drawRightString(A4[0]-14*mm,8*mm,f'Page {d.page}'); c.restoreState() doc=BaseDocTemplate('/tmp/workspace/dtc-notes/output/ATA_DTC_2025_Memory_Palace.pdf',pagesize=A4,leftMargin=14*mm,rightMargin=14*mm,topMargin=12*mm,bottomMargin=14*mm) doc.addPageTemplates([PageTemplate(id='a',frames=[Frame(14*mm,14*mm,W,A4[1]-26*mm,id='f',leftPadding=0,rightPadding=0,topPadding=0,bottomPadding=0)],onPage=foot)]) doc.build(story) print('ok') PYEOF cd /tmp/workspace/dtc-notes && python3 build.py && ls -la output && python3 -c " import pypdf;r=pypdf.PdfReader('output/ATA_DTC_2025_Memory_Palace.pdf');print(len(r.pages))"

cd /tmp/workspace/dtc-notes && python3 -c " import pypdf,re r=pypdf.PdfReader('output/ATA_DTC_2025_Memory_Palace.pdf') t=[p.extract_text() for p in r.pages] full='\n'.join(t) print([m for m in re.findall(r'&\w+;|<b>|</b>|<i>',full)][:10]) print('—' in full or '–' in full) for i in [0,5,8]: print('--- page',i+1); print(t[i][:700]) "