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Lorenz K, Machens A, Dralle H. [Individualization of treatment in sporadic and hereditary medullary thyroid cancer]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:186-191. [PMID: 38214736 DOI: 10.1007/s00104-023-02015-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Routine preoperative assessment of the tumor marker calcitonin for medullary thyroid cancer (MTC) and the generally improved diagnostics with high-resolution ultrasound, elastography and Doppler function as well as functional imaging, enable the earlier detection of organ-limited, non-metastasized MTC. Thereby, a new treatment option arises for surgical de-escalation in sporadic MTC, moving from routine thyroidectomy with bilateral central lymph node dissection towards unilateral thyroidectomy with ipsilateral central lymph node dissection. MATERIAL AND METHODS A search was carried out in PubMed for surgical approaches and selection of publications with results from limited resection in sporadic MTC. RESULTS In selected patient cohorts limited resection surgery can achieve adequate oncological results but requires long-term follow-up. DISCUSSION When sporadic unifocal primary tumors are identified and intraoperative frozen section pathological investigation is consistently employed for assessing the grade of desmoplasia and breach of the tumor capsule, the extent of resection can be intraoperatively adapted. Pivotal prerequisites for this personalized concept include consideration of preoperative clinical criteria and intraoperative surgical assessment in conjunction with the intraoperative frozen section examination in order to achieve an adequate oncological tumor resection and a biochemical cure.
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Affiliation(s)
- Kerstin Lorenz
- Klinik für Viszerale, Gefäß- und Endokrine Chirurgie, Universitätsmedizin Halle, Ernst-Grube-Str. 40, 06120, Halle/Saale, Deutschland.
| | - Andreas Machens
- Klinik für Viszerale, Gefäß- und Endokrine Chirurgie, Universitätsmedizin Halle, Ernst-Grube-Str. 40, 06120, Halle/Saale, Deutschland
| | - Henning Dralle
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion für Endokrine Chirurgie, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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2
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Mao YV, Hughes EG, Steinmetz D, Troob S, Kim J, Tseng CH, Fishbein GA, Sajed DP, Livhits MJ, Yeh MW, Lee D, Angell TE, Wu JX. Extent of Surgery for Medullary Thyroid Cancer and Prevalence of Occult Contralateral Foci. JAMA Otolaryngol Head Neck Surg 2024; 150:209-214. [PMID: 38270925 PMCID: PMC10811588 DOI: 10.1001/jamaoto.2023.4376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/21/2023] [Indexed: 01/26/2024]
Abstract
Importance Standard treatment for patients with medullary thyroid cancer (MTC) consists of total thyroidectomy with central neck dissection, but the rationale for bilateral surgery in patients with unilateral disease on ultrasonography remains unclear. Objective To determine the presence of occult contralateral disease (lesions not seen on preoperative ultrasonography) in patients with MTC as a rationale for total thyroidectomy. Design, Setting, and Participants This multi-institutional, retrospective cohort study was conducted from September 1998 to April 2022 in academic medical centers and included patients with MTC who underwent thyroidectomy with preoperative imaging. Main Outcomes and Measures The primary end point was the prevalence of sonographically occult foci of MTC in the contralateral lobe among patients with sporadic MTC. Results The cohort comprised 176 patients with a median age at diagnosis of 55 years (range, 2-87 years), 69 (57.6%) of whom were female. Genetic testing was performed in 109 patients (61.9%), 48 (27.5%) of whom carried germline RET variants. Initial surgical management consisted of total thyroidectomy (161 [91.0%]), lobectomy followed by completion thyroidectomy (7 [4.0%]), and lobectomy alone (8 [4.5%]). Central and lateral neck dissections were performed as part of initial therapy for 146 patients (83.1%). In the entire cohort of 176 patients, 46 (26.0%) had contralateral foci disease and 9 (5.1%) had occult contralateral foci that were not identified on preoperative ultrasonography. Among 109 patients who underwent genetic testing, 38 (34.9%) had contralateral disease, 8 (7.3%) of whom had occult contralateral disease not seen on preoperative ultrasonography. Patients with sporadic MTC experienced a 95.7% reduction in the odds of having a focus of MTC in the contralateral lobe compared with patients with a germline RET variant (odds ratio, 0.043; 95% CI, 0.013-0.123). When adjusting for age, sex, tumor size, and lymph node involvement, the odds ratio of having contralateral MTC in patients with sporadic disease was 0.034 (95% CI, 0.007-0.116). Among patients who underwent lobectomy alone with postoperative calcitonin levels, 5 of 12 (41.7%) achieved undetectable calcitonin levels (<2.0 pg/mL; to convert to pmol/L, multiply by 0.292). Conclusions and Relevance The results of this cohort study suggest that a staged approach involving initial thyroid lobectomy could be considered in patients with sporadic MTC and no contralateral ultrasonography findings, with no further surgery if calcitonin levels became undetectable. Further work using prospective randomized clinical trials to evaluate lobectomy as a biochemical cure in patients presenting with unilateral disease is warranted.
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Affiliation(s)
- Yifan V. Mao
- UCLA David Geffen School of Medicine, Los Angeles, California
| | - Elena G. Hughes
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - David Steinmetz
- Division of Metabolic, Endocrine, and Minimally Invasive Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Samantha Troob
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Jiyoon Kim
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Gregory A. Fishbein
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Dipti P. Sajed
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Masha J. Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Michael W. Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Denise Lee
- Division of Surgical Oncology and Endocrine Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Trevor E. Angell
- Division of Endocrinology and Diabetes, Keck School of Medicine of USC, Los Angeles, California
| | - James X. Wu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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Trivedi S, Salahuddin T, Mithi MT, Rathod P, Bandi A, Pandya SJ, Sharma M, Patel S, Warikoo V, Puj K, Salunkhe A, Patel K, Pandya S. Medullary Thyroid Carcinoma: A Single Institute Experience. Indian J Otolaryngol Head Neck Surg 2023; 75:2884-2889. [PMID: 37974849 PMCID: PMC10645935 DOI: 10.1007/s12070-023-03867-2] [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: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 11/19/2023] Open
Abstract
Medullary thyroid carcinoma is a rare tumour that is anatomically located in the thyroid gland but is functionally a neuroendocrine tumour. It is usually a disease of older age group but manifests in a young patient in familial form. It is derived from parafollicular c cells and has a predilection for lymph node metastasis. It is associated with slow growth in thyroid gland with early nodal metastasis. Serum calcitonin is useful as a preoperative marker of disease burden and prognosis. In the preoperative period serum levels of calcitonin can guide regarding the need for compartment wise lymph node dissection and the possibility of distant metastasis. It is used as a tool of surveillance in the postoperative period. The levels of serum CEA and calcitonin and their doubling time is a useful guide in the detection of early recurrence or distant metastasis. Imaging modality useful for diagnosis is USG in a majority of patients. Thus, the initial diagnosis and preoperative assessment of medullary thyroid carcinoma is similar to other forms of thyroid cancer but further management of disease differs significantly form other forms of differentiated thyroid carcinoma or even anaplastic carcinoma. Prognosis however differs according to age, gender, presence or absence of lymph node metastasis at presentation, metastatic disease at presentation and levels of biochemical markers.
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Affiliation(s)
- Sonal Trivedi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - T. Salahuddin
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Mohamed Taher Mithi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Priyank Rathod
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Arpit Bandi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shashank J. Pandya
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Mohit Sharma
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shailesh Patel
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Vikas Warikoo
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Ketul Puj
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Abhijeet Salunkhe
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Keval Patel
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shivam Pandya
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
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Wu X, Li B, Zheng C. Clinicopathological characteristics and prognosis of medullary thyroid microcarcinoma: a tumor with a similar prognosis to macrocarcinoma. Eur J Med Res 2023; 28:546. [PMID: 38017592 PMCID: PMC10683302 DOI: 10.1186/s40001-023-01534-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/16/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Tumor size plays an important role in the staging and treatment of thyroid carcinoma. A tumor with a maximum diameter of 1 cm or less is referred to as microcarcinoma. It is unclear if the clinicopathological characteristics and prognosis of medullary thyroid microcarcinoma (≤ 1 cm; MTMC) and macrocarcinoma (> 1 cm) differ. The present study aims to clarify the clinical features and prognosis of patients with MTMC. METHODS The patients with medullary thyroid carcinoma underwent radical operation at our hospital between December 2000 and January 2022 were retrospectively studied. A database was established for this study. Patients with MTMC and macrocarcinoma were grouped for comparison. The clinicopathological characteristics of the two groups were compared by χ2 test, Fisher's exact test, t-test, and Mann-Whitney U test. Cumulative survival rates were presented by the Kaplan-Meier curves and compared using the log-rank test. RESULTS A total of 198 patients were included. Of them, 56 and 142 with MTMC and macrocarcinoma, respectively. Few patients in the MTMC group had lateral lymph node metastasis. One hundred and seventy-eight (89.9%) patients were followed up, with a median follow-up period of 61 (35, 105) months. The disease-free survival rate was significantly higher in the MTMC group (log-rank test, p = 0.032); however, there was no significant difference in the overall survival rate between the two groups (log-rank test, p = 0.083). CONCLUSIONS Patients with MTMC have a lower risk of lateral lymph node metastasis and better disease-free survival than those with macrocarcinoma. However, there was no significant difference in the overall survival rate of both groups. MTMC should be treated in the same manner as macrocarcinoma.
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Affiliation(s)
- Xin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Binglu Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Chaoji Zheng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
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Gild ML, Clifton-Bligh RJ, Wirth LJ, Robinson BG. Medullary Thyroid Cancer: Updates and Challenges. Endocr Rev 2023; 44:934-946. [PMID: 37204852 PMCID: PMC10656709 DOI: 10.1210/endrev/bnad013] [Citation(s) in RCA: 3] [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] [Received: 10/13/2022] [Revised: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 05/20/2023]
Abstract
A personalized approach to the management of medullary thyroid cancer (MTC) presents several challenges; however, in the past decade significant progress has been made in both diagnostic and treatment modalities. Germline rearranged in transfection (RET) testing in multiple endocrine neoplasia 2 and 3, and somatic RET testing in sporadic MTC have revolutionized the treatment options available to patients. Positron emission tomography imaging with novel radioligands has improved characterization of disease and a new international grading system can predict prognosis. Systemic therapy for persistent and metastatic disease has evolved significantly with targeted kinase therapy especially for those harboring germline or somatic RET variants. Selpercatinib and pralsetinib are highly selective RET kinase inhibitors that have shown improved progression-free survival with better tolerability than outcomes seen in earlier multikinase inhibitor studies. Here we discuss changes in paradigms for MTC patients: from determining RET alteration status upfront to novel techniques for the evaluation of this heterogenous disease. Successes and challenges with kinase inhibitor use will illustrate how managing this rare malignancy continues to evolve.
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Affiliation(s)
- Matti L Gild
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
| | - Roderick J Clifton-Bligh
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
| | - Lori J Wirth
- Department of Medicine, Massachusetts General Hospital, & Harvard Medical School, Boston 02114, USA
| | - Bruce G Robinson
- Faculty of Health and Medicine, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney 2065, Australia
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Fu G, Li X, Guo F, Ruan X, Zhang W, Zhang W, Zhang Y, Chen Y, Li C, Chen J, Zheng X, Wang Z, Gao M. Partial preservation of the normal thyroid gland based on tumor diameter may be possible in small medullary thyroid carcinoma: a two-center 15-year retrospective study. Front Oncol 2023; 13:1216394. [PMID: 37519823 PMCID: PMC10374252 DOI: 10.3389/fonc.2023.1216394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Background At present, there are some controversies in the formulation of surgical protocol for small medullary thyroid carcinoma(s-MTC). We wanted to explore the feasibility of normal thyroid gland retention in small medullary thyroid carcinoma based on different tumor diameters and its prognostic impact on the tumor. Methods The data of patients with stage T1 MTC treated at Tianjin Cancer Hospital and Sichuan Cancer Hospital from 2006 to 2021 were analyzed. The tumor diameters of 0.5 cm and 1.0 cm were used as dividing points. The outcomes were tumor recurrence, metastasis, or patient death. Survival was estimated by the Kapan-Meier curve. Results A total of 121 T1 s-MTC patients were included, including 55 with total thyroidectomy (TT) and 66 with subthyroidectomy (Sub-TT). There were eleven cases of tumor recurrence and metastasis, and four patients died. When the tumor diameter was 1.0 cm as the cut-off point, tumor diameter (p = 0.010), TT (p = 0.028), unilateral and bilateral type (p = 0.009), and TNM staging (p = 0.007) had significant effects on progression-free survival (PFS). The tumor diameter, unilateral and bilateral type, and TT were risk factors for the prognosis of T1 MTC (p < 0.05). Conclusion The tumor diameter of 1.0 cm can be used as a cut-off point for stage T1 MTC. Alt-hough there was no significant difference in overall survival (OS) between T1a and T1b in patients, tumor diameter significantly influenced PFS. TT is not necessary for patients with sporadic MTC with T1a.
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Affiliation(s)
- Guiming Fu
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Thyroid-Otolaryngology Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoyi Li
- Medical Diagnostic Radiology Department, Sichuan GEM Flower Hospital & North Sichuan Medical College, Chengdu, China
| | - Fengli Guo
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Department of Thyroid and Breast Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Xianhui Ruan
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Wei Zhang
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- School of Medicine, Nankai University, Tianjin, China
| | - Weijing Zhang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yaping Zhang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yibo Chen
- Thyroid-Otolaryngology Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Chunhua Li
- Thyroid-Otolaryngology Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jin Chen
- Thyroid-Otolaryngology Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xiangqian Zheng
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Zhaohui Wang
- Thyroid-Otolaryngology Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Ming Gao
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Department of Thyroid and Breast Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Key Laboratory of General Surgery in Construction, Tianjin Union Medical Center, Tianjin, China
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Cosway B, Fussey J, Kim D, Wykes J, Elliott M, Smith J. Sporadic medullary thyroid cancer: a systematic review and meta-analysis of clinico-pathological and mutational characteristics predicting recurrence. Thyroid Res 2022; 15:12. [PMID: 35869537 PMCID: PMC9306201 DOI: 10.1186/s13044-022-00130-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Sporadic medullary thyroid cancer accounts for 75% of all medullary thyroid cancers and presents at a more advanced disease stage than its hereditary counterparts. Yet there is little evidence to support risk stratification of patients according to risk of recurrence. Methods A systematic review and meta-analysis was performed investigating clinical and pathological factors that are associated with recurrent disease in patients with medullary thyroid cancer. Results 10 studies totalling 458 patients were included in the meta-analyses. T3 and T4 disease (OR 9.33 (95% CI 2.5 – 34.82) p = 0.0009.), AJCC stage III and IV disease (OR 13.34 (95% CI 2.9 – 60.3) p = 0.0008) and the presence of nodal disease (OR 7.28 (95% CI 7.2–43.3) p = 0.03) were all associated with recurrent disease. RET mutations (OR 0.08 (95% CI -0.03–0.19) p = 0.17) and RET 918 T mutations (OR 1.77 (95% CI 0.804.0) P = 0.17) were not associated with disease recurrence. It was not possible to pool data with respect to extrathyroidal extension, extracapsular extension, peri-neural and lymphovascular invasion and RAS mutations. Conclusion T3 and T4 disease, AJCC stage III and IV disease and the presence of nodal disease are associated with recurrent disease. The heterogeneous reporting of recurrence and the lack of individual patient data precludes larger scale meta-analyses. Future research in this area should involve collaboration to establish standardised definitions of disease recurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s13044-022-00130-8.
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Gui Z, Wang Z, Xiang J, Sun W, He L, Dong W, Huang J, Zhang D, Lv C, Zhang T, Shao L, Zhang P, Zhang H. Incidental T1 stage medullary thyroid carcinoma: The effect of tumour diameter on prognosis and therapeutic implications. Clin Endocrinol (Oxf) 2022; 97:355-362. [PMID: 35192214 DOI: 10.1111/cen.14702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/06/2022] [Accepted: 02/12/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The definition of the tumour diameter of micro-medullary thyroid carcinoma (micro-MTC) is insufficient. It is controversial to perform a completion thyroidectomy immediately for incidental T1 stage MTC. DESIGN We used the Surveillance, Epidemiology and End Results (SEER) registry to retrospectively analyze all patients with T1 stage MTC diagnosed between 2004 and 2015. The tumour diameter 1.0 and 0.5 cm were used as the cut-off points to group and analyze the differences of clinicopathological features. We analyzed the prognosis of patients with less than total thyroidectomy. METHODS The disease-specific survival was the main outcome. Survival was estimated with Kaplan-Meier curves and Cox regression models estimated hazard ratios for tumour characteristics. RESULTS A total of 908 patients diagnosed with T1 stage MTC in the SEER database were included. Our study found that tumour diameter 1.0 cm is a key point affecting the prognosis of T1 stage MTC patients, although patients with tumour diameter ≤ 0.5 cm had a lower rate of lymph node metastasis and no distant metastasis. Cox proportional hazard multivariate analysis showed that distant metastasis was the only risk factor for survival in patients with T1 stage MTC. Kaplan-Meier survival analysis showed that, regardless of tumour diameter, there was no significant difference between less than total thyroidectomy and total thyroidectomy in T1 stage patients. CONCLUSIONS For incidental MTC with tumour diameter ≤ 1.0 cm and without distant metastasis, if there is no significant increase in serum calcitonin level after surgery and ret proto-oncogene (RET) gene mutation is negative, it may be not necessary to perform completion thyroidectomy immediately.
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Affiliation(s)
- Zhiqiang Gui
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Zhihong Wang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Jingzhe Xiang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Wei Sun
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Liang He
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Wenwu Dong
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Jiapeng Huang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Dalin Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Chengzhou Lv
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Ting Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Liang Shao
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Ping Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, PR China
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Zhang D, Colombo C, Sun H, Kim HY, Pino A, De Leo S, Gazzano G, Persani L, Dionigi G, Fugazzola L. Unilateral Surgery for Medullary Thyroid Carcinoma: Seeking for Clinical Practice Guidelines. Front Endocrinol (Lausanne) 2022; 13:875875. [PMID: 35898450 PMCID: PMC9309363 DOI: 10.3389/fendo.2022.875875] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Optimized preoperative diagnostic tools with calcitonin tests, ultrasound features, functional imaging modalities, and genetic testing to detect hereditary forms have led to an increased rate of earlier diagnosis and surgery for medullary thyroid cancer (MTC). This helps to adapt the primary surgery to the tumor stage and avoid surgical overtreatment for localized tumor growth, i.e., deviating from the regularly recommended thyroidectomy with bilateral central lymph node dissection in favor of a limited unilateral approach. To limit primary surgical therapy, it is crucial that the MTC is clinically unifocal, sporadic, and confined to the thyroid, and that calcitonin levels indicate biochemical recovery after surgery. The main requirement for such a limited approach is the availability of frozen section studies that reliably indicate (i) R0 resection of the MTC, (ii) absence of infiltration of the organ capsule, (iii) lack of desmoplasia (i.e., evidence of the metastatic potential of the MTC), (iiii) absence of contralateral disease or precancerous lesions. Informed consent is mandatory from the patient, who has been fully informed of the advantages, disadvantages, and potential risks of not undergoing the "classic" surgical procedure. The aim of this article is to review the guidelines for the management of early-stage MTC.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun City, China
| | - Carla Colombo
- Division of Endocrine and Metabolic Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Correspondence: Carla Colombo, ; Hui Sun,
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun City, China
- *Correspondence: Carla Colombo, ; Hui Sun,
| | - Hoon Yub Kim
- Korea University College of Medicine (KUMC) Thyroid Center, Department of Surgery, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Antonella Pino
- Division of Surgery, Istituto Auxologico Italiano INstituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Simone De Leo
- Division of Endocrine and Metabolic Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
| | - Giacomo Gazzano
- Pathology Unit, Istituto Auxologico Italiano INstituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Gianlorenzo Dionigi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Division of Surgery, Istituto Auxologico Italiano INstituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Completion thyroidectomy: is timing important for transcervical and remote access approaches? World J Otorhinolaryngol Head Neck Surg 2020; 6:165-170. [PMID: 33073211 PMCID: PMC7548381 DOI: 10.1016/j.wjorl.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 12/21/2022] Open
Abstract
Completion thyroidectomy (CT) is employed after lobectomy when histopathological results mandates total removal of the gland as in case of well differentiated thyroid carcinoma (DTC). It is also employed as a second stage thyroid surgery when unfavorable events occur as in recurrent laryngeal nerve injury or when the surgeon finds out the case is beyond his/her expertise in an attempt to protect the contralateral side and allowing time for recovery or for an expert surgeon to help.
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Abstract
Improvements in preoperative diagnostic modalities in conjunction with highly sensitive calcitonin assays, ultrasound and functional imaging modalities and differentiated genetic testing for detection of hereditary forms, have enabled detection and resection of medullary thyroid carcinoma at an increasingly earlier stage. These developments open up possibilities to deescalate primary surgery adapted to these stages and avoid surgical overtreatment in locally limited tumor growth: thus, promoting a shift from routinely recommended total thyroidectomy with bilateral central lymph node dissection in favor of limited unilateral thyroid resection. Prerequisites for limited thyroid resection include clinical evidence that the tumor is sporadic, unifocal and confined to the thyroid. Corresponding calcitonin levels should also indicate that a biochemical cure will be achieved after unilateral resection. A decisive structural prerequisite for such a limited concept is the low threshold availability of intraoperative frozen section analysis that reliably detects and evaluates a medullary thyroid carcinoma and can assess a breach of the thyroid capsule and desmoplasia with certainty.
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Azizi F, Mehran L, Hosseinpanah F, Delshad H, Amouzegar A. Secondary and tertiary preventions of thyroid disease. Endocr Res 2018; 43:124-140. [PMID: 29319359 DOI: 10.1080/07435800.2018.1424720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Secondary and tertiary preventions are concerned with the recognition of the disease process in a very early stage and delay in progression to complete disease and minimization of complications and the impact of illness. METHODS All articles related to secondary and tertiary prevention of thyroid diseases were reviewed. Using related key words, articles published between 2001 and 2015 were evaluated, categorized, and analyzed. RESULTS In secondary prevention, congenital hypothyroidism and subclinical hypo and hyperthyroidism are equally important. Routine screening of patients with multinodular goiter by either ultrasonography or calcitonin is a controversial issue, while calcitonin assessments in medullary cancer and RET in family members are recommended. Screening of thyroid disease in pregnancy is limited to those with risk factors. Views regarding the importance of thyroid autoimmunity in secondary prevention are also presented. In tertiary prevention, prescribing excessive doses of levothyroxine, in the elderly in particular and appropriate care of all patients to avoid progression and complications are the key issues. CONCLUSION Optimization of management of thyroid diseases requires timely screening, prevention of progression to more sever disease, optimal medical care, and avoidance of iatrogenic conditions.
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Affiliation(s)
- Fereidoun Azizi
- a Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Ladan Mehran
- a Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Farhad Hosseinpanah
- b Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Hossein Delshad
- b Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Atieh Amouzegar
- a Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran , Iran
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Clinicopathological Significance and Prognosis of Medullary Thyroid Microcarcinoma: A Meta-analysis. World J Surg 2017; 41:2551-2558. [DOI: 10.1007/s00268-017-4031-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Medullary thyroid carcinoma (MTC) is subdivided into sporadic (75%) and hereditary (25%) forms. Several germline mutations in the RET proto-oncogene are the source of distinct clinical phenotypes in hereditary MTC including familial MTC (FMTC) and multiple endocrine neoplasia 2A (MEN 2A) and 2B (MEN 2B). The higher the penetrance of the MEN 2 phenotype the earlier the progression of MTC which forms the basis for the currently recommended codon-related concept of prophylactic thyroidectomy. In patients with sporadic MTC, routine calcitonin (CT) measurement in nodular goiter patients has been shown to reduce the frequency of advanced tumor stages. Patients with CT levels over 100 pg/ml after pentagastrin stimulation are recommended for total thyroidectomy. In patients with unexpected sporadic MTC after histological examination, completion thyroidectomy is currently only recommended when CT levels remain elevated. The extent of lymph node dissection in patients with MTC is controversial. However, with respect to lymphonodal micrometastases, systematic compartment-oriented microdissection has been shown to reduce the frequency of lymphonodal recurrence. On the other hand, to avoid unnecessary lymph node dissection, a more individualized concept is required in the future. New chemotherapeutic agents (tyrosine kinase inhibitors), therapeutic nuclids (90Yttrium-labeled octreotide), and chemoembolization of liver metastases are currently the most promising therapeutical concepts in patients with distant metastases.
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Affiliation(s)
- M Brauckhoff
- Department of General, Visceral, and Vascular Surgery, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
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Mazeh H, Orlev A, Mizrahi I, Gross DJ, Freund HR. Concurrent Medullary, Papillary, and Follicular Thyroid Carcinomas and Simultaneous Cushing's Syndrome. Eur Thyroid J 2015; 4:65-8. [PMID: 25960965 PMCID: PMC4404927 DOI: 10.1159/000368750] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/29/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Papillary thyroid carcinoma is the most common thyroid cancer (85%). Follicular thyroid carcinoma is the second most common type of thyroid cancer, accounting for up to 10% of all thyroid cancers. Medullary thyroid carcinoma accounts for only 5-8% of thyroid cancers. Concurrent medullary, follicular, and papillary carcinomas of the thyroid gland are extremely rare and reported scarcely. CASE REPORT A 72-year-old male presented with nonspecific neck pain. The workup revealed a nodular thyroid gland with a follicular lesion on fine-needle aspiration. Total thyroidectomy was performed and pathological examination identified a 25-mm follicular carcinoma, two papillary microcarcinomas, and two medullary microcarcinomas. The genetic workup was negative and no other family members were diagnosed with any endocrinopathy. Two months after surgery, the patient was diagnosed with Cushing's syndrome that was treated with laparoscopic left adrenalectomy. On 3-year follow-up, the patient is asymptomatic with no evidence of recurrent disease. CONCLUSION We present a rare case of a patient with follicular, papillary, and medullary thyroid carcinoma, and Cushing's syndrome. To date, no known genetic mutation or syndrome can account for this combination of neoplastic thyroid and adrenal pathologies, although future research may prove differently.
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Affiliation(s)
- Haggi Mazeh
- Department of SurgeryEndocrinology and Metabolism Service Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- *Haggi Mazeh, MD, Department of Surgery, Hadassah University Hospital Mount Scopus, PO Box 24035, Jerusalem 91240 (Israel), E-Mail
| | - Amir Orlev
- Department of SurgeryEndocrinology and Metabolism Service Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ido Mizrahi
- Department of SurgeryEndocrinology and Metabolism Service Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David J. Gross
- Endocrinology and Metabolism Service Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Herbert R. Freund
- Department of SurgeryEndocrinology and Metabolism Service Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Saltiki K, Rentziou G, Stamatelopoulos K, Georgiopoulos G, Stavrianos C, Lambrinoudaki E, Alevizaki M. Small medullary thyroid carcinoma: post-operative calcitonin rather than tumour size predicts disease persistence and progression. Eur J Endocrinol 2014; 171:117-26. [PMID: 24760539 DOI: 10.1530/eje-14-0076] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Recently, small medullary thyroid carcinomas (smallMTCs; ≤1.5 cm) are frequently diagnosed, occasionally as incidental findings in surgical specimens. Their clinical course varies. We examined tumour size as a predictor of clinical behaviour. DESIGN A retrospective study. METHODS A total of 128 smallMTC patients (35.2% males and 45% familial) were followed up for 0.9-30.9 years. According to tumour size (cm), patients were classified into four groups: group 1, 0.1-0.5 (n=33); group 2, 0.6-0.8 (n=33); group 3, 0.8-1.0 (n=29) and group 4, 1.1-1.5 (n=33). RESULTS Pre- and post-operative calcitonin levels were positively associated with the tumour size (P<0.001). Capsular and lymph node invasion were more frequent in groups 3 and 4 (P<0.03); the stage was more advanced and the outcome was less favourable with an increasing tumour size (P<0.001). Groups 1 and 2 patients were more frequently cured (group 1, 87.8%; group 2, 72.7%; group 3, 68.9%; and group 4, 48.5%; P=0.002). The 10-year probability of lack of disease progression according to the tumour size differed between patients with tumour sizes of 0.1-1.0 and 1.1-1.5 cm (96.6%, 81.3%, x(2)=4.03, P=0.045 for log-rank test). Post-operative calcitonin was the only predictor significantly associated with the 10-year progression of disease. Post-operative calcitonin levels ≥4.65 pg/ml predicted disease persistence (sensitivity 93.8% and specificity 90%) and ≥14.5 pg/ml predicted disease progression (sensitivity 100%, specificity 82%, receiver operating characteristic curve analysis). CONCLUSIONS Tumour size may be of clinical importance only in patients with MTCs >1 cm in size. Post-operative calcitonin is a more important predictor than size for disease progression.
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Affiliation(s)
- Katerina Saltiki
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Gianna Rentziou
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Kimon Stamatelopoulos
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Georgios Georgiopoulos
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Charalambos Stavrianos
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Eirini Lambrinoudaki
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
| | - Maria Alevizaki
- Endocrine UnitDepartment of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias Avenue, 11528 Athens Greece
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Elisei R, Romei C. Calcitonin estimation in patients with nodular goiter and its significance for early detection of MTC: european comments to the guidelines of the American Thyroid Association. Thyroid Res 2013; 6 Suppl 1:S2. [PMID: 23514432 PMCID: PMC3599715 DOI: 10.1186/1756-6614-6-s1-s2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
One of the most discussed and controversial issue in the management of thyroid nodules is the need to perform a routine measurement of serum Calcitonin (Ct) in all cases. The American Thyroid Association guidelines do not recommend in favor or against this procedure since they retain that there are not enough evidences that it can determine an advantage to the health outcomes of these patients. This is not the view of many European experts who met in Lisbon in 2009 at the European Thyroid Association-Cancer Research Network meeting to discuss all the still open controversial issues on the management of medullary thyroid cancer patients. This paper is focused on the routine measurement of serum Ct in all patients with thyroid nodule(s): the evidences, the rational and the benefits of this procedure are deeply analysed following the discussion that was done in Lisbon. The conclusions reached at that time are reported in detail.
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Affiliation(s)
- Rossella Elisei
- Department of Endocrinology and Metabolism, University of Pisa, Lungarno Pacinotti 43 - 56126 Pisa, Italy.
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Dralle H, Musholt TJ, Schabram J, Steinmüller T, Frilling A, Simon D, Goretzki PE, Niederle B, Scheuba C, Clerici T, Hermann M, Kußmann J, Lorenz K, Nies C, Schabram P, Trupka A, Zielke A, Karges W, Luster M, Schmid KW, Vordermark D, Schmoll HJ, Mühlenberg R, Schober O, Rimmele H, Machens A. German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors. Langenbecks Arch Surg 2013; 398:347-75. [PMID: 23456424 DOI: 10.1007/s00423-013-1057-6] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages. METHODS The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization. RESULTS The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases. CONCLUSION These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.
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Affiliation(s)
- Henning Dralle
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Straße 40, 06097, Halle, Saale, Germany.
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Kazaure HS, Roman SA, Sosa JA. Medullary thyroid microcarcinoma. Cancer 2011; 118:620-7. [DOI: 10.1002/cncr.26283] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 04/14/2011] [Accepted: 04/19/2011] [Indexed: 01/03/2023]
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Abstract
The 5 main types of thyroid cancer (papillary, PTC, follicular, FTC, poorly differentiated, PDTC undifferentiated, UTC, medullary, MTC) not only differ regarding morphology, pathogenesis, genetics,and pathophysiology (iodine metabolism, thyroglobulin and calcitonin production), but also concerning tumor biology, metastatic behavior (lymphogenous, locally invasive and hematogenous routes) and prognosis. Knowledge of these features is the basis of the surgical concept of one or two-stage thyroidectomy, the exceptions and the concept of locoregional lymph node dissection. Lymph node surgery plays an important role in those cancers exhibiting mainly lymph node metastases (PTC, MTC) not only due to frequent recurrences but also due to its potential curative intent. Differentiated carcinomas may have an acceptable prognosis despite local invasion of the cervical aerodigestive system, thus resections are justified when technical prerequisites are given.
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Cherenko M, Slotema E, Sebag F, De Micco C, Henry JF. Mild hypercalcitoninaemia and sporadic thyroid disease. Br J Surg 2010; 97:684-90. [DOI: 10.1002/bjs.6965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Not operating on patients with mild hypercalcitoninaemia (MHCT) and sporadic thyroid disease carries the risk of omitting curative surgery for medullary thyroid cancer, but systematic surgery would result in unnecessary treatment of benign pathology. This study reviewed the management of MCHT and non-hereditary thyroid disease in one centre.
Methods
MCHT was defined as an increase in basal and stimulated calcitonin levels not exceeding 30 and 200 pg/ml respectively. Over 15 years, 125 patients who presented with MCHT and sporadic thyroid disease were followed. Surgery was indicated only if there were local pressure symptoms or suspicious histomorphological changes in solitary nodules.
Results
Fifty-five patients underwent total thyroidectomy and 18 unilateral total lobectomy. Histological examination revealed medullary microcarcinoma in six patients (two women and four men). C-cell hyperplasia was found in 54 patients (74 per cent) and 13 (18 per cent) harboured no C-cell pathology. Calcitonin levels stabilized after lobectomy and became undetectable following thyroidectomy. They normalized during follow-up in a third of patients who did not have surgery.
Conclusion
Not all patients with MHCT and sporadic thyroid disease require surgery.
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Affiliation(s)
- M Cherenko
- Department of Endocrine Surgery, University Hospital Marseilles, Marseilles, France
| | - E Slotema
- Department of Endocrine Surgery, University Hospital Marseilles, Marseilles, France
| | - F Sebag
- Department of Endocrine Surgery, University Hospital Marseilles, Marseilles, France
| | - C De Micco
- Department of Pathology, University Hospital Marseilles, Marseilles, France
| | - J F Henry
- Department of Endocrine Surgery, University Hospital Marseilles, Marseilles, France
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Machens A, Hauptmann S, Dralle H. Increased risk of lymph node metastasis in multifocal hereditary and sporadic medullary thyroid cancer. World J Surg 2007; 31:1960-5. [PMID: 17665245 DOI: 10.1007/s00268-007-9185-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In sporadic and hereditary medullary thyroid cancer, tumor multifocality may constitute an independent risk factor of lymph node metastasis on top of primary tumor size when the diameter of the largest primary tumor is the same. METHODS Included in this institutional cohort study were 232 consecutive patients operated on at our institution for hitherto untreated medullary thyroid cancer. Associations of clinicopathologic variables with lymph node metastasis were investigated simultaneously using multivariate Cox regression analysis. RESULTS On univariate analysis, multifocal cancers developed lymph node metastases significantly more often (p < or = 0.005) than unifocal cancers, in both the sporadic (90% vs. 41%) and the hereditary setting (48% vs. 14%). On multivariate Cox regression analysis on lymph node metastasis as a function of primary tumor diameter, only multifocal (vs. unifocal) tumor growth was significantly associated with lymph node metastasis (odds ratio [OR] = 2.5; p = 0.01). When multifocal growth was removed as an independent variable from the Cox model, heredity became the only significant predictor (OR = 3.1; p < 0.0001). CONCLUSION The excess risk of lymph node metastasis of 34%-49% in multifocal medullary thyroid cancer seems to be caused by concurrent smaller thyroid cancers. A diagnosis of more than one medullary thyroid cancer signifies a higher risk of lymph node metastasis, warranting systematic lymph node dissection.
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Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str 40, D-06097, Halle/Saale, Germany.
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Long-term clinical and biochemical follow-up in medullary thyroid carcinoma: a single institution's experience over 20 years. Ann Surg 2007; 246:815-21. [PMID: 17968174 DOI: 10.1097/sla.0b013e31813e66b9] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many patients with medullary thyroid carcinomas (MTC) have reoperative surgery in different hospitals, which makes their follow-up difficult. To comprehend these complex courses and to find relevant prognostic factors we report a 20-year single center experience of 289 patients with MTC or precursor C-cell-hyperplasias. PATIENTS AND METHODS Between April 1986 and May 2006, 289 consecutive patients with MTC or MEN2 gene carriers were treated at the Department of Surgery at the University Hospital Düsseldorf. Tumor stages were documented according to the classification of the International Union against Cancer 5th edition, 1997 (Schott. Endocr Relat Cancer. 2006;13:779-795). A system to easily comprehend operative procedures is suggested. RESULTS There were 159 female and 130 male patients (f/m ratio 1.22). Mean age at time of diagnosis was 32 years (4-77) in the familial cases and 53 years (23-84) years in the sporadic cases. Sixty-six patients (23%) had multifocal disease. Twelve MEN2-patients had only C-cell-hyperplasia (pT0). Tumor stage was pT1 in 86 patients, pT2 in 106 patients, pT3 in 25 patients, pT4 in 52 patients and unclear in 8 patients. In the 289 patients 648 operations were performed. One hundred seventy patients had more than 1 operation (59%). Ninety-nine patients (34%) are calcitonin-negative and 91 patients (31%) live with elevated calcitonin. Median follow-up time of the surviving 211 patients was 8.9 years (range, 0.3-30.7 years). The 5- and 10-year survival of all tumor patients was 86% and 68%, respectively. CONCLUSION The chance to achieve biochemical cure in MTC is clearly dependent on the primary tumor size. The chance for long-term biochemical cure in a pT4-tumor is almost nil even after multiple and extended reoperations, whereas a pT1 tumor can be cured in up to 67% of the patients. Long-term survival, however, can be achieved even in pT4 tumor patients in almost 50%.
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Medullary thyroid microcarcinoma recommendations for treatment – A single-center experience. Surgery 2007; 142:1003-10; discussion 1010.e1-3. [DOI: 10.1016/j.surg.2007.09.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2007] [Revised: 09/05/2007] [Accepted: 09/07/2007] [Indexed: 11/22/2022]
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Al-Rawi M, Wheeler MH. Medullary thyroid carcinoma--update and present management controversies. Ann R Coll Surg Engl 2007; 88:433-8. [PMID: 17002842 PMCID: PMC1964684 DOI: 10.1308/003588406x117043] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Medullary thyroid carcinoma (MTC) is a rare thyroid malignancy arising from the parafollicular C cells. It accounts for 5-10% of thyroid malignancies and occurs in sporadic and hereditary forms. There are still many controversial aspects relating to the diagnosis and management of this unusual tumour in its various forms. The present article addresses the more important of these issues. METHODS A literature review was performed using Pubmed database combined with additional original papers obtained from citations in those articles identified in the original literature search. Only those articles which related specifically to the controversial issues addressed in this review were included. RESULTS Genetically determined tumours constitute approximately 25% of MTC and have special clinical interest because of their association with other endocrinopathies including phaeochromocytoma and hyperparathyroidism in the multiple endocrine neoplasia syndromes (MEN IIa and MEN IIb). Familial medullary thyroid carcinoma (FMTC) is a rare form not associated with any other endocrinopathies. The genetic basis for these familial tumours derives from a series of missense germline mutations in the RET protooncogene. Genetic testing by DNA analysis facilitates identification of family members at risk who can now be offered early 'prophylactic thyroidectomy' with an increased prospect of surgical success and long-term survival. MTC is a tumour which does not take up radioactive iodine, is relatively radioresistant and poorly responsive to chemotherapy. Therefore, surgery is the only treatment which can offer the prospect of cure. Total thyroidectomy with central and lateral nodal dissection can achieve biochemical cure (normocalcitonaemia) in more than 80% of cases. Compartmental orientated microdissection of cervical nodes has significantly improved the results of primary surgery but even so a group of 20% of patients will prove to have recurrent or residual disease. These cases require detailed investigation by a variety of techniques including ultrasound, cross-sectional imaging, nuclear imaging and laparoscopy with liver biopsy to exclude disseminated disease and select those patients who can be offered a prospect of cure by further neck surgery. Such an approach may be associated with successful normalisation of calcitonin levels in about 40%. CONCLUSIONS It is hoped that in the near future new medical therapies may become available to treat MTC which still has a 10-year survival of only 60-80% in spite of the application of meticulous surgical techniques.
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Affiliation(s)
- Mahir Al-Rawi
- Department of Endocrine Surgery, University Hospital of Wales, Cardiff, UK
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Wahl RA, Vorländer C, Kriener S, Pedall J, Spitza M, Hansmann ML. Isthmus-Preserving Total Bilobectomy: An Adequate Operation for C-Cell Hyperplasia. World J Surg 2006; 30:860-71. [PMID: 16680601 DOI: 10.1007/s00268-005-0424-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Autopsy studies show that C cells deriving from the ultimobranchial body and migrating into the thyroid do not reach the isthmus region and are distributed along the vertical axes of thyroid lobes. This was confirmed in a surgical series of 58 patients (34 with preoperatively normal and 24 with elevated serum calcitonin) where no calcitonin-positive cells were demonstrable immunohistochemically within separately investigated isthmi. Consequently, isthmus-preserving total bilateral lobectomy (IPTB) may be regarded as an adequate surgical procedure for C-cell hyperplasia (CCH). PATIENTS AND METHODS IPTB was performed from October 2001 to December 2004 in 64 patients, 59 patients with nodular goiter and slightly to moderately elevated serum calcitonin (stimulated under 500 pg/ml) (group A, apparently sporadic cases) and in 5 patients undergoing prophylactic surgery for hereditary medullary thyroid carcinoma (MTC) with intermediate- or low-risk RET mutations (non-634) (group B). The surgical procedure focused on meticulous total extracapsular resection of both thyroid lobes, preservation of an isthmus remnant of about 3 ml (smaller in children), and histologic workup of the border zones of resection in addition to that of the completely removed lobes. When malignancy could be proven intraoperatively (7 patients) or when the isthmus turned out to contain nodular lesions (4 patients), completion total thyroidectomy (plus lymphadenectomy) was performed as a one-stage procedure. Second-stage total thyroidectomy was performed in 3 cases. Thus, IPTB was the definitive surgical procedure in 50 patients (45 of group A and all 5 of group B). RESULTS In all of the 50 definite IPTB cases, postoperative serum calcitonin was below the measurable limit (2 pg/ml); stimulated calcitonin was below the measurable limit in 47 (including all of group B) and was measurable in 3 sporadic cases in a lower-normal range between 2.4 and 3.5 pg/ml. Genetic screening of the apparently sporadic cases with CCH was positive in one (codon 791). The risk of recurrent laryngeal nerve paralysis seems not to be elevated (0% permanent); permanent hypocalcemia occurred in 1 patient (2%). Follow-up data of 37 patients, median 18 (6-36) months, showed continuously nonmeasurable serum calcitonin with one exception, where it was in the normal range after 18 months. All IPTB patients are still under substitution therapy with L-thyroxine (median 125 mug/day) with decreasing tendency in all 3 children after prophylactic operation, the latter also showing an increasing volume of well-vascularized isthmi (from 1.5 to 2.5 ml). CONCLUSION IPTB reliably removes all C cells. There may not be need for total thyroidectomy (TTx) in cases with CCH. When necessary, completion TTx can be performed easily without additional risk. IPTB leaves a functionally relevant remnant, corresponding to that of a subtotal resection. This might be of importance especially for prophylactic surgery in children where the isthmus can compensate for the loss of thyroid function with time.
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Affiliation(s)
- Robert Arnulf Wahl
- Department of Surgery, Bürgerhospital Frankfurt am Main, Nibelungenallee 37 - 41, 60318, Frankfurt am Main, Germany.
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