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Toro-Tobon D, Brito JP. Controversies in the Management of Intermediate-Risk Differentiated Thyroid Cancer. Endocr Pract 2024; 30:879-886. [PMID: 38876179 DOI: 10.1016/j.eprac.2024.06.003] [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: 04/12/2024] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Intermediate-risk thyroid cancer accounts for up to two-thirds of all cases of differentiated thyroid cancer (DTC), yet it is subject to substantial variations in risk stratification and management strategies. METHODS This comprehensive review examines the current controversies regarding diagnosis and management of intermediate risk DTC. RESULTS The evolution of risk stratification systems is discussed, highlighting limitations such as heterogeneity in patient cohorts, variability in outcome definitions, and the need for more precise risk estimation tools incorporating genetic profiles and individual risk modifiers. The role of radioactive iodine therapy in intermediate-risk DTC is examined, considering evolving evidence, conflicting study results, and the necessity for personalized treatment decisions based on risk modifiers, potential morbidity, and patient preferences. Furthermore, the shift from total thyroidectomy to lobectomy in certain intermediate-risk cases is explored, emphasizing the need for tailored surgical approaches and the impact on long-term outcomes, recurrence rates, and quality of life. CONCLUSION Management of intermediate-risk DTC remains controversial. This review summarizes current evidence to aid decision-making. Further research, prospective trials, and collaboration are crucial to address these complexities and personalize care for patients.
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Affiliation(s)
- David Toro-Tobon
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester; Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota.
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Cao M, Yu T, Miao X, Wu Z, Wang W. The preferred surgical choice for intermediate-risk papillary thyroid cancer: total thyroidectomy or lobectomy? A systematic review and meta-analysis. Int J Surg 2024; 110:5087-5100. [PMID: 38967517 PMCID: PMC11325972 DOI: 10.1097/js9.0000000000001556] [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: 02/24/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The optimal surgical approach for intermediate-risk papillary thyroid carcinoma (IR-PTC) (according to ATA definition), whether total thyroidectomy (TT) or lobectomy (LT), has remained a contentious clinical gray area for several decades. This systematic review and meta-analysis aim to provide robust evidence and address this clinical dilemma comprehensively. MATERIALS AND METHODS A comprehensive literature search was conducted in Pubmed, Embase, Web of Science, and the Cochrane Library from 1st January 2009 to 29th December 2023 to evaluate the impact of different surgical options (TT or LT) on patients with IR-PTC. The primary outcomes included survival, recurrence rates, and postoperative complications. I2 and sensitivity analysis was used to explore the heterogeneity. RESULTS A total of 8 studies involving 2984 participants were included in this meta-analysis and systematic review. The results indicated that LT was a superior choice for mitigating complications compared to TT [risk ratio (RR), 0.32; 95% CI: 0.24-0.44, P <0.01], particularly for transient complications (RR, 0.24; 95% CI: 0.08-0.65, P <0.01), such as the transient parathyroid dysfunction (RR, 0.04; 95% CI: 0.01-0.15, P <0.01). However, TT did not increase the risk of recurrent laryngeal nerve palsy (RR, 0.78; 95% CI: 0.24-2.47, P =0.67), hemorrhage/seroma (RR, 0.77; 95% CI: 0.48-1.25, P =0.30), and permanent complications (RR, 0.18; 95% CI: 0.02-1.42, P =0.10). Besides, both LT and TT presented similar effect on survival outcomes (overall survival: RR, 1.00; 95% CI: 0.97-1.03, P =0.92, disease-specific survival: RR, 0.99; 95% CI: 0.97-1.02, P =0.69, recurrence-free survival: RR, 1.00; 95% CI: 0.96-1.05, P =0.86), recurrence (RR, 1.05; 95% CI: 0.76-1.46, P =0.76). CONCLUSION The present meta-analysis revealed that TT did not yield improved outcomes in IR-PTC patients, but was associated with an increased incidence of temporary complications. In light of these findings, it may be advisable to consider LT as the optimal choice for IR-PTC patients.
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Affiliation(s)
- Mingyu Cao
- Department of General Surgery, Xiangya Hospital, Central South University
| | - Tiexin Yu
- Department of General Surgery, Xiangya Hospital, Central South University
| | - Xingyu Miao
- Department of General Surgery, Xiangya Hospital, Central South University
| | - Zhijing Wu
- Department of General Surgery, Xiangya Hospital, Central South University
| | - Wenlong Wang
- Department of General Surgery, Xiangya Hospital, Central South University
- Clinical Research Center for Breast Cancer Control and Prevention in Hunan Province, Changsha
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
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do Prado Padovani R, Duarte FB, Nascimento C. Current practice in intermediate risk differentiated thyroid cancer - a review. Rev Endocr Metab Disord 2024; 25:95-108. [PMID: 37995023 DOI: 10.1007/s11154-023-09852-y] [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] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
Although the overall prognosis for differentiated thyroid cancer (DTC) is excellent, a subset of patients will experience disease recurrence or may not respond to standard treatments. In recent years, DTC management has become more personalized in order to enhance treatment efficacy and avoid unnecessary interventions.In this context, major guidelines recommend post-surgery staging to assess the risk of disease persistence, recurrence, and mortality. Consequently, risk stratification becomes pivotal in determining the necessity of postoperative adjuvant therapy, which may include radioiodine therapy (RIT), the degree of TSH suppression, additional imaging studies, and the frequency of follow-up.However, the intermediate risk of recurrence is a highly heterogeneous category that encompasses various risk criteria, often combined, resulting in varying degrees of aggressiveness and a recurrence risk ranging from 5 to 20%. Furthermore, there is not enough long-term prognosis data for these patients. Unlike low- and high-risk DTC, the available literature is contradictory, and there is no consensus regarding adjuvant therapy.We aim to provide an overview of intermediate-risk differentiated thyroid cancer, focusing on criteria to consider when deciding on adjuvant therapy in the current context of personalized approach, including molecular analysis to enhance the accuracy of patient management.
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Affiliation(s)
- Rosalia do Prado Padovani
- Section of Endocrinology and Metabolism, Department of Medicine, Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Doutor Cesário Mota Junior, , 61 - SAO PAULO -CEP, São Paulo, 1221020, Brazil.
| | - Fernanda Barbosa Duarte
- Section of Endocrinology and Metabolism, Department of Medicine, Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Doutor Cesário Mota Junior, , 61 - SAO PAULO -CEP, São Paulo, 1221020, Brazil
| | - Camila Nascimento
- Nuclear Medicine Department, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
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Del Rio P, Polistena A, Chiofalo MG, De Pasquale L, Dionigi G, Docimo G, Graceffa G, Iacobone M, Medas F, Pezzolla A, Sorrenti S, Spiezia S, Calò PG. Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2023; 75:1393-1417. [PMID: 37198359 PMCID: PMC10435599 DOI: 10.1007/s13304-023-01522-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/23/2023] [Indexed: 05/19/2023]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.
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Affiliation(s)
- P Del Rio
- Unit of General Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - A Polistena
- Department of Surgery Pietro Valdoni, University of Rome Sapienza, Rome, Italy
| | - M G Chiofalo
- Department Head and Neck, Thyroid Surgery Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - L De Pasquale
- Thyroid and Parathyroid Service, Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - G 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
| | - G Docimo
- Division of Thyroid Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - G Graceffa
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - M Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
| | - A Pezzolla
- Division of Videolaparoscopic Surgery, Department of Emergency and Organ Transplanatation, University of Bari "A. Moro", Bari, Italy
| | - S Sorrenti
- Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - S Spiezia
- Department of Endocrine and Ultrasound-guided Surgery, Ospedale del Mare, Naples, Italy
| | - P G Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Gambardella C, Mongardini FM, Paolicelli M, Bentivoglio D, Cozzolino G, Ruggiero R, Pizza A, Tolone S, del Genio G, Parisi S, Brusciano L, Cerbara L, Docimo L, Lucido FS. Role of Inflammatory Biomarkers (NLR, LMR, PLR) in the Prognostication of Malignancy in Indeterminate Thyroid Nodules. Int J Mol Sci 2023; 24:6466. [PMID: 37047439 PMCID: PMC10094849 DOI: 10.3390/ijms24076466] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
Indeterminate follicular thyroid lesions (Thyr 3A and 3B) account for 10% to 30% of all cytopathologic diagnoses, and their unpredictable behavior represents a hard clinical challenge. The possibility to preoperatively predict malignancy is largely advocated to establish a tailored surgery, preventing diagnostic thyroidectomy. We analyzed the role of the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR) and the lymphocyte-to-monocyte ratio (LMR) as prognostic factors of malignancy for indeterminate thyroid nodules. In patients affected by cytological Thyr 3A/3B nodules, NLR, PLR and LMR were retrospectively compared and correlated with definitive pathology malignancy, utilizing student's t-test, ROC analysis and logistic regression. One-hundred and thirty-eight patients presented a Thyr 3A and 215 patients presented a Thyr 3B. After the logistic regression, in Thyr 3A, none of the variables were able to predict malignancy. In Thyr 3B, NLR prognosticated thyroid cancer with an AUC value of 0.685 (p < 0.0001) and a cut-off of 2.202. The NLR results were also similar when considering the overall cohort. The use of cytological risk stratification in addressing the management of indeterminate thyroid nodules in patients is not always reliable. NLR is an easy and reproducible inflammatory biomarker capable of improving the accuracy of preoperative prognostication of malignancy.
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Affiliation(s)
- Claudio Gambardella
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Maddalena Paolicelli
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Davide Bentivoglio
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Giovanni Cozzolino
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Roberto Ruggiero
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Alessandra Pizza
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Gianmattia del Genio
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Simona Parisi
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Luigi Brusciano
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Loredana Cerbara
- Institute for Research on Population and Social Policies, National Research Council of Italy, 00185 Rome, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Francesco Saverio Lucido
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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Canu GL, Medas F, Cappellacci F, Giordano ABF, Gurrado A, Gambardella C, Docimo G, Feroci F, Conzo G, Testini M, Calò PG. Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study. Cancers (Basel) 2022; 14:cancers14102472. [PMID: 35626075 PMCID: PMC9139447 DOI: 10.3390/cancers14102472] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/09/2022] [Accepted: 05/14/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary The increasing use of high-quality imaging techniques together with improved access to healthcare has led to an increase in the detection of thyroid nodules. Fine-needle aspiration cytology (FNAC) is currently considered the most accurate examination for the assessment of thyroid nodular disease. However, in about 25% of cases, FNAC leads to the diagnosis of an indeterminate thyroid nodule, which represents a problem because malignancy, although relatively low (up to 30%), cannot be excluded with certainty. According to the 2015 American Thyroid Association guidelines, patients with thyroid nodular disease with an indeterminate cytology can undergo, based on established factors, a total thyroidectomy or a hemithyroidectomy. However, if an intermediate or high-risk differentiated thyroid carcinoma is detected after the hemithyroidectomy, through histological examination, the above-mentioned guidelines recommend performing a completion thyroidectomy. The main aim of this study was to assess the rate of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology. Abstract There is still controversy as to whether patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology have a comparable, increased or decreased risk of complications compared to those submitted to primary thyroid surgery. The main aim of this study was to investigate this topic. Patients undergoing a thyroidectomy for thyroid nodular disease with an indeterminate cytology in four high-volume thyroid surgery centres in Italy, between January 2017 and December 2020, were retrospectively analysed. Based on the surgical procedure performed, four groups were identified: the TT Group (total thyroidectomy), HT Group (hemithyroidectomy), CT Group (completion thyroidectomy) and HT + CT Group (hemithyroidectomy with subsequent completion thyroidectomy). A total of 751 patients were included. As for the initial surgery, 506 (67.38%) patients underwent a total thyroidectomy and 245 (32.62%) a hemithyroidectomy. Among all patients submitted to a hemithyroidectomy, 66 (26.94%) were subsequently submitted to a completion thyroidectomy. No statistically significant difference was found in terms of complications comparing both the TT Group with the HT + CT Group and the HT Group with the CT Group. The risk of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology was comparable to that of patients submitted to primary thyroid surgery (both a total thyroidectomy and hemithyroidectomy).
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Affiliation(s)
- Gian Luigi Canu
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato, CA, Italy; (F.M.); (F.C.); (P.G.C.)
- Correspondence:
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato, CA, Italy; (F.M.); (F.C.); (P.G.C.)
| | - Federico Cappellacci
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato, CA, Italy; (F.M.); (F.C.); (P.G.C.)
| | | | - Angela Gurrado
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, 70124 Bari, BA, Italy; (A.G.); (M.T.)
| | - Claudio Gambardella
- Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, NA, Italy; (C.G.); (G.D.)
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, NA, Italy; (C.G.); (G.D.)
| | - Francesco Feroci
- Department of General and Oncologic Surgery, Santo Stefano Hospital, 59100 Prato, PO, Italy; (A.B.F.G.); (F.F.)
| | - Giovanni Conzo
- Department of Traslational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, NA, Italy;
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, 70124 Bari, BA, Italy; (A.G.); (M.T.)
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato, CA, Italy; (F.M.); (F.C.); (P.G.C.)
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