Surgical treatment of thyroid carcinoma in a defined population: 1960 to 1977. Evaluation of the results after a conservative surgical approach

Partial thyroidectomy for papillary thyroid microcarcinoma: Is completion total thyroidectomy indicated?

AIM

Papillary thyroid microcarcinoma (PTMC) is increasing in incidence. Despite its excellent clinical outcomes, there is still debate regarding which surgical approach is more appropriate for PTMC, procedures including hemithyroidectomy (HT), total thyroidectomy (TT), and completion thyroidectomy (CT) after initial HT and histopathologic examination confirming a PTMC. Here we report our experience in the surgical management of PTMC.

METHODS

We conducted a retrospective evaluation of all patients who received a postoperative diagnosis of PTMC between January 2001 and January 2016. Every patient was divided according to the type of surgery performed (TT or HT alone). Follow-up consisted of regular clinical and neck ultrasonographic examination. Clinical and histopathological parameters (e.g. age, sex, lesion size, histological features, multifocality, lymph node metastases, BRAF status when available) as well as clinical outcomes (e.g. complications rates, recurrence, overall survival) were analyzed.

RESULTS

Group A consisted of 86 patients who underwent TT, whereas Group encompassed 19 patients who underwent HT. Mean follow-up period was 58.5 months. In Group A, one patient (1.2%) experienced recurrence in cervical lymph nodes with need for reoperation. In Group B, eight patients (42%) underwent completion thyroidectomy after histopathological examination confirming PTMC, while one patient (5.3%) developed PTMC in the contralateral lobe with need for reoperation at 2 years after initial surgery. Multifocality was found in 19 patients in Group A (22%). Of these, 14 presented bilobar involvement, whereas in 3 cases multifocality involved only one lobe. 1 patient in Group B (5.3%) presented with unilateral multifocal PTMC (p = 0.11).

CONCLUSIONS

Low-risk patients with PTMC may benefit from a more conservative treatment, e.g. HT followed by close follow-up. However, appropriate selection of patients based on risk stratification is the key to differentiate therapy options and gain better results.

Total versus hemithyroidectomy for small unilateral papillary thyroid carcinoma

The correct approach to treat low-risk intrathyroidal papillary thyroid carcinoma (PTC) is controversial. Specific authors advocate unilateral thyroidectomy to minimize perioperative morbidity. The purpose of the present study was to determine an effective treatment strategy for patients with small unilateral papillary thyroid. This was a retrospective comparative analysis of 161 patients with PTC treated between 2001–2010; 60 consecutive patients following hemithyroidectomy and 101 patients following total thyroidectomy. Only patients with preoperatively-predicted localized unilateral disease were included. No between-group difference was identified in the rate of permanent surgical complications. In total, 36 hemithyroidectomy patients (60%) exhibited benign thyroid nodules in the contralateral lobe on preoperative ultrasound; this factor was found to positively correlate with the performance of ≥1 fine needle aspirations (FNAs) during follow-up. In addition, 47 hemithyroidectomy patients (78.3%) were prescribed thyroxine postoperatively. The hemithyroidectomy patients visited the endocrine clinic significantly less frequently than the total thyroidectomy patients (P=0.01), but were referred more often for neck ultrasound (P=0.03) and FNA (P<0.001). In addition, an increased number of patients in the hemithyroidectomy group were reoperated for suspected recurrent/persistent disease (P=0.06). Results of this retrospective study indicate that hemithyroidectomy for small unilateral PTC is associated with a significant follow-up burden and provides no clear patient benefit.

Utility of BRAF V600E mutation detection in cytologically indeterminate thyroid nodules

Background

Fine needle aspiration (FNA) is widely utilized for evaluation of patients with thyroid nodules. However, approximately 30% are indeterminate for malignancy. Recently, a mutation in the BRAF gene has been reported to be the most common genetic event in papillary thyroid carcinoma (PTC). In this retrospective study, we assessed the utility of BRAF V600E mutation detection for refining indeterminate preoperative cytologic diagnoses in patients with PTC.

Methods

Archival indeterminate thyroid FNAs and corresponding formalin-fixed, paraffin-embedded (FFPE) surgical samples with PTC were identified in our patient files. DNA extracted from slide scape lysates and 5 μm FFPE sections were evaluated for the BRAF V600E mutation using LightCycler PCR and fluorescent melting curve analysis (LCPCR). Amplification products that showed deviation from the wild-type genomic DNA melting peak, discordant FNA and FFPE matched pairs, and all benign control samples, underwent direct DNA sequencing.

Results

A total of 19 indeterminate thyroid FNAs demonstrating PTC on FFPE surgical samples were included in the study. Using BRAF mutation analysis, the preoperative diagnosis of PTC was confirmed in 3/19 (15.8%) FNA samples that could not be conclusively diagnosed on cytology alone. However, 9/19 (47.4%) FFPE tissue samples were positive for the V600E mutation. Of the discordant pairs, 5/6 FNAs contained less than 50% tumor cells.

Conclusion

When used with indeterminate FNA samples, BRAF mutation analysis may be a useful adjunct technique for confirming the diagnosis of malignancy in an otherwise equivocal case. However, overall tumor cell content of some archival FNA smear slides is a limiting factor for mutation detection.

Papillary thyroid microcarcinoma: A surgical perspective

Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid cancer measuring less than 10mm in its greatest diameter. It is the most common form of thyroid cancer, detected in up to 36% in autopsy studies. The wide availability and use of neck ultrasonography in the evaluation of carotid arteries and of the thyroid resulted in an increased detection of PTMC. PTMC is often multifocal. The diagnosis is usually based on a combination of clinical examination, laboratory investigations, and specialized radiological techniques (mainly neck ultrasonography combined with fine-needle aspiration cytology). A common scenario is the diagnosis of PTMC as an incidental finding following thyroidectomy for a presumably benign thyroid disease. Despite some controversy, most authors agree that PTMC should be treated by total or near-total thyroidectomy, provided it can be performed safely. Because of its many and major advantages, in our clinical practice, total or near-total thyroidectomy is the procedure of choice for the management of PTMC. Given the high incidence of PTMC as an incidental finding and the frequent multi-focality, we also favor total or near-total thyroidectomy for the surgical management of nodular thyroid disease (multinodular goiter or dominant presumably benign thyroid nodule/s). Despite some controversy, we perform central neck lymph node dissection electively, in the presence of cervical lymphadenopathy. Radioiodine ablation therapy may be used as an adjuvant therapy. Prognostic factors (such as tumor multicentricity, positive lymph nodes, capsular or vascular invasion) or scoring systems (such as the AMES) can be used to select patients for radioiodine adjuvant therapy. Suppression therapy is needed after surgical management. Despite the potential for neck lymph node and even distant metastases, the biological behavior of PTMC is in general benign and the prognosis is very good.

Follicular neoplasms of the thyroid: view, biases, and experiences

The authors review the group of thyroid tumors characterized by a follicular growth pattern; these include follicular adenoma, follicular carcinoma, and the follicular variant of papillary carcinoma. Most of these lesions can be diagnosed with ease, but a subgroup has generated recent controversy in the literature. The authors present their views based on their experience with the cytologic and histologic diagnosis of these tumors and propose a scheme to assist in their classification and appropriate clinical management.

Prognostic Factors in Mortality and Morbidity in Patients with differentiated Thyroid Cancer

We attempted to determine if women younger than 45 years of age who have isolated papillary thyroid cancer and whose tumors are smaller than 4 cm (T2N0M0) are at low risk for mortality and morbidity following thyroid lobectomy. To this end, we analyzed information on both women and men obtained from our review of the literature, and we integrated it with data compiled in the Delaware Cancer Registry. We performed a secondary analysis to determine if the risk of death and recurrence can be predicted on the basis of age, tumor size, sex, histology, and the type of operation. We found that among patients who had undergone either thyroid lobectomy or total thyroidectomy, mortality rates were 1.3% for those younger than 45 years of age and 15.6% for those 45 years and older (p< 0.0001). With respect to tumor size, patients whose masses were smaller than 4 cm had significantly lower mortality (3.0%) and recurrence (11.1%) rates than did those whose tumors were 4 cm or larger (16.8 and 33.3%, respectively; p< 0.0001). Other significant risk factors for death were male sex and the presence of follicular thyroid cancer (as opposed to papillary thyroid cancer). The risk of permanent hypocalcemia was significant among patients who had undergone total thyroidectomy, but not among those who had been treated with lobectomy. The subgroup of patients who had the lowest risk of mortality and morbidity was made up of women younger than 45 years who had a papillary thyroid tumor smaller than 4 cm that was limited to one lobe and who had undergone lobectomy. On the other hand, we found that lobectomy might carry a higher risk of recurrence (from a micrometastasis in the cervical lymph node) than does total thyroidectomy. Experienced surgeons whose rates of hypocalcemia and recurrent laryngeal nerve paralysis following total thyroidectomy are low offer their patients the unambiguous advantage of superior follow-up with thyroglobulin and radioactive iodine.

An audit of the management of thyroid cancer in a district general hospital

OBJECTIVE

Thyroid cancer is the commonest endocrine malignancy yet it appeared to present infrequently to the endocrinologists at this large District General Hospital. The management of well-differentiated thyroid cancer remains controversial with a wide variation in clinical practice. The aim of this survey was to determine the characteristics of the patients diagnosed with thyroid cancer and whether any deficiencies existed in the management of subjects diagnosed with thyroid cancer over a five-year period using standards of care based upon long-term outcome data and recently published USA guidelines.

DESIGN AND PATIENTS

Retrospective case-note survey of all patients newly registered with thyroid cancer from 1990 to 1994 in North Staffordshire (estimated total population 450,000).

RESULTS

The annual incidence of all thyroid cancer was two per 100,000 of which well-differentiated tumours comprised 70%. Medical records were obtained in 48 new cases (91% of total) identified. Fifteen subjects who presented as surgical emergencies received only palliative treatment and had a poor outcome. Two patients presented with metastatic medullary thyroid carcinoma (3% of total). Thirty-one patients (97% of whom presented with a thyroid nodule) were referred electively to either surgical (n = 22), ENT (n = 2) or endocrinology (n = 7) outpatients with well-differentiated papillary (n = 17) and follicular (n = 14) tumours. Thirteen patients (42%) had fine-needle aspiration cytology performed preoperatively. Of the 22 tumours (71%) greater than 1.5 cm, five (27%) had a total thyroidectomy and two (9%) also had radioiodine ablation. There was inadequate serum thyrotrophin suppression postoperatively in 12 patients (39%) and only five (16%) were being monitored for recurrence with serum thyroglobulin measurements.

CONCLUSIONS

Deficiencies in the optimum management of small, well-differentiated thyroid cancers were identified. Improved communication between specialties has led to the development of an agreed management protocol to increase the quality of care offered to patients with thyroid cancer and for auditing the coordinated service in the future.

Papillary thyroid cancer in Mexico: review of 409 cases

This is a retrospective review of 409 cases of papillary thyroid cancer treated at the Hospital of Oncologia, National Medical Center, IMSS in Mexico City. The clinical features, histopathologic findings, analysis of recurrences and survivals according to age, sex, tumor size, and modality of treatment are described. The results showed that tumoral diameter > 5 cm, distant metastasis at diagnosis, age > 40 years, and tumoral infiltration beyond the thyroid capsule significantly affect the patient's survival.

"Occult" papillary carcinoma of the thyroid: a questionable entity

A series of 72 cases of "occult" thyroid papillary cancer, i.e. tumours of less than 1.5 cm in diameter, was analysed. The patients--26 males and 46 females--were treated surgically, 25 by lobectomy and isthmusectomy and 47 by total thyroidectomy. In 51 cases nodal neck dissection was performed, bilateral in 2 cases. 9 thyroidectomised patients received radiometabolic therapy. Hormone therapy (T4) was continuously administered to 57 patients. The median duration of follow-up was 99 months (60-189). All the patients were alive (except one who died from other causes) and free of disease at last control. No relapses in the thyroid were observed in the conservatively treated patients. 2 patients of the 47 radically operated upon subsequently presented nodal metastasis and underwent neck dissection. The so-called "occult" thyroid papillary cancer does not differ from other papillary cancers with respect to morphological, clinical and prognostic factors--it differs only in size. Considering occult papillary tumours as an entity is questioned in this paper.

Surgery in papillary thyroid carcinoma: a review of 730 patients

Between 1956 and 1978, 1143 patients with thyroid cancer, nearly half of all patients with thyroid carcinomas in Norway in this period, were seen in our hospital. Of 730 papillary cancer patients, 447 were operated with total thyroidectomy (TT), 179 with hemi-thyroidectomy (HT), while 104 patients had minor thyroid resections (RT). Survival and recurrence rates were similar in the TT- and HT-groups. Local recurrences were seen in 15.2% of the patients following total thyroidectomy and in 16.2% following hemi-thyroidectomy; distant metastases were seen in 10.7% and 11.2%, respectively. Beyond the seventh year of follow-up the cumulative survival was similar following total thyroidectomies, hemi-thyroidectomies, and thyroid resections. Unless grossly malignant residues were left behind, the impact of the surgical procedure on prognosis in papillary thyroid cancer seems minor.

Operative strategy for thyroid cancer. Is total thyroidectomy worth the price?

The authors conducted a retrospective analysis with 5- to 30-year follow-up on 109 patients in order to determine the optimum management of nonmedullary thyroid cancer. Results of total thyroidectomy were compared to partial thyroidectomy, among patients well matched for prognostic indicators. No differences in cancer mortality or recurrence rates were evident. However, there were significantly more complications when total thyroidectomy was employed. In view of these results, partial thyroidectomy is recommended as the treatment of choice for nonmedullary thyroid cancer.

Survival and prognostic factors in thyroid carcinoma

A multivariate analysis of prognostic factors and survival was carried out in a series of 200 patients with thyroid carcinoma. The cumulative survival rate corrected for intercurrent deaths was higher for papillary carcinoma than for follicular carcinoma both at 5 years (92% vs 74%) and at ten years (87% vs 66%) after the diagnosis. Seventeen of the eighteen patients with anaplastic carcinoma died within 24 months after the diagnosis. The most important independent prognostic factor in patients with papillary or follicular carcinoma, by multivariate analysis, was age at time of diagnosis, followed by tumor penetration beyond the thyroid capsule and follicular histologic type. When different types of treatment were included in the analysis, age at diagnosis still remained the most important prognostic factor. Misdiagnosed intercurrent deaths in the elderly did not explain the negative effect of age on survival.

[Radicality principles in operations on malignant thyroid tumors]

Different concepts are required by different tumors: anaplastic carcinomas rarely are accessible to curative surgery, but tumor reduction gives sense in combined concepts. In follicular carcinomas general ("near"-) total thyroidectomy + radioiodine + hormonal suppressive therapy is recommended, with respect to the high incidence of distant metastases even in low 1 degree Tu-stages. Papillary carcinomas allow a stage related procedure with exceptions from total thyroidectomy: no reintervention for "occult" carcinomas and-in patients under 40 years of age-hemithyroidectomy for intrathyroid tumors without regional metastases. In C-Cell-carcinomas total thyroidectomy has to be accompanied by lymph-node dissections of various extent, depending on familiary or sporadic type and tumor-stage.

Surgery for thyroid disease

Thyroidectomy is the keystone of management in most patients with thyroid cancer, and has unique advantages in many cases of hyperthyroidism. The role of thyroidectomy in these two conditions is considered, with specific discussion of indications, extent of operation, complications, and technique.

Delayed aerodigestive tract complications following combined therapy for thyroid cancer

Radical surgery for papillary adenocarcinoma of the thyroid has been associated with a significant incidence of complications. In some instances, postoperative irradiation is given when there is some suspicion of persistent or occult disease, although thyroid suppression and ablative radioiodine therapy have proved to be very effective adjuvants to surgery. Three patients with papillary adenocarcinoma of the thyroid developed severe, delayed complications 25, 7, and 2 years, respectively, after treatment with primary radical surgery and postoperative irradiation. The degree of injury to the aerodigestive tract as a result of the surgery and irradiation therapy makes treatment difficult regardless of the modality. The possible mechanisms that cause these complications, along with proposed methods of treatment, are discussed.

Surgery for thyroid carcinoma

The cases of thyroid carcinoma treated at this hospital during the period 1948 to 1981 were reviewed retrospectively. Nine hundred eighty-six patients with thyroid nodules were operated on. One hundred fifty-two were thyroid carcinoma (59 papillary, 36 mixed papillary-follicular, 30 follicular, 20 anaplastic, 5 medullary, and 2 Hurthle cell tumors). There was a 92% follow-up for a mean of 10 years. In the last decade, patients presented at a younger age, the female predominance was diminished, and 15% had had previous neck irradiation. Surgery consisted of total (27) or subtotal thyroidectomy (89), lobectomy or nodulectomy (24), and biopsy (12). Total thyroidectomy had an incidence of postoperative complications that was 20 times higher than that with partial thyroidectomy (P less than 0.001). Disease-related death, recurrence, and survivor status were discussed. There was no significant difference between total versus subtotal thyroidectomy. This study reaffirms the usefulness of subtotal resection and the avoidance of morbidity of more radical total thyroidectomy surgery.

A clinical epidemiologic study of thyroid carcinoma in Malmö, Sweden

The annual incidence of clinically diagnosed TC in Malmö was, on an average, 2.4 per 100,000 population during the years 1960-1977. This was 1.2 per 100,000 population lower than the corresponding incidence in the whole of Sweden as reported by the National Cancer Registry. The main reason for the difference was suggested to be inclusion in the official figures of autopsy cases and of cases with a benign diagnosis, rather than a true difference in the prevalence of TC. During the later part of the study an increase in the incidence of differentiated TC of approximately 70% was noted. This was considered to be due to increased health awareness and the availability of medical care, because only the number of tumors with less advanced growth increased. The average annual mortality from TC in Malmö was 0.9 per 100,000, which was 0.4 per 100,000 lower than the corresponding official rate in all of Sweden. The difference was suggested to be mainly due to inclusion in the official figures of persons not dying of TC. The mortality did not change significantly during the period of investigation. The percentage distribution by histologic type of tumors clinically diagnosed (N = 104) was as follows: papillary cancer, 65%; follicular, 21%; medullary, 4%; and anaplastic, 12%. The prognosis as estimated by the life table method was worst for patients with anaplastic TC, followed by those with follicular, papillary, and medullary TC. The validity of using the relationship of the tumor to the thyroid capsule (i.e., intrathyroidal and extrathyroidal growth) as a basis for classification into tumor stages was supported in the present study: the mortality in patients with intrathyroidal tumors was lower than in those with extrathyroidal tumors. The definition of occult TC--TC not larger than 1.5 cm, without regard to the relation to the thyroid capsule--was considered inappropriate and a change in the conception of occult TC was proposed. The presence or absence of node metastases in TC did not seem to have major significance for the prognosis. The significance of age for survival was strongly supported in our study. Deaths from TC clinically diagnosed before the age of 60 were infrequent, whereas the disease after this age increasingly often was fatal. This was partly due to a late onset of anaplastic TC and partly to a higher mortality in older than in younger patients with papillary or follicular TC.(ABSTRACT TRUNCATED AT 400 WORDS)

Thyroid carcinoma in Malmö, 1960-1977. Epidemiologic, clinical, and prognostic findings in a defined urban population

One hundred four cases of clinically significant thyroid carcinoma (TC) occurred in a demographically well defined area with, on an average, 243,000 inhabitants, during an 18-year period, corresponding to a yearly incidence of 2.4 per 100,000. During the later years of the study there was an increase of the age-standardized incidence of differentiated TC. The reason for this is suggested to be a greater health awareness, because only the number of tumors with less advanced growth increased. Sixty-one patients had, as the only presenting sign, a solitary thyroid nodule, while 24 had obviously malignant disease. All cases were revised histologically. Sixty-six patients were found to have papillary carcinoma, whereas 22 cases were diagnosed as follicular, 4 as medullary, and 12 as anaplastic. The prognosis, as estimated by the life-table method, was worse for patients with anaplastic cancer followed by follicular, papillary, and medullary. Within the papillary group, patients with occult cancer, i.e., thyroid tumor not larger than 1.5 cm, and intrathyroidal cancer, i.e., thyroid tumor larger than 1.5 cm but not penetrating the thyroid capsule, had a cumulated survival rate not significantly different from the expected rate, and only 1 of the 46 patients belonging to these two subgroups, died from TC.