51
|
Gao L, Li X, Liu C, Liu R, Shi X, Ma L, Zhao H, Xia Y, Jiang Y. What Are the Characteristics of Papillary Thyroid Microcarcinoma Prone to High-Volume Lateral Lymph Node Metastasis? - An Analysis of 2981 Consecutive Cases. J INVEST SURG 2022; 35:1519-1525. [PMID: 35610088 DOI: 10.1080/08941939.2022.2075494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To identify candidate factors for predicting high-volume lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC). METHODS We retrospectively studied 2981 patients with PTMC who underwent thyroidectomy from 2013 to 2016. LLNM was identified by histopathology. Patients with different LLNM statuses were compared according to clinical, sonographic and pathological parameters. A multivariate logistic model was established to predict high-volume LLNM (number of metastatic lymph nodes >5). RESULTS High-volume LLNM of PTMC was independently associated with age < 40 years (OR = 1.791, P = 0.023), male sex (OR = 2.401, p = 0.001), tumor size > 0.5 cm (OR = 4.839, p < 0.001), extrathyroidal extension (OR = 2.097, p = 0.007) and microcalcification (OR = 2.894, p = 0.002). These five factors were incorporated together to develop a multivariate analysis, which showed good predictive ability (AUC = 0.78, 95% CI 0.72-0.83), with a sensitivity of 80.0% and a specificity of 61.4%. Moreover, more level II or V lateral regions were involved in patients with high-volume LLNM than in those with small-volume LLNM (69.2% vs. 25.0%, p < 0.001; 10.8% vs. 4.7%, p < 0.001). CONCLUSION Multilevel LLNM tended to be more common in patients with PTMC who had high-volume LLNM. The high-volume LLNM rates of patients with PTMC with age < 40 years, male sex, tumor size > 0.5 cm, extrathyroidal extension and microcalcification were relatively higher than those without. These findings may be useful for identifying patients at higher high-volume LLNM risk who may require more aggressive treatment or intensive follow-up management.
Collapse
Affiliation(s)
- Luying Gao
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyi Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunhao Liu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruifeng Liu
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinlong Shi
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liyuan Ma
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Zhao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Xia
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxin Jiang
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
52
|
Stan MN, Papaleontiou M, Schmitz JJ, Castro MR. Nonsurgical Management of Thyroid Nodules: The Role of Ablative Therapies. J Clin Endocrinol Metab 2022; 107:1417-1430. [PMID: 34953163 PMCID: PMC9016471 DOI: 10.1210/clinem/dgab917] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/02/2022]
Abstract
CONTEXT After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma surgery or radioactive iodine (RAI) (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (eg, scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks. CASES We present 4 cases of thyroid lesions causing concern (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients' attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation [RFA] being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects, and conclude with a simplified description of how these procedures are performed. CONCLUSION Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules, while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.
Collapse
Affiliation(s)
- Marius N Stan
- Correspondence: Marius N. Stan, Division of Endocrinology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John J Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
53
|
Sonographic assessment of minor extrathyroidal extension of papillary thyroid microcarcinoma involving the posterior thyroid capsule. Eur Radiol 2022; 32:6090-6096. [PMID: 35380227 DOI: 10.1007/s00330-022-08765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study aimed to determine sonographic features and clinical significance of minor extrathyroidal extension (ETE) to the posterior thyroid capsule in papillary thyroid microcarcinoma (PTMC) patients. METHODS We retrospectively reviewed the records of 506 PTMC patients consisting of 151 patients with minor ETE and 355 patients without ETE. Significant clinicoradiologic features associated with ETE were identified by logistic regression analyses. The diagnostic performance of sonographic features, including the presence of capsular abutment, capsular abutment degree (< 25%, 25-50%, ≥ 50%), and protrusion, were assessed for the diagnosis of posterior minor ETE. Interobserver agreement was calculated. RESULTS PTMC patients with posterior minor ETE were more likely to have lymphovascular invasion and lateral neck lymph node metastasis (OR = 2.636, 95%CI: 1.754, 3.963 and OR = 2.897, 95%CI: 1.069, 7.848). Regarding the diagnostic performance, the capsular abutment yielded the highest sensitivity (81.5%), followed by ≥ 25% abutment, protrusion, and ≥ 50% abutment (57.0%, 21.9%, and 4.6%, respectively), with similar levels of diagnostic accuracy (71.3-75.1%). The specificity was highest for the sonographic feature of ≥ 50% abutment (99.7%), followed by protrusion, ≥ 25% abutment, and capsular abutment (97.8%, 82.0%, and 68.7%, respectively). Abutment assessment had a moderate interobserver agreement (K = 0.705), and abutment degree and protrusion assessment had a fair and slight interobserver agreement (K = 0.553 and 0.287). CONCLUSIONS Sonographic features of posterior capsular abutment are sensitive and reliable for diagnosis of posterior minor ETE and are associated with lymphovascular invasion and lateral neck lymph node metastasis in PTMC patients. The assessment of posterior minor ETE is important for considering candidates for active surveillance among PTMC patients. KEY POINTS • PTMC patients with posterior minor ETE were more likely to have lymphovascular invasion and lateral neck lymph node metastasis. • Sonographic features of posterior capsular abutment are sensitive and reliable for the diagnosis of posterior minor ETE. • The assessment of posterior minor ETE is important for considering candidates for active surveillance among PTMC patients.
Collapse
|
54
|
Pasqual E, Sosa JA, Chen Y, Schonfeld SJ, Berrington de González A, Kitahara CM. Trends in the Management of Localized Papillary Thyroid Carcinoma in the United States (2000-2018). Thyroid 2022; 32:397-410. [PMID: 35078347 PMCID: PMC9048184 DOI: 10.1089/thy.2021.0557] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: In response to evidence of overdiagnosis and overtreatment of papillary thyroid carcinoma (PTC), the 2009 and 2015 American Thyroid Association (ATA) adult guidelines recommended less extensive surgery (lobectomy vs. total thyroidectomy) and more restricted use of postsurgical radioactive iodine (RAI) in management of PTC at low risk of recurrence. In 2015, active surveillance was suggested as a viable option for some <1-cm PTCs, or microcarcinomas. The 2015 ATA pediatric guidelines similarly shifted toward more restricted use of RAI for low-risk PTCs. The impact of these recommendations on low-risk adult and pediatric PTC management remains unclear, particularly after 2015. Methods: Using data from 18 Surveillance, Epidemiology, and End Results (SEER) U.S. registries (2000-2018), we described time trends in reported first-course treatment (total thyroidectomy alone, total thyroidectomy+RAI, lobectomy, no surgery, and other/unknown) for 105,483 patients diagnosed with first primary localized PTC (without nodal/distant metastases), overall and by demographic and tumor characteristics. Results: The declining use of RAI represented the most pronounced change in management of PTCs <4 cm (44-18% during the period 2006-2018), including microcarcinomas (26-6% during the period 2007-2018). In parallel, an increasing proportion of PTCs were managed with total thyroidectomy alone (35-54% during the period 2000-2018), while more subtle changes were observed for lobectomy (declining from 23% to 17% during the period 2000-2006, stabilizing, and then rising from 17% to 24% during the period 2015-2018). Use of nonsurgical management did not meaningfully change over time, impacting <1% of microcarcinomas annually during the period 2000-2018. Similar treatment trends were observed by sex, age, race/ethnicity, metropolitan vs. nonmetropolitan residence, and insurance status. For pediatric patients (<20 years), use of RAI peaked in 2009 (59%), then decreased markedly to 11% (2018), while use of total thyroidectomy alone and, to a lesser extent, lobectomy increased. No changing treatment trends were observed for ≥4-cm PTCs. Conclusions: The declining use of RAI in management of low-risk adult and pediatric PTC is consistent with changing recommendations from the ATA practice guidelines. Post-2015 trends in use of lobectomy and nonsurgical management of low-risk PTCs, particularly microcarcinomas, were more subtle than expected; however, these trends may change as evidence regarding their safety continues to emerge.
Collapse
Affiliation(s)
- Elisa Pasqual
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yingxi Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Sara J. Schonfeld
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Cari M. Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Address correspondence to: Cari M. Kitahara, PhD, MHS, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rm. 7E-456, Bethesda, MD 20892, USA
| |
Collapse
|
55
|
Escalante DA, Anderson KG. Workup and Management of Thyroid Nodules. Surg Clin North Am 2022; 102:285-307. [DOI: 10.1016/j.suc.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
56
|
Newman SK, Harries V, Wang L, McGill M, Ganly I, Girshman J, Tuttle RM. Invasion of a Recurrent Laryngeal Nerve from Small Well-Differentiated Papillary Thyroid Cancers: Patient Selection Implications for Active Surveillance. Thyroid 2022; 32:164-169. [PMID: 34714169 PMCID: PMC8861915 DOI: 10.1089/thy.2021.0310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: The success of an active surveillance management approach to low-risk papillary thyroid cancer (PTC) is heavily dependent on proper patient selection. For example, primary tumors located in a subcapsular position immediately adjacent to the trachea or a recurrent laryngeal nerve (RLN) are considered to be inappropriate for active surveillance. Since preoperative imaging cannot reliably rule out extrathyroidal extension or reveal the full course of the RLN relative to the thyroid gland, it is important for clinicians to understand subcapsular tumor locations and minimum tumor sizes that are most likely to be associated with gross invasion of the RLNs. Methods: We assessed the medical records of 123 patients treated at Memorial Sloan Kettering Cancer Center (MSK) between 1986 and 2015 who had a primary PTC tumor demonstrating gross extrathyroidal extension to either the right or left RLN. Thirty patients with a primary tumor ≤2 cm in diameter demonstrating extrathyroidal extension into an RLN were included in the analysis. Results: Gross invasion of an RLN by tumors ≤2 cm is a rare event that was seen in only 0.8% (35/4334) of patients with PTC who underwent initial thyroid surgery at MSK between 1986 and 2015. Gross RLN invasion was associated with subcapsular PTC tumors located in either the right paratracheal area (60%), left paratracheal area (36.7%), or right lateral posterior lobe area not adjacent to the trachea (3.3%). Only a quarter of the patients had imaging findings suggestive of extrathyroidal extension and only 30% had clinically apparent vocal paresis/paralysis on preoperative examination. Invasion of the RLN was not observed for primary tumors <0.9 cm in diameter, regardless of tumor location. Conclusions: Well-differentiated PTC tumors ≥0.9 cm in maximal diameter that are located in the right paratracheal, left paratracheal, and right lateral posterior lobe subcapsular positions are usually not appropriate for active surveillance even in the absence of definitive evidence for nerve invasion on preoperative imaging or vocal cord examination. Patient selection for active surveillance management should take into account not only the size and growth rate of a tumor but also its location in relation to the expected course of RLNs.
Collapse
Affiliation(s)
- Samantha K. Newman
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Victoria Harries
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Wang
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marlena McGill
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey Girshman
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R. Michael Tuttle
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Address correspondence to: R. Michael Tuttle, MD, Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, USA
| |
Collapse
|
57
|
Zhang L, Zhang GP, Zhan WW, Zhou W. The feasibility and efficacy of ultrasound-guided percutaneous laser ablation for multifocal papillary thyroid microcarcinoma. Front Endocrinol (Lausanne) 2022; 13:921812. [PMID: 36060950 PMCID: PMC9428260 DOI: 10.3389/fendo.2022.921812] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility and efficacy of percutaneous laser ablation (PLA) for patients with multifocal papillary thyroid microcarcinoma (PTMC). MATERIALS AND METHODS A cohort of patients who underwent ultrasound (US)-guided PLA for primary PTMC were enrolled in this study. The patients were divided into a multifocal PTMC (multi-PTMC) group and a unifocal PTMC (uni-PTMC) group. Before PLA, conventional US and contrast-enhanced ultrasound (CEUS) were performed to evaluate the PTMC and cervical lymph nodes. The operation time, energy, power, amount of isolation liquid, and complications during PLA were recorded. Patients were followed up at 2 days, 1 month, 3 months, and 6 months, and every 6 months after that. Volume reduction rate (VRR), local tumor recurrence, and lymph node metastasis after PLA were observed. RESULTS The study included 12 patients with 26 PTMCs and 60 patients with 60 PTMCs. The operation time, total energy, and amount of isolation liquid in the multi-PTMC group were more than those in the uni-PTMC group (p = 0.000, 0.007, and 0.020, respectively). The mean follow-up durations in multi-PTMC and uni-PTMC groups were 19.75 ± 11.46 months (6-36 months) and 16.33 ± 10.01 months (4-40 months), with a similar VRR of the ablated lesions in the two groups. One and three cases with newly developed PTMCs were observed in the multi-PTMC group and the uni-PTMC group during follow-up, respectively. There was no regrowth of treated lesions, lymph node metastasis, or distant metastasis. At the end of the follow-up, all the ablated lesions in the two groups completely disappeared or only remained scar strips. CONCLUSION PLA is a safe and effective technique for treating multifocal PTMC, which might be an alternative technique for patients who are not eligible or are unwilling to undergo surgery.
Collapse
|
58
|
Abstract
Thyroid nodules are extremely prevalent among older adults, and pose a challenge due to the frequency in which they are incidentally encountered. Approximately 5% of all nodules are malignant. Ultrasound is the first line tool to evaluate thyroid nodules, and can help identify nodules that are high-risk for malignancy. Fine needle aspiration (FNA) is an excellent low-risk procedure used to evaluate suspicious thyroid nodules and identify thyroid malignancy. It is performed with a 22-27-gauge needle under ultrasound guidance. Core needle biopsy (CNB) is usually not required; however, it can be helpful if FNA is non-diagnostic or inconclusive. On-site pathologist evaluation can help determine which patients need additional sampling. CNB is usually performed with a trocar technique using an 18-gauge biopsy device under ultrasound guidance. Complications from thyroid biopsy are rare, and the most common complications are discomfort, small to moderate hematoma, and insufficient sampling. Although rare, a rapidly expanding large hematoma can cause airway compression requiring intubation and surgery to preserve the airway and achieve hemostasis. Following biopsy, approximately 10.8% of thyroid nodules will require surgical excision.
Collapse
Affiliation(s)
- Tyler Smith
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology, University of Utah School of Medicine, Salt Lake City, UT.
| | - Claire S Kaufman
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology, University of Utah School of Medicine, Salt Lake City, UT.
| |
Collapse
|
59
|
Abstract
Incidental findings are common in the evaluation of surgical patients. Understanding the appropriate assessment and management of these frequent occurrences is important for the provision of comprehensive quality care. This review details the epidemiology, considerations, and recommendations for management of common incidental manifestations in surgical patients, including Meckel diverticulum, adrenal incidentaloma, thyroid nodule, solitary pulmonary nodule, small bowel intussusception, gallstones, and incidental appendectomy.
Collapse
Affiliation(s)
- Keely Reidelberger
- University of Nebraska Medical Center College of Medicine, 986880 Nebraska Medical Center, Omaha, NE 68198-6880, USA
| | - Abbey Fingeret
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE 68198-6880, USA.
| |
Collapse
|
60
|
Ha EJ, Chung SR, Na DG, Ahn HS, Chung J, Lee JY, Park JS, Yoo RE, Baek JH, Baek SM, Cho SW, Choi YJ, Hahn SY, Jung SL, Kim JH, Kim SK, Kim SJ, Lee CY, Lee HK, Lee JH, Lee YH, Lim HK, Shin JH, Sim JS, Sung JY, Yoon JH, Choi M. 2021 Korean Thyroid Imaging Reporting and Data System and Imaging-Based Management of Thyroid Nodules: Korean Society of Thyroid Radiology Consensus Statement and Recommendations. Korean J Radiol 2021; 22:2094-2123. [PMID: 34719893 PMCID: PMC8628155 DOI: 10.3348/kjr.2021.0713] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/15/2022] Open
Abstract
Incidental thyroid nodules are commonly detected on ultrasonography (US). This has contributed to the rapidly rising incidence of low-risk papillary thyroid carcinoma over the last 20 years. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors in small (1-2 cm) thyroid nodules. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.
Collapse
Affiliation(s)
- Eun Ju Ha
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Sae Rom Chung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Gyu Na
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.
| | - Hye Shin Ahn
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jin Chung
- Department of Radiology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ji Ye Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Seon Park
- Department of Radiology, Hanyang University College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Roh-Eul Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Mi Baek
- Department of Radiology, Haeundae Sharing and Happiness Hospital, Busan, Korea
| | - Seong Whi Cho
- Department of Radiology, Kangwon National University Hospital, Chuncheon, Korea
| | - Yoon Jung Choi
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Yeon Hahn
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Lyung Jung
- Department of Radiology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Soo Jin Kim
- Department of Radiology, New Korea Hospital, Gimpo, Korea
| | - Chang Yoon Lee
- Department of Radiology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ho Kyu Lee
- Department of Radiology, Jeju National University, Jeju, Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hen Lee
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hyun Kyung Lim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jung Hee Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Suk Sim
- Department of Radiology, Withsim Clinic, Seongnam, Korea
| | - Jin Young Sung
- Department of Radiology and Thyroid Center, Daerim St. Mary's Hospital, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| |
Collapse
|
61
|
Zu Y, Liu Y, Zhao J, Yang P, Li J, Qian L. A cohort study of microwave ablation and surgery for low-risk papillary thyroid microcarcinoma. Int J Hyperthermia 2021; 38:1548-1557. [PMID: 34719323 DOI: 10.1080/02656736.2021.1996643] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The optimal treatment method for papillary thyroid microcarcinoma (PTMC) is lacking consensus. Here we aimed to compare the efficacy and safety of surgery and microwave ablation (MWA) for PTMC. METHODS The clinical data of 644 patients with PTMC treated between July 2013 and June 2020 were retrospectively analyzed. A total of 320 and 324 patients underwent MWA and surgery, respectively. We observed lesion changes in the MWA group and compared the recurrence, metastasis, complications, and other health economic indicators between the 2 groups. RESULTS The mean follow-up time was 890.7 ± 532.9 (187.9-2679.0) days in the MWA group and 910.9 ± 568.4 (193.8-2821.5) days in the surgery group. In the MWA group, lesion volume increased significantly after ablation and then gradually decreased. The final lesion volume reduction rate was 90.73% ± 7.94%, and 193 lesions (60.3%) disappeared completely. There were no significant intergroup differences in recurrence or metastasis. The incidence of main complications (temporary hypothyroidism, hypoparathyroidism, and temporary hoarseness) was significantly lower in the MWA group than in the surgery group (p < 0.001). The treatment time, intraoperative blood loss, and hospital stay were significantly lower in the MWA group than in the surgery group (p < 0.001). CONCLUSIONS MWA is effective for treating PTMC, with a low incidence of complications and less trauma. The rates of post-treatment recurrence and metastasis are similar to those of surgery, indicating that MWA is a suitable alternative to surgery.
Collapse
Affiliation(s)
- Yuan Zu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yujiang Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Junfeng Zhao
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Peipei Yang
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jianming Li
- Department of Interventional Ultrasound, The General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Linxue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
62
|
Faro FN, Simões VRF, Ricardo GP, Cabral CP, de Cássia Braga Ribeiro K, Scalissi NM, Cury AN, Marone MM, do Prado Padovani R, Ferraz C. Prognostic factors for incomplete response in thyroid microcarcinoma: an analysis of initial response to therapy in 517 patients. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:579-587. [PMID: 33740337 PMCID: PMC10528575 DOI: 10.20945/2359-3997000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 01/10/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although thyroid microcarcinoma (TMC) usually has a favorable prognosis, some patients present a higher risk of disease recurrence or persistence. Thus, we aimed at identifying possible risk factors associated with an incomplete response to therapy in TMC. METHODS This was a retrospective study of 517 patients with TMC treated with total thyroidectomy, with or without radioactive iodine (RAI) therapy, reclassified after 1.1 ± 0.4 years according to the response to treatment into "favourable" (excellent/indeterminate) or "unfavorable" (biochemical/structural incomplete) responses. We evaluated participants' age, sex, tumor size, histological variants, multifocality, presence of vascular/lymphatic/perineural invasion, extrathyroidal extension, metastatic lymph nodes (LN), and distant metastasis. The effect of RAI therapy on the response range was analyzed in a given subgroup. RESULTS The mean age observed was 46.4 ± 12.0 years, and 89.7% were female. We noted 97.5% with papillary carcinoma, 27.8% with multifocality and 11.2% with LN metastasis. Although the majority of patients had a low risk of recurrence/persistence (78%), 75% were submitted to RAI therapy. Incomplete response (20.7%) was associated with multifocality (p=0.041; OR=1.619) and metastatic LN (p=0.041; OR=1.868). These variables were strongly correlated (p=0.000; OR=3.283). No cut-off of tumor size was identified as a predictor of incomplete response by the receiver operating curve analysis. RAI treatment did not influence the response of patients with multifocality or LN metastasis. CONCLUSION Multifocality and LN metastasis are independent risk factors for incomplete response in TMC patients and are strongly correlated. Additional RAI therapy was not associated with a more favorable response in these subgroups.
Collapse
Affiliation(s)
- Fernanda Nascimento Faro
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Vivian Roberta Ferreira Simões
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Gustavo Piech Ricardo
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Cristal Peters Cabral
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | | | - Nilza Maria Scalissi
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Adriano Namo Cury
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Marília Martins Marone
- Serviço de Medicina Nuclear, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Rosália do Prado Padovani
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil
- Serviço de Medicina Nuclear, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Carolina Ferraz
- Unidade de Doenças da Tireoide, Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brasil,
| |
Collapse
|
63
|
Hartl DM, Hadoux J, Garcia C, Ghuzlan AA, Guerlain J, Breuskin I, Baudin E, Lamartina L. [De-escalation strategies in differentiated thyroid cancer]. Bull Cancer 2021; 108:1132-1144. [PMID: 34649722 DOI: 10.1016/j.bulcan.2021.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/26/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Thyroid cancer runs the gamut from indolent micropapillary carcinoma to highly aggressive metastatic disease. Today, using prognostic algorithms, treatment and follow-up can be tailored to each patient in order to decrease overtreatment and over-medicalization of indolent disease. Active surveillance of papillary thyroid carcinoma less than 1cm avoids surgery and thyroid hormone replacement in a large proportion of patient whose tumors remain stable for years. Total thyroidectomy, once a dogma in the treatment of all thyroid cancer, is being supplanted by thyroid lobectomy for low-risk cancers, thereby decreasing the surgical risks involved and improving patients' quality of life. Indications for prophylactic central neck dissection, once mandatory, are now being adapted to the risk of cancer recurrence. Radioactive iodine therapy, also previously mandatory for all, is now only employed according to risk factors and expected outcomes. Follow-up is also being tailored to risk factors for recurrence, with less frequent visits and less use of ultrasound and scintigraphy. For more advanced disease, molecular therapies tailored to somatic mutations are opening opportunities for redifferentiation of aggressive tumors which become amenable to radioactive iodine therapy which carries fewer side effects than other systemic therapies. These advances in the management of thyroid cancer with a personalized approach and de-escalation of treatment and follow-up are improving the way we treat thyroid cancer, avoiding overtreatment and improving patients' quality of life.
Collapse
Affiliation(s)
- Dana M Hartl
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de chirurgie, service de cancérologie cervico-faciale, 114, rue Edouard-Vaillant, 94805 Villejuif, France.
| | - Julien Hadoux
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de médecine nucléaire et d'oncologie endocrinienne, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Camilo Garcia
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de médecine nucléaire et d'oncologie endocrinienne, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Abir Al Ghuzlan
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de biologie et de pathologie, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Joanne Guerlain
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de chirurgie, service de cancérologie cervico-faciale, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Ingrid Breuskin
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de chirurgie, service de cancérologie cervico-faciale, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Eric Baudin
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de médecine nucléaire et d'oncologie endocrinienne, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Livia Lamartina
- Gustave-Roussy Cancer Campus and Université Paris-Saclay, département de médecine nucléaire et d'oncologie endocrinienne, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| |
Collapse
|
64
|
Jin M, Kim HI, Ha J, Jeon MJ, Kim WG, Lim DJ, Kim TY, Chung JH, Shong YK, Kim TH, Kim WB. Tumor Volume Doubling Time in Active Surveillance of Papillary Thyroid Microcarcinoma: A Multicenter Cohort Study in Korea. Thyroid 2021; 31:1494-1501. [PMID: 34225475 DOI: 10.1089/thy.2021.0094] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Some papillary thyroid microcarcinomas (PTMCs) may progress with tumor enlargement or development of new lymph node (LN) metastasis during active surveillance (AS). This study evaluated the relevant predictors of disease progression, especially new cervical LN metastasis. Methods: This was a long-term follow-up study conducted using a previous multicenter cohort of AS in Korea. After excluding 54 (14.2%) patients with a short follow-up duration, 326 PTMC patients were evaluated for tumor kinetics, including changes in tumor volume (TV) and TV doubling time (TVDT). Results: During a median follow-up duration of 4.9 years, 17 (5.2%, 95% confidence intervals [CI] 2.7-7.6%) patients showed a maximal diameter increase of ≥3 mm after a median of 4.0 years follow-up, while 9 (2.8%, CI 1.0-4.5%) developed new LN metastasis after a median of 2.2 years follow-up. New cervical LN metastasis occurred exclusively of a maximal diameter increase of ≥3 mm. The prevalence of new development of LN metastasis was higher in patients with TVDT <5 years (7.4%) than in those with TV ≥50% (3.2%). Furthermore, only TVDT <5 years was significantly associated with LN metastasis (p = 0.002). In univariate and multivariate analyses, TVDT <5 years was an independent risk factor for disease progression with respect to new development of LN metastasis (hazard ratio [HR] = 6.51, CI 1.73-24.50; p = 0.002) and tumor enlargement (HR = 20.89, CI 5.78-75.48; p < 0.001). Finally, 86 (22.6%) patients underwent delayed surgery, and the most common reason was patient anxiety. Conclusions: TVDT <5 years is a predictor of disease progression during AS in terms of new LN metastasis development as well as tumor enlargement. Determination of TVDT in the early phase of AS could help in predicting disease progression, tailoring follow-up intensity of AS and in determining if early surgical intervention is needed.
Collapse
Affiliation(s)
- Meihua Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hye In Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Ji Jeon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Gu Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Jun Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Yong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Cancer, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Kee Shong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Cancer, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Bae Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
65
|
Abstract
Background: Thyroid cancer is a common malignancy whose detection has increased significantly in past decades. Most of the increased incidence is due to detection of early well-differentiated thyroid cancer, but the incidence of more advanced thyroid cancers has increased as well. Recent methodological advancements have allowed for a deep understanding of the molecular underpinnings of the various types of thyroid cancer. Summary: Thyroid cancers harbor a high frequency of potential druggable molecular alterations, including the highest frequency of oncogenic driver kinase fusions seen across all solid tumors. Analyses of poorly differentiated and anaplastic thyroid carcinoma confirmed that these tumors develop from more well-differentiated follicular-derived thyroid cancers through acquired additional mutations. The recognition of driver genomic alterations in thyroid cancers not only predicts tumor phenotype but also now can inform treatment approaches. Conclusions: Major progress in understanding the oncogenic molecular underpinnings across the array of thyroid cancers has led to considerable gains in gene-specific systemic therapies for many cancers. This article focuses on the molecular characteristics of aggressive follicular-derived thyroid cancers and medullary thyroid cancer and highlights advancements in treating thyroid cancer in the era of targeted therapy.
Collapse
MESH Headings
- Adenocarcinoma, Follicular/genetics
- Adenocarcinoma, Follicular/pathology
- Adenocarcinoma, Follicular/therapy
- Adenoma, Oxyphilic/genetics
- Adenoma, Oxyphilic/pathology
- Adenoma, Oxyphilic/therapy
- Carcinoma, Neuroendocrine/genetics
- Carcinoma, Neuroendocrine/pathology
- Carcinoma, Neuroendocrine/therapy
- Humans
- Immunotherapy/methods
- Immunotherapy/trends
- Molecular Targeted Therapy/methods
- Molecular Targeted Therapy/trends
- Mutation
- Oncogene Fusion
- Phosphotransferases/genetics
- Proto-Oncogene Proteins B-raf
- Thyroid Carcinoma, Anaplastic/genetics
- Thyroid Carcinoma, Anaplastic/pathology
- Thyroid Carcinoma, Anaplastic/therapy
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/pathology
- Thyroid Neoplasms/therapy
Collapse
Affiliation(s)
- Carrie C. Lubitz
- Department of Surgery; Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts, USA
| | - Peter M. Sadow
- Department of Pathology; Harvard Medical School, Boston, Massachusetts, USA
| | - Gilbert H. Daniels
- Department of Medicine; Harvard Medical School, Boston, Massachusetts, USA
- Department of Thyroid Unit; Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lori J. Wirth
- Department of Medicine; Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
66
|
Liu W, Yan X, Cheng R. The active surveillance management approach for patients with low risk papillary thyroid microcarcinomas: is China ready? Cancer Biol Med 2021; 19:j.issn.2095-3941.2021.0058. [PMID: 34553851 PMCID: PMC9196058 DOI: 10.20892/j.issn.2095-3941.2021.0058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/30/2021] [Indexed: 11/17/2022] Open
Abstract
Due to exponential increases in incidences, low risk papillary thyroid microcarcinoma (PTMC) has become a clinical and social issue in recent years. An active surveillance (AS) management approach is an alternative to immediate surgery for patients with low risk PTMC. With decreased doubts about the safety and validity due to evidence from a large number of studies, the AS approach has become increasingly popular worldwide. However, Chinese thyroid surgeons still lag behind other countries in their knowledge of clinical practices and research related to AS. To promote the implementation of AS in China, thyroid surgeons should understand the implications, advantages, and disadvantages of management approaches for AS, and should also consider the willingness of Chinese patients, the impact on the medical billing system, and the enthusiasm of doctors. Thus, a management approach for AS based on the Chinese population should be developed to reduce the risk of disease progression and enhance patient adherence. Herein, we summarize the recent research achievements and deficiencies in AS approaches, and describe the initial experiences regarding AS in the Chinese population, in order to assist Chinese thyroid surgeons in preparing for AS management in the era of PTMC precision medicine.
Collapse
Affiliation(s)
- Wen Liu
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, China
| | - Xuejing Yan
- Department of Management of Chronic Non-communicable Diseases, Yunnan Center for Disease Control and Prevention, Kunming 650034, China
| | - Ruochuan Cheng
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, China
| |
Collapse
|
67
|
Back K, Lee J, Choe JH, Kim JH, Oh YL, Kim JS. Total thyroidectomy can be overtreatment in cN1a papillary thyroid carcinoma patients whose tumor is smaller than 1 cm. Am J Surg 2021; 223:635-640. [PMID: 34446213 DOI: 10.1016/j.amjsurg.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/19/2021] [Accepted: 08/10/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association (ATA) guidelines recommend pursuing total thyroidectomy with therapeutic central lymph-node dissection (CND) in patients with clinically apparent nodal disease (cN1a), regardless of tumor size. The aim of this study was to investigate whether total thyroidectomy is necessary for thyroid papillary microcarcinoma (PTMC) patients with preoperative unilateral cN1a. METHODS This study included 295 papillary thyroid microcarcinoma patients who underwent total thyroidectomy with bilateral CND from January 2012 to June 2015. RESULTS The median follow-up time was 42.5 months. Locoregional recurrence (LRR) was observed in only two (0.9%) patients. Among 70 cN1a patients, only 19 (27.1%) were at intermediate risk for disease recurrence and required total thyroidectomy per the ATA guidelines. Lobectomy can be considered as a treatment option for the remaining patients (72.9%). CONCLUSIONS Our study showed that more than two-thirds of PTMC patients with clinical nodal disease who underwent total thyroidectomy and CND were actually lobectomy candidates. Total thyroidectomy as the first surgical option for cN1a, especially in PTMC patients, should be reconsidered.
Collapse
Affiliation(s)
- Kyorim Back
- Division of Endocrine Surgery, Department of Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, South Korea
| | - Jiyeon Lee
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
| | - Jun-Ho Choe
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
| | - Jung-Han Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
| | - Young Lyun Oh
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
| | - Jee Soo Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
| |
Collapse
|
68
|
Lončar I, van Dijk SPJ, Metman MJH, Lin JF, Kruijff S, Peeters RP, Engelsman AF, van Ginhoven TM. Active Surveillance for Papillary Thyroid Microcarcinoma in a Population with Restrictive Diagnostic Workup Strategies. Thyroid 2021; 31:1219-1225. [PMID: 33430696 DOI: 10.1089/thy.2020.0845] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: The worldwide incidence of papillary thyroid carcinoma (PTC) has increased. Efforts to reduce overtreatment follow two approaches: limiting diagnostic workup of low-risk thyroid nodules and pursuing active surveillance (AS) after diagnosis of microscopic PTC (mPTC). However, most studies on AS have been performed in countries with a relatively high proportion of overdiagnosis and thus incidental mPTC. The role of AS in a population with a restrictive diagnostic workup protocol for imaging and fine-needle aspiration remains unknown. Therefore, the aim of this study was to describe the proportion and characteristics of patients with mPTC in the Netherlands and to describe the potential candidates for AS in a situation with restrictive diagnostic protocols since 2007. Methods: All operated patients with an mPTC in the Netherlands between 2005 and 2015 were identified from the Netherlands Cancer Registry database. Three groups were defined: (Group 1) mPTC with preoperative distant or lymph node metastases, (Group 2) mPTC in pathology report after thyroid surgery for another indication, and (Group 3) patients with a preoperative high suspicious thyroid nodule or proven mPTC (Bethesda 5 or 6). Only patients in Group 3 were considered potential candidates for AS. Results: A total of 1018 mPTC patients were identified. Group 1 consisted of 152 patients with preoperatively discovered metastases. Group 2 consisted of 667 patients, of whom 16 (2.4%) had lymph node metastases. There were 199 patients in Group 3, of whom 27 (13.6%) had lymph node metastases. After initial treatment in Group 3, 3.5% (7/199) of the patients had recurrence. Conclusions: Restrictive diagnostic workup strategies of patients with small thyroid nodules lead to limited patients eligible for AS and a higher incidence of lymph node metastases. We believe that there is limited additive value for AS in countries with restrictive diagnostic workup guidelines such as in the Netherlands. However, if an mPTC is encountered, AS can be offered on an individual basis.
Collapse
Affiliation(s)
- Ivona Lončar
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sam P J van Dijk
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Madelon J H Metman
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jia Feng Lin
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Schelto Kruijff
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Robin P Peeters
- Department of Internal medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anton F Engelsman
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Tessa M van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| |
Collapse
|
69
|
Jeon MJ, Kim WG, Kim TY, Shong YK, Kim WB. Active Surveillance as an Effective Management Option for Low-Risk Papillary Thyroid Microcarcinoma. Endocrinol Metab (Seoul) 2021; 36:717-724. [PMID: 34379969 PMCID: PMC8419618 DOI: 10.3803/enm.2021.1042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Active surveillance (AS) for low-risk papillary thyroid microcarcinoma (PTMC) has been accepted worldwide as safe and effective. Despite the growing acceptance of AS in the management of low-risk PTMCs, there are barriers to AS in real clinical settings, and it is important to understand and establish appropriate AS protocol from initial evaluation to follow-up. PTMC management strategies should be decided upon after careful consideration of patient and tumor characteristics by a multidisciplinary team of thyroid cancer specialists. Patients should understand the risks and benefits of AS, participate in decision-making and follow structured monitoring strategies. In this review, we discuss clinical outcomes of AS from previous studies, optimal indications and follow-up strategies for AS, and unresolved questions about AS.
Collapse
Affiliation(s)
- Min Ji Jeon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Gu Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Yong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Bae Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
70
|
Shih P, Nickel B, Degeling C, Thomas R, Brito JP, McLeod DSA, McCaffery K, Carter SM. Terminology Change for Small Low-Risk Papillary Thyroid Cancer As a Response to Overtreatment: Results from Three Australian Community Juries. Thyroid 2021; 31:1067-1075. [PMID: 33238815 DOI: 10.1089/thy.2020.0694] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: The majority of small papillary thyroid cancers (sPTCs) are treated surgically, rather than by active surveillance. Patient and clinician preference for surgery may be partially driven by the use of cancer terminology. Some experts propose that changing terminology would better communicate the indolent nature of sPTCs and improve uptake of active surveillance. Others argue that terminology that includes "cancer" correctly reflects the biological nature of these tumors. The views of informed lay publics can provide value-based perspectives on complex issues and guide policy discussions. Methods: We recruited 40 people for three community juries, held in Sydney, Wodonga, and Cairns, Australia. Participants were of diverse backgrounds and ages, recruited through random digit dialing and a topic-blinded social media strategy. Juries were informed about thyroid cancer, overdiagnosis, and overtreatment, and heard arguments for and against terminology change before deliberation. The deliberative process in Jury 1 led to a refinement of jury charge, the updated version that was then used in Juries 2 and 3. Results: Jury 1 favored no terminology change, and Juries 2 and 3 were divided on the topic. Key reasons for opposing terminology change included a strong desire to retain terminology that aligns with the pathological definition of cancer, and to avoid even a minimal risk of harm that could arise if patients became complacent in follow-up. Key reasons to support terminology change included a desire to reduce psychological distress, stigma, and discrimination associated with a cancer diagnosis, and an argument that terminology change may be a more effective trigger for health system reform compared with other options. The juries unanimously recommended community education and health system reforms to reduce harms of overtreatment, and expressed an expectation that clinicians and researchers reach agreement on clinical guidelines to promote better uptake of active surveillance. Conclusions: The conceptual tension between a pathological and an outcome-based understanding of cancer was apparent in deliberation. This highlights an ongoing challenge for those advocating changing disease terminology. Regardless of action on terminology, jurors shared a strong expectation that practical changes would be made to respond to the harms of overtreatment.
Collapse
Affiliation(s)
- Patti Shih
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, and Wiser Healthcare, University of Wollongong, Wollongong, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, and Wiser Healthcare, University of Wollongong, Wollongong, Australia
| | - Rae Thomas
- Institute for Evidence-Based Healthcare, and Wiser Healthcare, Bond University, Gold Coast, Australia
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald S A McLeod
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
- Department of Diabetes and Endocrinology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stacy M Carter
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, and Wiser Healthcare, University of Wollongong, Wollongong, Australia
| |
Collapse
|
71
|
Nagaoka R, Ebina A, Toda K, Jikuzono T, Saitou M, Sen M, Kazusaka H, Matsui M, Yamada K, Mitani H, Sugitani I. Multifocality and Progression of Papillary Thyroid Microcarcinoma During Active Surveillance. World J Surg 2021; 45:2769-2776. [PMID: 34100116 DOI: 10.1007/s00268-021-06185-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prospective trials of active surveillance (AS) have shown low rates of progression in low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0). However, the significance of multifocality as a prognostic factor remains controversial. METHODS Data from 571 patients (mean age, 53.1 years; 495 females) who underwent AS were reviewed. PTMC was unifocal in 457 patients (80.0%) and multifocal in 114 patients (20.0%), with 2-5 lesions each (261 tumors in total). Tumor progression was defined as tumor size enlargement ≥ 3 mm and/or development of clinically evident lymph node metastasis (LNM). RESULTS After a mean duration of AS of 7.6 years, 53 patients (9.3%) showed tumor enlargement and 8 patients (1.4%) developed LNM. The 10-year progression rate was 13.1%. Age, sex, and calcification pattern did not differ significantly between uni- and multifocal diseases. However, anti-thyroglobulin antibody and/or anti-thyroid peroxidase antibody was more frequently positive with multifocal PTMCs (46.7%) than with unifocal disease (34.4%, p = 0.024). Patients with uni- and multifocal disease showed no significant differences in 10-year rate of tumor enlargement (11.4% vs. 14.8%), LNM development (1.1% vs. 2.4%), or progression (12.4% vs 15.9%). Multivariate analysis of predictors for progression showed multifocality was not a significant risk factor (odds ratio, 1.45; 95% confidence interval, 0.79-2.54; p = 0.22). Eventually, 9 patients (7.9%) with multifocal PTMCs underwent surgery and 7 needed total thyroidectomy, although 7 still showed T1N0M0 low-risk cancer. CONCLUSIONS Even patients with multiple PTMCs (T1amN0M0) are good candidates for AS. Many patients can avoid total thyroidectomy and subsequent surgical complications.
Collapse
Affiliation(s)
- Ryuta Nagaoka
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Aya Ebina
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.,Division of Head and Neck, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Kazuhisa Toda
- Division of Head and Neck, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tomoo Jikuzono
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Marie Saitou
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Masaomi Sen
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroko Kazusaka
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Mami Matsui
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Keiko Yamada
- Division of Ultrasonography, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiroki Mitani
- Division of Head and Neck, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.,Division of Head and Neck, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| |
Collapse
|
72
|
Fiorentino V, Dell’ Aquila M, Musarra T, Martini M, Capodimonti S, Fadda G, Curatolo M, Traini E, Raffaelli M, Lombardi CP, Pontecorvi A, Larocca LM, Pantanowitz L, Rossi ED. The Role of Cytology in the Diagnosis of Subcentimeter Thyroid Lesions. Diagnostics (Basel) 2021; 11:diagnostics11061043. [PMID: 34204172 PMCID: PMC8230300 DOI: 10.3390/diagnostics11061043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023] Open
Abstract
Thyroid nodules are common and typically detected by palpation and/or ultrasound (US). Guidelines have defined the management of large nodules, but controversy exists regarding nodules ≤ 1 cm. We evaluated a cohort of patients with subcentimeter nodules to determine their rate of malignancy (ROM). A total of 475 thyroid FNAs of lesions ≤ 1 cm with available follow-up were identified from January 2015–December 2019. For comparative analysis, we added a control series of 606 thyroid lesions larger than 1 cm from the same reference period. All aspirates were processed with liquid-based cytology and classified according to The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). Subcentimeter nodules were stratified as 35 category I—non-diagnostic cases (ND; 7.3%), 144 category II—benign lesions (BL; 30.3%), 12 category III—atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS; 2.5%), 12 category IV—follicular neoplasm/suspicious for follicular neoplasm (FN/SFN; 2.5%), 124 category V—suspicious for malignancy (SM; 26.1%), and 148 category VI—positive for malignancy (PM; 31.1%). A total of 307 cases (64.6%) underwent subsequent surgery. Only one ND and three BLs had a malignant outcome. ROM for indeterminate lesions (III + IV) was 3.2%; with 1.6% for category III and 3.2% for category IV. ROM for the malignant categories (V + VI) was 88.2%. The control cohort of lesions demonstrated a higher number of benign histological diagnoses (67.3%). We documented that 57.2% of suspected subcentimeter lesions were malignant, with a minor proportion that belonged in indeterminate categories. There were very few ND samples, suggesting that aspirates of subcentimeter lesions yield satisfactory results. Suspected US features in subcentimeter lesions should be evaluated and followed by an interdisciplinary team for appropriate patient management.
Collapse
Affiliation(s)
- Vincenzo Fiorentino
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Marco Dell’ Aquila
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Teresa Musarra
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Maurizio Martini
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Sara Capodimonti
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Guido Fadda
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Mariangela Curatolo
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Emanuela Traini
- Division of Endocrine Surgery, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (E.T.); (M.R.); (C.P.L.)
| | - Marco Raffaelli
- Division of Endocrine Surgery, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (E.T.); (M.R.); (C.P.L.)
| | - Celestino Pio Lombardi
- Division of Endocrine Surgery, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (E.T.); (M.R.); (C.P.L.)
| | - Alfredo Pontecorvi
- Division of Endocrinology-Fondazione, Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy;
| | - Luigi Maria Larocca
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
| | - Liron Pantanowitz
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, MI 48103, USA;
| | - Esther Diana Rossi
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, 00168 Rome, Italy; (V.F.); (M.D.A.); (T.M.); (M.M.); (S.C.); (G.F.); (M.C.); (L.M.L.)
- Correspondence: ; Tel.: +39-06-3015-4433
| |
Collapse
|
73
|
Ha EJ, Na DG, Baek JH. Korean Thyroid Imaging Reporting and Data System: Current Status, Challenges, and Future Perspectives. Korean J Radiol 2021; 22:1569-1578. [PMID: 34132081 PMCID: PMC8390814 DOI: 10.3348/kjr.2021.0106] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 12/18/2022] Open
Abstract
The Korean Thyroid Imaging Reporting and Data System (K-TIRADS) is an ultrasound-based risk stratification system for thyroid nodules that has been widely applied for the diagnosis and management of thyroid nodules since 2016. This review article provides an overview of the use of the K-TIRADS compared with other risk stratification systems. Moreover, this review describes the challenges in the clinical application of the K-TIRADS, as well as future development directions toward the personalized management of patients with thyroid nodules.
Collapse
Affiliation(s)
- Eun Ju Ha
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Dong Gyu Na
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
74
|
Cohen O, Blank A, Meiersdorf S, Hod K, Gabay S, Guindy M, Khafif A. Impact of high-quality ultrasound following community ultrasound on surgical planning and active surveillance in patients with thyroid cancer. Clin Endocrinol (Oxf) 2021; 94:990-997. [PMID: 33448046 DOI: 10.1111/cen.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Ultrasound (US) has gained a critical role in thyroid cancer treatment planning, yet it is limited by its user-dependent nature. The aim of this study was to compare the impact of US performed by radiologists specializing in thyroid imaging (hqUS) and US performed by radiographers in the community (cUS) on treatment plans of patients diagnosed with well-differentiated thyroid malignancies. DESIGN Retrospective single-centre case series with chart review. PATIENTS Patients diagnosed with thyroid cancer during 2017-2019 that had cUS followed by hqUS pre-operative counselling were included in this retrospective analysis. MEASUREMENTS The main outcome was management alternations based on one of two sonographic measures: (1) extrathyroid extension (ETE); (2) The presence of central or lateral lymph nodes suspicious for metastases (LNM), which were compared with the final pathology. RESULTS Among those with non-recurrent tumour (n = 76), ETE was reported 22 times more by hqUS compared with cUS (28.9% vs 1.3%, P < .001). Central and lateral LNM were reported approximately 6.5 and 1.5 times more by hqUS, respectively (25.0% vs 3.9%, P < .001 and 15.8% vs., 9.2%, P = .227, respectively). Overall, hqUS altered the initial treatment plan of 35.5% of patients. In 27.6% of patients, hqUS and its subsequent surgery resulted in a change to the patients' 2015 ATA risk stratification system. In 40% of patients with microcarcinomas, hqUS findings mandated surgery according to findings that were not reported by cUS. False-positive rate was 5.2%. CONCLUSIONS Community US may under-diagnose important features such as ETE and LNM, leading to potential under-treatment in many patients. High-quality US of the neck should be considered in patients with differentiated thyroid carcinoma before making any treatment decisions.
Collapse
Affiliation(s)
- Oded Cohen
- A.R.M. Center for Otolaryngology Head and Neck Surgery, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Annat Blank
- A.R.M. Center for Otolaryngology Head and Neck Surgery, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Shmuel Meiersdorf
- A.R.M. Center for Otolaryngology Head and Neck Surgery, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Keren Hod
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Academy and Research, Assuta Medical Centers, Tel Aviv, Israel
| | - Shiran Gabay
- A.R.M. Center for Otolaryngology Head and Neck Surgery, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Michal Guindy
- Department of Radiology, Assuta Medical Centers, Tel Aviv, Israel
| | - Avi Khafif
- A.R.M. Center for Otolaryngology Head and Neck Surgery, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| |
Collapse
|
75
|
Pagano L, Falco EC, Bisceglia A, Gambella A, Rossetto R, Garberoglio S, Maletta F, Pacchioni D, Garberoglio R, Ghigo E, Papotti MG. Retrospective analysis of the ultrasound features of resected thyroid nodules. Endocrine 2021; 72:486-494. [PMID: 33006725 DOI: 10.1007/s12020-020-02495-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/07/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE Several ultrasound (US) risk stratification systems (US-RSSs) have been proposed to stratify the risk of malignancy (ROM) of thyroid nodules. This risk might be overestimated due to selection bias and comparison with the cytological report alone. Our study aimed to compare ROM and diagnostic performance of three guidelines (ATA, AACE/ACE/AME, EUTIRADS) and evaluate the changes in unnecessary biopsy according to the nodule size cutoff for biopsy, using histology as gold standard. METHODS This retrospective observational study included 146 consecutive patients who underwent surgery after US and cytological characterization. We analyzed the effectiveness and accuracy of three US-RSSs. RESULTS 46.6% of nodules were diagnosed as malignant. Applying US-RSS, the percentage of nodules that should have been analyzed by biopsy was 84.25% with ATA, 69.86% with EUTIRADS and 64.38% with AACE/ACE/AME systems. The ROM was 94.9%, 86.0%, 87.0% for high-risk category, 36.4%, 32.0%, 35.4% for intermediate-risk category and 22.9%, 0.0%, 22.9% for low-risk category by ATA, AACE/ACE/AME and EUTIRADS systems, respectively. EUTIRADS and AACE/ACE/AME systems were more accurate in differentiating malignant from benign cases. ATA score was the more sensitive US-RSS to identify malignant tumors within the high-risk category. About the unnecessary biopsies, in the intermediate-risk category, the application of the size criterion helps to increase specificity in all systems. CONCLUSIONS The US categorization of low and high-risk thyroid nodules using current US-RSSs helps alone to determine the optimal treatment option. Nodule size remains relevant to recommend biopsy for the intermediate-risk category.
Collapse
Affiliation(s)
- Loredana Pagano
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Alessandro Bisceglia
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alessandro Gambella
- Pathology Unit, City of Health and Science University Hospital, Turin, Italy
| | - Ruth Rossetto
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Sara Garberoglio
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Maletta
- Pathology Unit, City of Health and Science University Hospital, Turin, Italy
| | - Donatella Pacchioni
- Pathology Unit, City of Health and Science University Hospital, Turin, Italy
| | - Roberto Garberoglio
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Mauro Giulio Papotti
- Pathology Unit, City of Health and Science University Hospital, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| |
Collapse
|
76
|
Jensen CB, Saucke MC, Pitt SC. Active surveillance for thyroid Cancer: a qualitative study of barriers and facilitators to implementation. BMC Cancer 2021; 21:471. [PMID: 33910527 PMCID: PMC8080390 DOI: 10.1186/s12885-021-08230-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/08/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The 2015 American Thyroid Association guidelines supported active surveillance (AS) as a strategy for managing select low-risk thyroid cancers. Data examining physicians' attitudes about the acceptability of this option are limited. This study aimed to characterize the barriers and facilitators to implementing AS as perceived by practicing endocrinologists and surgeons in the United States. METHODS We conducted 24 semi-structured interviews probing physicians' attitudes toward AS for patients with small, low-risk thyroid cancer. We used deductive content analysis guided by a well-known model of guideline implementation. Analysis characterized concepts and themes related to AS implementation as physician, guideline, or external factors. We performed member checking to validate results. RESULTS The most prominent barriers to AS were related to physician factors, although guideline-specific and external barriers were also observed. Physician attitudes towards AS comprised the majority of physician-related barriers, while lack of knowledge about the guideline was also discussed. Participants' concerns about the potential negative outcomes resulting from observing a cancer were notable as were the lack of confidence in performing and offering surveillance. Beliefs about patient expectations and lack of knowledge about the guideline were also identified as barriers to offering surveillance. Guideline-specific and external barriers included the vagueness of surveillance protocols, lack of data supporting active surveillance, and societal beliefs about cancer. Facilitators of active surveillance included patients' desire to avoid surgery and shared decision-making. CONCLUSIONS Barriers and facilitators of active surveillance for low-risk thyroid cancers exist at multiple levels. Strategies to increase adoption of active surveillance should focus on physicians' attitudes, patient expectations, data supporting surveillance outcomes, and promoting societal-level acceptance of surveillance.
Collapse
Affiliation(s)
- Catherine B Jensen
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Megan C Saucke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Susan C Pitt
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., CSC H4/724, Madison, WI, 53792-7375, USA.
| |
Collapse
|
77
|
Jeon MJ, Kang YE, Moon JH, Lim DJ, Lee CY, Lee YS, Kim SW, Kim MH, Kim BH, Kang HC, Shong M, Cho SW, Kim WB. Protocol for a Korean Multicenter Prospective Cohort Study of Active Surveillance or Surgery (KoMPASS) in Papillary Thyroid Microcarcinoma. Endocrinol Metab (Seoul) 2021; 36:359-364. [PMID: 33752303 PMCID: PMC8090471 DOI: 10.3803/enm.2020.890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A Korean Multicenter Prospective cohort study of Active Surveillance or Surgery (KoMPASS) for papillary thyroid microcarcinomas (PTMCs) has been initiated. The aim is to compare clinical outcomes between active surveillance (AS) and an immediate lobectomy for low-risk PTMCs. We here outline the detailed protocol for this study. METHODS Adult patients with a cytopathologically confirmed PTMC sized 6.0 to 10.0 mm by ultrasound (US) will be included. Patients will be excluded if they have a suspicious extra-thyroidal extension or metastasis of a PTMC or multiple thyroid nodules or other thyroid diseases which require a total thyroidectomy. Printed material describing the prognosis of PTMCs, and the pros and cons of each management option, will be provided to eligible patients to select their preferred intervention. For the AS group, thyroid US, thyroid function, and quality of life (QoL) parameters will be monitored every 6 months during the first year, and then annually thereafter. Disease progression will be defined as a ≥3 mm increase in maximal diameter of a PTMC, or the development of new thyroid cancers or metastases. If progression is detected, patients should undergo appropriate surgery. For the lobectomy group, a lobectomy with prophylactic central neck dissection will be done within 6 months. After initial surgery, thyroid US, thyroid function, serum thyroglobulin (Tg), anti-Tg antibody, and QoL parameters will be monitored every 6 months during the first year and annually thereafter. Disease progression will be defined in these cases as the development of new thyroid cancers or metastases. CONCLUSION KoMPASS findings will help to confirm the role of AS, and develop individualized management strategies, for low-risk PTMCs.
Collapse
Affiliation(s)
- Min Ji Jeon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Yea Eun Kang
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon,
Korea
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Dong Jun Lim
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chang Yoon Lee
- Department of Radiology, National Cancer Center, Goyang,
Korea
| | - Yong Sang Lee
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul,
Korea
| | - Sun Wook Kim
- Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Min-Hee Kim
- Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Bo Hyun Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan,
Korea
| | - Ho-Cheol Kang
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun,
Korea
| | - Minho Shong
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon,
Korea
| | - Sun Wook Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Won Bae Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| |
Collapse
|
78
|
Kwon O, Lee S, Bae JS, Jung CK. Thyroid Isthmusectomy with Prophylactic Central Compartment Neck Dissection is a Feasible Approach for Papillary Thyroid Cancer on the Isthmus. Ann Surg Oncol 2021; 28:6603-6612. [PMID: 33768393 DOI: 10.1245/s10434-021-09833-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The treatment for papillary thyroid cancer (PTC) has become more conservative, but still no specific guidelines exist for managing isthmic PTC. This study analyzed the outcomes from isthmusectomy in single isthmic PTC and compared it with those for patients who previously had undergone a total thyroidectomy. METHODS An isthmusectomy with prophylactic central compartment neck dissection (pCCND) was planned for a single isthmic PTC between 2014 and 2018 (isthmusectomy group). For cases with gross extrathyroidal extension (ETE) or multiple nodal metastasis, the procedure was converted to a total thyroidectomy. The study analyzed the characteristics and outcomes of the isthmusectomy group. Additionally, the results were compared with those of the isthmusectomy-feasible group who met the eligibility criteria for isthmusectomy among total thyroidectomies performed between 2009 and 2013. RESULTS Of the 90 patients in the isthmusectomy group, 81 received isthmusectomy and 9 had conversion to a total thyroidectomy. Microcarcinoma occurred in 72 cases and gross ETE in 3 cases. One patient showed occult satellite cancer, and seven patients showed more than five metastatic nodes. Transient hypocalcemia developed in five and patients and permanent hypocalcemia in one patient with total thyroidectomy. Of 46 patients who began hormone replacement postoperatively, 13 completely stopped taking medication during the follow-up period. Metachronous PTC was diagnosed for one patient 12 months after isthmusectomy. The isthmusectomy group and the isthmusectomy-feasible group showed similar clinicopathologic properties including multifocality, ETE, and nodal metastasis. However, the isthmusectomy group showed significantly less transient or permanent hypocalcemia and thyroid hormone dependency. CONCLUSIONS Isthmusectomy with pCCND may be a feasible alternative for properly selected isthmic PTC, resulting in a better quality of life than total thyroidectomy.
Collapse
Affiliation(s)
- Ohjoon Kwon
- Department of Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sohee Lee
- Department of Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Ja Seong Bae
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
79
|
Pitt SC, Yang N, Saucke MC, Marka N, Hanlon B, Long KL, McDow AD, Brito JP, Roman BR. Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey. J Clin Endocrinol Metab 2021; 106:e1728-e1737. [PMID: 33373458 PMCID: PMC7993571 DOI: 10.1210/clinem/dgaa942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. OBJECTIVE This work aimed to understand factors associated with the adoption of AS. METHODS We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases). RESULTS The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS. CONCLUSION Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.
Collapse
Affiliation(s)
- Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Correspondence: Susan C. Pitt, MD, MPHS, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, CSC H4/721, Madison, WI 53792, USA.
| | - Nan Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bret Hanlon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristin L Long
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexandria D McDow
- Division of Surgery Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - J P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin R Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
80
|
Meng C, Wang W, Zhang Y, Li X. The influence of nodule size on the aggressiveness of thyroid carcinoma varies with patient's age. Gland Surg 2021; 10:961-972. [PMID: 33842240 DOI: 10.21037/gs-20-747] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Thyroid nodule size is one of the key parameters that determines the operative approach for thyroid carcinoma. It is necessary to evaluate the influence of nodule size on the aggressiveness of thyroid carcinoma. The eighth edition of staging system has updated the prognostic age cutoff from 45 to 55 years old. It is needed to re-evaluate the difference in aggressiveness of thyroid carcinoma between younger (<55 years old) and older (≥55 years old) patients. Importantly, whether the influence of nodule size on the aggressiveness of thyroid carcinoma varies according to the new age stratification remains to be explored. Methods Medical records from patients were retrospectively reviewed. Patients with a documented thyroid ultrasonography (US), US-guided fine needle aspiration (FNA) and histopathology were included. The risks of unfavorable events such as central-compartment neck lymph node (CLN) metastasis, lateral-compartment neck lymph node (LLN) metastasis and gross extrathyroidal extension (ETE) were analyzed in four subsets of patients according to size and age. Results Large nodule size (≥10 mm) significantly increased the frequencies of CLN metastasis, LLN metastasis and gross ETE (P<0.05). The frequency of CLN metastasis was significantly higher in younger patients compared with that in older ones. Logistic regression analysis recognized large nodule size as an independent risk factor for all CLN metastasis (OR: 3.304, 95% CI: 2.473-4.415), LLN metastasis (OR: 9.673, 95% CI: 4.542-20.597), and gross ETE (OR: 2.430, 95% CI: 1.508-3.916). Secondly, in younger patients, frequencies of all CLN metastasis, LLN metastasis and gross ETE were significantly higher in nodules ≥10 mm than in nodules <10 mm (P<0.001). However, in older patients, no significant difference was found in the frequencies of LLN metastasis or gross ETE between nodules <10 mm and ≥10 mm. Logistic regression analysis showed, in younger patients, large nodule size was an independent risk factor for all CLN metastasis (OR: 3.241, 95% CI: 2.393-4.389), LLN metastasis (OR: 12.495, 95% CI: 5.281-29.562), and gross ETE (OR: 2.591, 95% CI: 1.519-4.419), while in older patients large nodule size was recognized as an independent risk factor for CLN metastasis (OR: 3.924, 95% CI: 1.413-10.899) but not for LLN metastasis or gross ETE. Conclusions Large nodule size is significantly related to high aggressiveness of thyroid carcinoma. The correlation between large nodule size and high aggressiveness varies according to patient's age, indicating that the presence of unfavorable events has different clinical significance for patients of varied ages. These findings contribute to accurately assessing the prognosis of individual patient and developing a better management strategy.
Collapse
Affiliation(s)
- Chaoyang Meng
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,Xiangya School of Medicine, Central South University, Changsha, China
| | - Wenlong Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yuezhong Zhang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Xinying Li
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
81
|
Qian K, An N, Zhang M, Guo K, Chen L, Xiang J, Wu Y, Wang J, Guan H, Wang Z. Choosing Optimal Microcarcinoma Patients for Active Surveillance Study (Compass): Effectiveness Evaluation of a Preoperative Clinical Framework. Endocr Pract 2021; 27:912-917. [PMID: 33610810 DOI: 10.1016/j.eprac.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/27/2021] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Active surveillance (AS) is a management alternative for patients with low-risk papillary thyroid microcarcinoma (PTMC). To decide the best candidates for AS, clinicians can use a framework to classify PTMC patients as ideal, appropriate, or inappropriate. This study aimed to explore the correlation between the framework categories and surgical pathology. METHODS This multicenter retrospective study was conducted between 2014 and 2016. We included 1997 patients who underwent thyroid surgery for the first time due to suspected PTMC and were confirmed as PTMC by postoperative pathology. The consistency of modified preoperative risk stratification and the pathologic condition were evaluated using a consistency ratio and the Kappa coefficient. Stratified analysis was also performed to test consistency in different age groups. RESULTS Based on the decision-making framework, 558 (27.9%) patients could receive AS while 810 (40.6%) patients did not require immediate surgery according to the actual postoperative pathology. The sensitivity, false-positive rate, specificity, false-negative rate, and consistency rate were 82.39%, 56.91%, 43.09%, 17.61%, and 66.45%, respectively. The Kappa value was 0.268. Stratified analysis showed that the sensitivity was 87.7% among patients aged 18 to 59 years. In the group aged ≥60 years, the specificity was up to 87.5%, but the sensitivity was low. CONCLUSION The results of the modified risk-stratified clinical decision-making framework did not have a high consistency with the postoperative results. However, the framework showed a good effect in selecting patients for immediate surgery in the younger group and patients for AS in the older group.
Collapse
Affiliation(s)
- Kai Qian
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Ning An
- Department of Head and Neck Surgery, Gansu Provincial Cancer Hospital, Lanzhou, China
| | - Mengmeng Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Department of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Kai Guo
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Lili Chen
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China; Department of Facial Plastic and Reconstructive Surgery, Eye & ENT Hospital, Fudan University, Shanghai, China
| | - Jun Xiang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Yi Wu
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Jun Wang
- Department of Head and Neck Surgery, Gansu Provincial Cancer Hospital, Lanzhou, China.
| | - Haixia Guan
- Department of Endocrinology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Zhuoying Wang
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China.
| |
Collapse
|
82
|
Sugitani I, Ito Y, Takeuchi D, Nakayama H, Masaki C, Shindo H, Teshima M, Horiguchi K, Yoshida Y, Kanai T, Hirokawa M, Hames KY, Tabei I, Miyauchi A. Indications and Strategy for Active Surveillance of Adult Low-Risk Papillary Thyroid Microcarcinoma: Consensus Statements from the Japan Association of Endocrine Surgery Task Force on Management for Papillary Thyroid Microcarcinoma. Thyroid 2021; 31:183-192. [PMID: 33023426 PMCID: PMC7891203 DOI: 10.1089/thy.2020.0330] [Citation(s) in RCA: 179] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: The question of how to manage patients with low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0) has recently become an important clinical issue. Two Japanese centers have conducted prospective clinical trials of active surveillance (AS) for low-risk PTMC since the 1990s, reporting favorable outcomes. This policy has thus seen gradual adoption worldwide to avoid overtreatment. Not all PTMCs are suitable for AS, however, and many physicians still hesitate to apply the management policy in daily clinical practice. A task force on management for PTMC created by the Japan Association of Endocrine Surgery collected and analyzed bibliographic evidence and has produced the present consensus statements regarding indications and concrete strategies for AS to facilitate the management of adult patients diagnosed with low-risk PTMC. Summary: These statements provide indications for AS in adult patients with T1aN0M0 low-risk PTMC. PTMCs with clinical lymph node metastasis, distant metastasis, recurrent laryngeal nerve (RLN) paralysis due to carcinoma invasion, or protrusion into the tracheal lumen warrant immediate surgery. Tumors suspected of aggressive subtypes on cytology are recommended for immediate surgery. Immediate surgery is also recommended for tumors adherent to the trachea or located along the course of the RLN. Practical strategies include diagnosis, decision-making, follow-up, and monitoring related to the implementation of AS. The rate of low-risk PTMC progression is lower in older patients. However, we recommend continuing AS as long as circumstances permit. Future tasks in optimizing management for low-risk PTMC are also described, including molecular markers and patient-reported outcomes. Conclusions: An appropriate multidisciplinary team is necessary to accurately evaluate primary tumors and lymph nodes at the beginning of and during AS, and to adequately reach a shared-decision with individual patients. If appropriately applied, AS of low-risk PTMC is a safe management strategy offering favorable outcomes and preserves quality of life at low cost.
Collapse
Affiliation(s)
- Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
- Address correspondence to: Iwao Sugitani, MD, PhD, Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Yasuhiro Ito
- Department of Surgery, Kuma Hospital, Kobe, Japan
| | - Dai Takeuchi
- Department of Breast and Endocrine Surgery, Nagoya University, Nagoya, Japan
| | | | - Chie Masaki
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | - Hisakazu Shindo
- Department of Surgery, Yamashita Thyroid Hospital, Fukuoka, Japan
| | - Masanori Teshima
- Department of Otolaryngology, Head and Neck Surgery, Kobe University, Kobe, Japan
| | - Kazuhiko Horiguchi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University, Maebashi, Japan
| | - Yusaku Yoshida
- Department of Breast and Endocrine Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshiharu Kanai
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | | | | | - Isao Tabei
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | | |
Collapse
|
83
|
Roman BR, Gupta P, Tuttle RM, Morris LGT, Lohia S. Assessing the Number of Candidates There Are for Active Surveillance of Low-risk Papillary Thyroid Cancers in the US. JAMA Otolaryngol Head Neck Surg 2021; 146:585-586. [PMID: 32379291 DOI: 10.1001/jamaoto.2020.0523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Piyush Gupta
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shivangi Lohia
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
84
|
Update on ACR TI-RADS: Successes, Challenges, and Future Directions, From the AJR Special Series on Radiology Reporting and Data Systems. AJR Am J Roentgenol 2021; 216:570-578. [PMID: 33112199 DOI: 10.2214/ajr.20.24608] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) is an ultrasound-based risk stratification system (RSS) for thyroid nodules that was released in 2017. Since publication, research has shown that ACR TI-RADS has a higher specificity than other RSSs and reduces the number of unnecessary biopsies of benign nodules compared with other systems by 19.9-46.5%. The risk of missing significant cancers using ACR TI-RADS is mitigated by the follow-up recommendations for nodules that do not meet criteria for biopsy. In practice, after a nodule's ultrasound features have been enumerated, the ACR TI-RADS points-based approach leads to clear management recommendations. Practices seeking to implement ACR TI-RADS must engage their radiologists in understanding how the system addresses the problems of thyroid cancer overdiagnosis and unnecessary surgeries by reducing unnecessary biopsies. This review compares ACR TI-RADS to other RSSs and explores key clinical questions faced by practices considering its implementation. We also address the challenge of reducing interobserver variability in assigning ultrasound features. Finally, we highlight emerging imaging techniques and recognize the ongoing international effort to develop a system that harmonizes multiple RSSs, including ACR TI-RADS.
Collapse
|
85
|
Masaki C, Sugino K, Ito K. Clinical management of low-risk papillary thyroid microcarcinoma. Minerva Endocrinol (Torino) 2021; 46:413-427. [PMID: 33435642 DOI: 10.23736/s2724-6507.20.03283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Papillary thyroid microcarcinoma (PTMC) is well known to have an indolent nature with an excellent prognosis. Surgery has been the standard treatment during the past several decades, with metastasis or recurrence being exceedingly rare. Active surveillance (AS) is a new risk-adapted approach alternative to surgery that involves just watching, but not giving any treatment unless needed, not addressing the tumor itself. The patients for whom AS is adopted spend their time "with tumors." In follow-up, it is possible that alarming factors such as tumor progression appear, causing anxiety about progression. Furthermore, endless follow-up is needed. However, considering the indolent nature and unfavorable events such as surgical complications caused by surgery, AS is a good management plan for selected PTMC patients. Decision making balancing between the prognosis and unfavorable events is needed for the treatment plan. Consideration of the factors and timing of surgical conversion is also needed. In this review article, how AS should be adopted as a new management option that is an alternative to surgery, which has been the absolute choice of treatment up to recently, is discussed. Concurrently, the characteristics of the two treatment strategies are reviewed, while introducing the background that explains how AS came to attention.
Collapse
Affiliation(s)
- Chie Masaki
- Department of Surgery, Ito Hospital, Tokyo, Japan -
| | | | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo, Japan
| |
Collapse
|
86
|
Czarniecka A, Zeman M, Wozniak G, Maciejewski A, Stobiecka E, Chmielik E, Oczko-Wojciechowska M, Krajewska J, Handkiewicz-Junak D, Jarzab B. Therapeutic Strategy in Low-Risk Papillary Thyroid Carcinoma - Long-Term Results of the First Single-Center Prospective Non-Randomized Trial Between 2011 and 2015. Front Endocrinol (Lausanne) 2021; 12:718833. [PMID: 34552559 PMCID: PMC8450606 DOI: 10.3389/fendo.2021.718833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Optimal therapeutic strategy in low advanced papillary thyroid carcinoma (PTC) is still a matter of debate. The management differs depending on the country. A prospective non-randomized study was performed to evaluate whether less extensive surgery could be a safe, acceptable, and sufficient therapeutic option in PTC cT1N0M0 patients. The present paper summarizes the results of over a 5-year follow-up. MATERIAL Our prospective group (PG) treated between 2011 and 2015 consisted of 139 patients with cT1aN0M0 PTC who underwent lobectomy (LT) as initial surgical treatment (PGcT1aN0M0 group) and 102 cT1bN0M0 patients in whom total thyroidectomy (TT) with unilateral central neck dissection (CND) was performed (PGcT1bN0M0). PG was compared with the retrospective group (RG) of patients who underwent TT with bilateral CND between 2004 and 2006: 103 cT1aN0M0 patients (RGcT1aN0M0) and 91cT1bN0M0 (RGcT1bN0M0). The risks of reoperation, cancer relapse and postoperative complications were analyzed. RESULTS Only 12 cT1aN0M0 patients (7.6%) withdrew from the trial and underwent TT with bilateral CND. Over 90% of patients accepted less extensive surgery. In 4 cT1aN0M0 cases, TT with CND was performed due to lymph node metastases found intraoperatively. The initial clinical stage according to the TNM/AJCC 7th edition was confirmed histologically in 77% of cases in PGT1aN0M0 and in 72% in PGT1bN0M0, respectively. 24 PGcT1aN0M0 patients were reoperated on. In this group, cancer lesions in the postoperative histological specimens were found in 8 cases (32%). Five-year disease-free survival (DFS) was excellent. However, no statistically significant differences were found between PG and RG groups (99.3% in PGcT1aN0M0 and 99.0%, in RGcT1aN0M0; p = 0.41 and 98%, in PGcT1bN0M0 and 94.4% in RGcT1bN0M0; p=0.19). No significant differences were observed in the incidence of early paresis of the recurrent laryngeal nerves between PG and RG. However, as predicted, LT completely eliminated the risk of postoperative hypoparathyroidism. SUMMARY The results of the prospective clinical trial confirm that less extensive surgery in adequately selected low-advanced PTC patients is both safe and sufficient.
Collapse
Affiliation(s)
- Agnieszka Czarniecka
- The Oncologic and Reconstructive Surgery Clinic, M. Sklodowska-Curie National Research, Institute of Oncology Gliwice Branch, Gliwice, Poland
- *Correspondence: Agnieszka Czarniecka,
| | - Marcin Zeman
- The Oncologic and Reconstructive Surgery Clinic, M. Sklodowska-Curie National Research, Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Grzegorz Wozniak
- The Oncologic and Reconstructive Surgery Clinic, M. Sklodowska-Curie National Research, Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Adam Maciejewski
- The Oncologic and Reconstructive Surgery Clinic, M. Sklodowska-Curie National Research, Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Ewa Stobiecka
- Tumor Pathology Department, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Ewa Chmielik
- Tumor Pathology Department, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Malgorzata Oczko-Wojciechowska
- Genetic and Molecular Diagnostics of Cancer Department, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Jolanta Krajewska
- Department of Nuclear Medicine and Endocrine Oncology, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Daria Handkiewicz-Junak
- Department of Nuclear Medicine and Endocrine Oncology, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Barbara Jarzab
- Department of Nuclear Medicine and Endocrine Oncology, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| |
Collapse
|
87
|
Zhang X, Chen W, Fang Q, Fan J, Feng L, Guo L, Liu S, Ge H, Du W. Lateral Lymph Node Metastases in T1a Papillary Thyroid Carcinoma: Stratification by Tumor Location and Size. Front Endocrinol (Lausanne) 2021; 12:716082. [PMID: 34335480 PMCID: PMC8320373 DOI: 10.3389/fendo.2021.716082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/25/2021] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To analyze the incidence and risk factors for lateral lymph node metastases (LNMs) in T1a papillary thyroid carcinoma (PTC) with a focus on tumor location and size. MATERIALS AND METHODS The incidence of lateral LNM in 345 cases of T1a PTC was retrospectively analyzed. Univariate and multivariate analyses were performed to assess the relationships between lateral LNM and clinicopathological characteristics. RESULTS The incidence of skip metastasis to lateral LNM in T1a PTC located in the upper lobe was 12.1% (8/66). Logistic regression analysis indicated tumor size >5 mm (OR = 5.04, 95% CI = 1.79 to 14.18, P = 0.002), upper lobe location (OR = 7.68, 95% CI = 3.05-19.34, P < 0.001) and the number of central neck LNM (<2: OR = 24.79, 95% CI = 8.23-74.60, P < 0.001; ≥2: OR = 4.99, 95% CI = 1.95-12.73, P < 0.001) were independently associated with lateral LNM. Comparing the lateral and central LNM stratification based on tumor location revealed that both the incidences of lateral (33.3%) and central (30.3%) LNM of T1a PTC located in the upper lobe were higher than those of T1a PTC located in the middle and lower lobes. Of T1a PTC located in the upper lobe, the incidence of lateral LNM was 33.3% (22/66), which was higher than that [30.3% (20/66)] of central LNM. This finding is reversed in all T1a PTC cases and T1a PTC cases with tumor located in the middle and lower lobes. CONCLUSION A particularly high likelihood of lateral LNM was observed in T1a PTC patients with tumor located in the upper lobe of the thyroid gland, especially the tumor >5 mm in size, which could be considered a risk factor for lateral LNM in the clinical management of T1a PTC.
Collapse
Affiliation(s)
- Xiaojun Zhang
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Wenkuan Chen
- Department of Head and Neck Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qigen Fang
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Jie Fan
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Lu Feng
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Lanwei Guo
- Office for Cancer Control and Research, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Shanting Liu
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Hong Ge
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
- *Correspondence: Wei Du, ; Hong Ge,
| | - Wei Du
- Department of Head Neck and Thyroid Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China
- *Correspondence: Wei Du, ; Hong Ge,
| |
Collapse
|
88
|
Does the ATA Risk Stratification Apply to Patients with Papillary Thyroid Microcarcinoma? World J Surg 2020; 44:452-460. [PMID: 31605172 DOI: 10.1007/s00268-019-05215-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of papillary thyroid microcarcinoma (PTMC) has increased over the past decade. The American Thyroid Association (ATA) suggests that these patients may undergo either thyroid lobectomy or active surveillance. It remains unclear whether there exists a subgroup of PTMC patients who may benefit from more aggressive treatment due to increased risk of recurrence. METHODS We retrospectively reviewed 357 patients with PTMC who underwent surgery at a single institution from 2004 to 2016. Patients were classified according to 2015 ATA risk stratification for structural disease recurrence. Demographic, oncologic, and clinicopathologic data were compared between groups. RESULTS Out of 357 patients, 246 were classified as low-risk PTMC, 93 were intermediate-risk, and 18 were high-risk. There were more male patients in the high-risk group (38.9%) than the intermediate- (31.2%) or low-risk groups (15.4%) (p < 0.001). Patients with low-risk microcarcinomas were more likely to have an incidental PTMC when compared to intermediate- or high-risk groups (98[39.8%], 15[16.1%], 1[5.6%], respectively, p < 0.001). Patients with high-risk PTMCs, compared to those with intermediate- and low-risk PTMCs, were more likely to have rising postoperative thyroglobulin levels after total thyroidectomy (6[40.0%], 4[5.1%], 9[5.7%], respectively, p = 0.001) and structural recurrence after lobectomy or total thyroidectomy (3[16.7%], 0[0%], 0[0%], respectively, p < 0.001). The median follow-up time was 17.5 (IQR 3-55) months. CONCLUSIONS Patients with high-risk PTMC have an increased risk of recurrence when compared to low- and intermediate-risk microcarcinomas, whereas intermediate-risk PTMC may behave similarly to low-risk tumors. ATA risk stratification may inform clinical decision making for patients with PTMC.
Collapse
|
89
|
Luo H, Yan F, Lan L, Ma B, Zhao H, He Y, Peng Y. Ultrasonographic Features, Nodule Size, Capsular Invasion, and Lymph Node Metastasis of Solitary Papillary Carcinoma of Thyroid Isthmus. Front Oncol 2020; 10:558363. [PMID: 33117691 PMCID: PMC7551305 DOI: 10.3389/fonc.2020.558363] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023] Open
Abstract
Objective: This retrospective study aimed to analyze the ultrasound (US) imaging features of solitary papillary thyroid carcinoma (PTC) located in the isthmus and to assess the risk factors for lymph node metastasis (LNM) and tumor capsular invasion. Methods: We included a total of 135 patients with solitary PTC located in the isthmus. All the cases underwent US, total thyroidectomy, and prophylactic central lymph node dissection. Patients' demographic and thyroid isthmus nodules' US characteristics, as well as risk factors associated with LNM and tumor capsular invasion, were analyzed. Results: It was revealed that the occurrence of LNM was higher in male patients than in female patients (P < 0.001). As risk factors, the size of PTC in the isthmus was found to be associated with LNM and tumor capsular invasion (P = 0.005 and 0.000, respectively). The area under the receiver operating characteristic curve (AUC) of the size of the isthmus PTC was 0.64 [95% confidence interval (CI) = 0.55-0.72], indicating a probability for LNM. The AUC value for tumor capsular invasion was 0.77 (95% CI: 0.68-0.83). When the threshold was set to 1.1 cm, the larger size indicated that there was a probability of occurrence of LNM with sensitivity and specificity of 47.4 and 73.7%, respectively. When the threshold was set to 0.7 cm, the larger size indicated that there was potentially a tumor capsular invasion, with sensitivity and specificity of 80.6 and 56.3%, respectively. Wider-than-tall nodules were found to be significantly different from those in LNM and tumor capsular invasion (P = 0.038 and 0.030, respectively). There were significant differences in tumor capsular invasion in extrathyroidal extension (ETE) compared with smooth or ill-defined and lobulated or irregular nodules (P = 0.017). Conclusions: This study showed that the incidence of LNM in male patients was higher than that in female ones. When a US image shows a thyroid isthmus nodule with a wider-than-tall shape, LNM and tumor capsular invasion were likely to occur. When a US image shows a thyroid isthmus nodule with an ETE, tumor capsular invasion was likely to occur. ETE and wider-than-tall may be indicators of FNA under US guidance, even though the size of thyroid isthmus nodule may be <1 cm.
Collapse
Affiliation(s)
- Honghao Luo
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Feng Yan
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Lin Lan
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Buyun Ma
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Haina Zhao
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yushuang He
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yulan Peng
- Department of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
90
|
Molecular Aspects of Thyroid Calcification. Int J Mol Sci 2020; 21:ijms21207718. [PMID: 33086487 PMCID: PMC7589718 DOI: 10.3390/ijms21207718] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023] Open
Abstract
In thyroid cancer, calcification is mainly present in classical papillary thyroid carcinoma (PTC) and in medullary thyroid carcinoma (MTC), despite being described in benign lesions and in other subtypes of thyroid carcinomas. Thyroid calcifications are classified according to their diameter and location. At ultrasonography, microcalcifications appear as hyperechoic spots ≤ 1 mm in diameter and can be named as stromal calcification, bone formation, or psammoma bodies (PBs), whereas calcifications > 1 mm are macrocalcifications. The mechanism of their formation is still poorly understood. Microcalcifications are generally accepted as a reliable indicator of malignancy as they mostly represent PBs. In order to progress in terms of the understanding of the mechanisms behind calcification occurring in thyroid tumors in general, and in PTC in particular, we decided to use histopathology as the basis of the possible cellular and molecular mechanisms of calcification formation in thyroid cancer. We explored the involvement of molecules such as runt-related transcription factor-2 (Runx-2), osteonectin/secreted protein acidic and rich in cysteine (SPARC), alkaline phosphatase (ALP), bone sialoprotein (BSP), and osteopontin (OPN) in the formation of calcification. The present review offers a novel insight into the mechanisms underlying the development of calcification in thyroid cancer.
Collapse
|
91
|
Pollack R, Mazeh H. Active Surveillance of Thyroid Microcarcinoma-Can This Approach Be Safely Implemented Worldwide? J Surg Res 2020; 258:145-152. [PMID: 33010560 DOI: 10.1016/j.jss.2020.08.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/28/2020] [Accepted: 08/26/2020] [Indexed: 12/20/2022]
Abstract
The incidence of thyroid cancer has been increasing exponentially worldwide, mainly due to increased detection of small papillary thyroid microcarcinomas (PTMCs). Given the indolent nature of the disease, active surveillance (AS) has been suggested as an alternative approach to immediate surgery in the management of low-risk PTMCs. The decision to proceed with AS must take into account patient characteristics, tumor characteristics, and medical team characteristics. In this review, we discuss the rationale and evidence to support AS, as well as important considerations and limitations to implementing this approach for PTMC worldwide.
Collapse
Affiliation(s)
- Rena Pollack
- Department of Endocrinology and Metabolism, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Haggi Mazeh
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
92
|
Pusztaszeri MP, Tamilia M, Payne RJ. Active surveillance for low-risk small papillary thyroid cancer in North American countries: past, present and future (bridging the gap between North American and Asian practices). Gland Surg 2020; 9:1685-1697. [PMID: 33224846 DOI: 10.21037/gs-20-389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Papillary thyroid cancer (PTC) is increasingly being diagnosed worldwide; yet the mortality remains very low, suggesting widespread overdiagnosis. While traditional management of PTC includes thyroid surgery, sometimes followed by radioactive iodine treatment, there is a global trend towards more conservative approaches for patients who are considered as the lowest risk of recurrence or death from their disease. Active surveillance (AS), once called watchful waiting, involves close follow-up, with the intention to intervene if the cancer progresses, or on patient request. The Kuma Hospital in Japan was the first to introduce AS as an alternative to immediate thyroid surgery for low-risk papillary thyroid microcarcinomas (PTMC, <1 cm) in 1993. Accumulated evidence over the years has shown that AS is a safe and effective approach in select patients, with a low rate of cancer progression during AS. Consequently, the Japanese Clinical Guidelines for treatment of thyroid tumor approved AS as a first-line management for patients with asymptomatic PTMC in 2010. Subsequently, the latest 2015 American Thyroid Association guidelines endorsed AS as an alternative approach to immediate surgery for cytologically confirmed very low-risk PTC. However, the acceptance, feasibility and results of AS in patients with low-risk PTC outside of Japan are still largely unknown. Most guidelines recommend that thyroid nodules <1 cm should not be aspirated but instead monitored regardless of the ultrasonographic characteristics. In essence, these patients are also being subjected to AS. Specific recommendations and the role of molecular testing for the optimal selection of PTMC patients for an AS management approach are not well established. Furthermore, research is needed to assess the long-term clinical and psychosocial outcomes in patients with larger tumor sizes (>1 cm) who undergo screening and diagnosis according to the North American guidelines and practices. The first Canadian prospective observational study launched in 2016 is intended to complement the existing data for AS of small low-risk PTC (≤2 cm) and may provide insight into the different approaches in North American and Asian practices. This review intends to summarize the development and the rationale of AS for PTMC and highlights significant differences between North American and Japanese practices.
Collapse
Affiliation(s)
- Marc P Pusztaszeri
- Department of Pathology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Michael Tamilia
- Division of Endocrinology & Metabolism, Jewish General Hospital, McGill University, Montreal, Canada
| | - Richard J Payne
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, Montreal, Canada
| |
Collapse
|
93
|
Abstract
In 1993, active surveillance of low-risk papillary thyroid microcarcinomas (PTMCs) started in Kuma Hospital, Kobe, Japan. It has spread globally after the publishing of American Thyroid Association (ATA) guidelines. During our hospital's active surveillance program, few patients (8.0%) showed tumor size enlargement ≥3 mm or the new appearance of node metastasis (3.8%) at 10-year follow-up. Conversion surgery was recommended for patients with disease progression. To date, no patients showed significant recurrence or metastasis or died with thyroid carcinoma when patients underwent active surveillance or after surgery due to PTMC progression. Unlike clinical papillary thyroid carcinoma (PTC), elderly patients' PTMCs were less progressive compared to those of young and middle-aged patients, indicating that elderly patients are strong candidates for the active surveillance of their PTMC. Although young patients' PTMCs are the most progressive, >50% and >75% of patients in their 20s and 30s would avoid conversion surgical treatment in their lifetime, respectively (according to estimated lifetime probability), indicating that such young patients are still candidates for active surveillance. It can thus be concluded that active surveillance is appropriate to be first management for PTMCs, based on the accumulation of favorable outcomes of PTMC patients who have undergone active surveillance, as well as the lower incidences of unfavorable events and lower medical cost than immediate surgery.
Collapse
Affiliation(s)
- Yasuhiro Ito
- Department of Surgery, Kuma Hospital, Kobe, Japan
| | | |
Collapse
|
94
|
Hu R, Xu G, Stricker T, Li B, Weiss VL, Bischoff L. INCIDENTAL PULMONARY METASTASES REVEALING SUBCENTIMETER PAPILLARY THYROID CARCINOMA. AACE Clin Case Rep 2020; 6:e273-e278. [PMID: 32984537 DOI: 10.4158/accr-2020-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/17/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Here we present 2 cases of papillary thyroid microcarcinomas (PMCs) that had metastasized at presentation. The 2015 American Thyroid Association and the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) criteria do not recommend biopsy of the majority of subcentimeter thyroid nodules, as PMCs are mostly indolent with excellent prognosis. However, the paradigm of active surveillance presents a conundrum on how to identify the rare patient with distant metastatic disease while avoiding unnecessary intervention in the majority. Methods After initial discovery of incidental lesions on chest computed tomography, core or wedge biopsies of the lung lesion were performed. Thyroid nodules on ultrasound were classified by TI-RADS. Tumor DNA was sequenced, annotated, filtered on 119 known cancer genes, and filtered for variants with an exome allele frequency of <0.001. Results A 70-year-old woman and a 29-year-old woman presented with incidental pulmonary lesions on computed tomography scan. Lung biopsy revealed lung metastases from papillary thyroid carcinoma. The thyroid nodules in both patients were TI-RADS 3 and American Thyroid Association low-suspicion. Molecular testing showed a c.1721C>G mutation (p.Thr574Ser) in the TSHR gene in patient 1 and a codon 61 mutation in the NRAS gene in patient 2. Both patients were iodine-avid, with complete structural remission in one patient and ongoing treatment with evidence of structural response in the other. Conclusion The 2 presentations demonstrate unexpected and concerning behavior of PMCs. Both thyroid tumors were subcentimeter in diameter, meaning they would have escaped detection using traditional risk-stratification algorithms in active surveillance. Further knowledge of tumor genetics and microenvironment may assist in predicting tumor behavior in PMCs.
Collapse
Affiliation(s)
- Ruey Hu
- Department of Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - George Xu
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas Stricker
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bingshan Li
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Vivian L Weiss
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsay Bischoff
- Division of Endocrinology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
95
|
Hay ID, Lee RA, Kaggal S, Morris JC, Stan MN, Castro MR, Fatourechi V, Thompson GB, Charboneau JW, Reading CC. Long-Term Results of Treating With Ethanol Ablation 15 Adult Patients With cT1aN0 Papillary Thyroid Microcarcinoma. J Endocr Soc 2020; 4:bvaa135. [PMID: 33073159 PMCID: PMC7543935 DOI: 10.1210/jendso/bvaa135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background Currently acceptable management options for patients with adult papillary thyroid microcarcinoma (APTM) range from immediate surgery, either unilateral lobectomy or bilateral lobar resection, to active surveillance (AS). An alternative minimally invasive approach, originally employed for eliminating neck nodal metastases, may be ultrasound-guided percutaneous ethanol ablation (EA). Here we present our experience of definitively treating with EA 15 patients with APTM. Patients and Methods During 2010 through 2017, the 15 cT1aN0M0 patients selected for EA were aged 36 to 86 years (median, 45 years). Tumor volumes (n = 17), assessed by sonography, ranged from 25 to 375 mm3 (median, 109 mm3). Fourteen of 15 patients had 2 ethanol injections on successive days; total volume injected ranged from 0.45 to 1.80 cc (median, 1.1 cc). All ablated patients were followed with sonography and underwent recalculation of tumor volume and reassessment of tumor perfusion at each follow-up visit. Results The ablated patients have now been followed for 10 to 100 months (median, 64 months). There were no complications and no ablated patient developed postprocedure recurrent laryngeal nerve dysfunction. All 17 ablated tumors shrank (median 93%) and Doppler flow eliminated. Median tumor volume reduction in 9 identifiable avascular foci was 82% (range, 26%-93%). After EA, 8 tumors (47%) disappeared on sonography after a median of 10 months. During follow-up no new PTM foci and no nodal metastases have been identified. Conclusions Definitive treatment of APTM by EA is effective, safe, and inexpensive. Our results suggest that, for APTM patients who do not wish neck surgery and are uncomfortable with AS, EA represents a well-tolerated and minimally invasive outpatient management option.
Collapse
Affiliation(s)
- Ian D Hay
- Departments of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Robert A Lee
- Departments of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Suneetha Kaggal
- Departments of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - John C Morris
- Departments of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Marius N Stan
- Departments of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - M Regina Castro
- Departments of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Vahab Fatourechi
- Departments of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Geoffrey B Thompson
- Departments of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - J William Charboneau
- Departments of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Carl C Reading
- Departments of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
96
|
Grani G, Sponziello M, Pecce V, Ramundo V, Durante C. Contemporary Thyroid Nodule Evaluation and Management. J Clin Endocrinol Metab 2020; 105:5850848. [PMID: 32491169 PMCID: PMC7365695 DOI: 10.1210/clinem/dgaa322] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Approximately 60% of adults harbor 1 or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant. The widespread use of diagnostic imaging and improved access to health care favor the discovery of small, subclinical nodules and small papillary cancers. Overdiagnosis and overtreatment is associated with potentially excessive costs and nonnegligible morbidity for patients. EVIDENCE ACQUISITION We conducted a PubMed search for the recent English-language articles dealing with thyroid nodule management. EVIDENCE SYNTHESIS The initial assessment includes an evaluation of clinical risk factors and sonographic examination of the neck. Sonographic risk-stratification systems (e.g., Thyroid Imaging Reporting and Data Systems) can be used to estimate the risk of malignancy and the need for biopsy based on nodule features and size. When cytology findings are indeterminate, molecular analysis of the aspirate may obviate the need for diagnostic surgery. Many nodules will not require biopsy. These nodules and those that are cytologically benign can be managed with long-term follow-up alone. If malignancy is suspected, options include surgery (increasingly less extensive), active surveillance or, in selected cases, minimally invasive techniques. CONCLUSION Thyroid nodule evaluation is no longer a 1-size-fits-all proposition. For most nodules, the likelihood of malignancy can be confidently estimated without resorting to cytology or molecular testing, and low-frequency surveillance is sufficient for most patients. When there are multiple options for diagnosis and/or treatment, they should be discussed with patients as frankly as possible to identify an approach that best meets their needs.
Collapse
Affiliation(s)
- Giorgio Grani
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marialuisa Sponziello
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Pecce
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Ramundo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cosimo Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Correspondence and Reprint Requests: Cosimo Durante, MD, PhD, Dipartimento di Medicina Traslazionale e di Precisione, Università di Roma “Sapienza,” Viale del Policlinico 155, 00161, Roma, Italy. E-mail:
| |
Collapse
|
97
|
Smulever A, Pitoia F. High rate incidence of post-surgical adverse events in patients with low-risk papillary thyroid cancer who did not accept active surveillance. Endocrine 2020; 69:587-595. [PMID: 32328966 DOI: 10.1007/s12020-020-02310-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To describe the outcomes and the incidence of adverse events following active surveillance (AS) versus immediate surgery in patients with low-risk papillary thyroid carcinoma (PTC). METHODS We prospectively evaluated 286 patients who attended the Hospital de Clínicas, with a single thyroid nodule <1.5 cm classified as Bethesda category V or VI (PTC). Those patients with no aggressive features were considered as harboring a low-risk PTC and were offered AS or immediate surgery. For patients who opted for AS, surgery was recommended if tumor progression was observed. Post-operative adverse events were recorded for those patients treated with surgery (after AS or immediate surgery). RESULTS From 286 eligible patients, 164 harbored a low-risk PTC. Among these, 75% (n = 123) underwent immediate surgery and 25% (n = 41) opted for AS. Within the last group, increase in tumor size more than 3 mm was observed in 14.6 and 4.8% was diagnosed with lymph-node metastases after a median of 37.5 months (range, 12-65) of follow-up. One hundred and thirty five patients underwent surgery: in 123, it was immediate after diagnosis and in 12 after a median of 35 months (range, 12-65) of AS. Both groups had excellent oncological outcomes. The frequency of postoperative adverse events was 24.4%, which was permanent in 9.6% of cases. The immediate-surgery group presented higher incidence of permanent vocal cord paralysis (2.4 vs. 0%); permanent hypoparathyroidism (5.7 vs. 0%) and local complications (4 vs. 2.4%) compared with the AS group, all non-statistically significant. CONCLUSIONS The high incidence of postoperative complications observed in our media could be avoided if AS was performed as the initial approach in patients with low-risk PTCs. The frequency of tumor growth and LN metastases during AS was similar to other series.
Collapse
Affiliation(s)
- Anabella Smulever
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Buenos Aires, Argentina
| | - Fabián Pitoia
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Buenos Aires, Argentina.
| |
Collapse
|
98
|
Abstract
The diagnostic modalities, stratification tools, and treatment options for patients with thyroid cancer have rapidly evolved since the development of the American Thyroid Association (ATA) guidelines in 2015. This review compiles newer concepts in diagnosis, stratification tools and treatment options for patients with differentiated thyroid cancer (DTC), medullary thyroid carcinoma (MTC) and anaplastic thyroid cancer (ATC). Newer developments apply precision medicine in thyroid cancer patients to avoid over-treatment in low risk disease and under-treatment in high risk disease. Among novel patient-tailored therapies are selective RET inhibitors that have shown efficacy in the treatment of MTC with limited systemic toxicity compared with non-specific tyrosine kinase inhibitors. The combination of BRAF and MEK inhibitors have revolutionized management of BRAF V600E mutant ATC. Several immunotherapeutic agents are being actively investigated in the treatment of all forms of thyroid cancer. In this review, we describe the recent advances in the diagnosis and management of DTC, MTC, and ATC, with an emphasis on novel treatment modalities.
Collapse
Affiliation(s)
- Katherine A. Araque
- Endocrinology Department, Pacific Neuroscience Institute, John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Sriram Gubbi
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| |
Collapse
|
99
|
Chung SR, Baek JH, Choi YJ, Sung TY, Song DE, Kim TY, Lee JH. Sonographic Assessment of the Extent of Extrathyroidal Extension in Thyroid Cancer. Korean J Radiol 2020; 21:1187-1195. [PMID: 32729261 PMCID: PMC7458864 DOI: 10.3348/kjr.2019.0983] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 11/15/2022] Open
Abstract
Objective This study aimed to determine the sonographic features suggestive of extrathyroidal extension (ETE) of thyroid cancers. Materials and Methods We retrospectively reviewed the sonographic images of 1656 consecutive patients who had undergone thyroidectomy in 2017. The diagnostic performance of sonographic features suggestive of ETE was evaluated using operation and histopathologic reports. Sonographic features for gross ETE to the strap muscle and minor ETE were assessed for thyroid cancer abutting the anterolateral thyroid capsule. Sonographic features for tracheal invasion were assessed according to whether the angle between the tumor and the trachea was an acute, right, or obtuse angle. Sonographic features for recurrent laryngeal nerve (RLN) invasion were assessed based on the association between the tumor and tracheoesophageal groove (TEG) as preserved normal tissue, abutting or protruding into the TEG. Results ETE was observed in 783 patients (47.3%), including 123 patients with gross ETE (7.4% [strap muscle, n = 97; RLN, n = 24; and trachea, n = 14]) and 660 patients with minor ETE (39.9%). Regarding the diagnosis of gross and minor ETE to the strap muscle, sonographic features of replacement of the strap muscle and capsular disruption showed the highest positive predictive value (75.9% and 58.5%, respectively). Thyroid cancer forming an obtuse angle with the trachea had the highest sensitivity for the diagnosis of tracheal invasion (85.7%), and thyroid cancer protrusion into the TEG showed the highest sensitivity for the diagnosis of RLN (83.3%). Conclusion Sonography is considered beneficial in the diagnosis of ETE to the strap muscle, trachea, and RLN. Assessment of ETE is important for the accurate staging of thyroid cancer, which in turn determines the extent of surgery or whether active surveillance is appropriate or not.
Collapse
Affiliation(s)
- Sae Rom Chung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Young Jun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Yon Sung
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Eun Song
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Yong Kim
- Department of Endocrinology and Metabolism, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
100
|
Abstract
Background: The incidence of thyroid carcinoma is growing worldwide. More than 50% of new malignant tumors are classified as classical papillary carcinomas in low-risk category with a low rate of recurrence and high long-term survival. Active surveillance is a strategy to control low-risk tumor evolution with the intention to avoid unnecessary treatments and maintain thyroid function. The aim of this study was to report a cohort of patients with thyroid nodules classified as Bethesda V-VI and who are under active surveillance in Colombia. Methods: A prospective cohort was assembled since January 2015. All patients had been evaluated clinically, biochemically with ultrasonography and fine needle aspiration biopsy previous to the first evaluation. Active surveillance was proposed to patients with asymptomatic low-risk carcinoma (<1.5 cm, encapsulated, without evidence of lymph node metastasis), independent of sex or age. The strategy included a specific discussion about the surgical option and expected risk of complications, risk of long-term thyroxine support, and the active surveillance strategy. The data on age, sex, reason for an ultrasound examination, ultrasound risk by American Thyroid Association (ATA) classification, size and volume of the nodule, reason to consider active surveillance and follow-up ultrasounds, and surgical decision were recorded prospectively. A Kaplan-Meier curve was constructed for the rate of growth and increase in volume of the nodule, growth >3 mm and increase in volume >50%, and need of operation. Results: One hundred two patients were analyzed. Seventy-five percent of patients had a nodule smaller than 1 cm. Only 24/102 (23%) nodules were classified as ATA low risk. Thirty-four of 102 (33.3%) nodules were classified as Bethesda VI and the others were Bethesda V. The median follow-up was 13.9 months, and 32.3% of patients had more than 24 months of follow-up. Only 11/102 (10.8%) nodules grew more than 3 mm and 26/102 (25.5%) nodules grew more than 50% in volume. 12.7% patients were submitted to surgery. The overall stability rate without growth >3 mm, without volume increase >50%, and without surgery at 24 months were 89.8%, 77.0%, and 85.5%, respectively Conclusions: Active surveillance is possible in developing Western countries with similar results to those provided by Asian and American authors.
Collapse
Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Medellín, Colombia
- Centro de Excelencia en Enfermedades de Cabeza y Cuello (CEXCA), Medellín, Colombia
| |
Collapse
|