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Sfreddo HJ, Koh ES, Zhao K, Swartzwelder CE, Untch BR, Marti JL, Roman BR, Dublin J, Wang RS, Xia R, Cohen JM, Xu B, Ghossein R, Givi B, Boyle JO, Tuttle RM, Fagin JA, Wong RJ, Morris LGT. RAS-Mutated Cytologically Indeterminate Thyroid Nodules: Prevalence of Malignancy and Behavior Under Active Surveillance. Thyroid 2024; 34:450-459. [PMID: 38407967 DOI: 10.1089/thy.2023.0544] [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: 02/28/2024]
Abstract
Background: Genomic profiling is now available for risk stratification of cytologically indeterminate thyroid nodules (ITNs). Mutations in RAS genes (HRAS, NRAS, KRAS) are found in both benign and malignant thyroid nodules, although isolated RAS mutations are rarely associated with aggressive tumors. Because the long-term behavior of RAS-mutant ITNs is not well understood, most undergo immediate surgery. In this multicenter retrospective cohort study, we characterize tumor growth kinetics of RAS-mutant ITNs followed with active surveillance (AS) using serial ultrasound (US) scans and examine the histopathologic diagnoses of those surgically resected. Methods: US and histopathologic data were analyzed retrospectively from two cohorts: (1) RAS-mutant ITNs managed with AS at three institutions (2010-2023) and (2) RAS-mutant ITNs managed with immediate surgery at two institutions (2016-2020). AS cohort subjects had ≥3 months of follow-up and two or more US scans. Cumulative incidence of nodule growth was determined by the Kaplan-Meier method and growth by ≥72% change in tumor volume. Pathological diagnoses for the immediate surgery cohort were analyzed separately. Results: Sixty-two patients with 63 RAS-mutated ITNs under AS had a median diameter of 1.7 cm (interquartile range [IQR] 1.2-2.6) at time of diagnosis. During a median AS period of 23 months (IQR 9.5-53.5 months), growth was observed in 12 of 63 nodules (19.0%), with a cumulative incidence of 1.9% (1 year), 23.0% (3 years), and 28.0% (5 years). Most nodules (81.0%) demonstrated stability. Surgery was ultimately performed in 6 nodules, of which 1 (16.7%) was malignant. In the cohort of 209 RAS-mutant ITNs triaged to immediate surgery, 33% were malignant (23.9% American Thyroid Association [ATA] low-risk cancers, 7.2% ATA intermediate-risk, and 1.9% ATA high-risk. During a median follow-up of 6.9 (IQR 4.4-7.1) years, there were no disease-specific deaths in these patients. Conclusions: We describe the behavior of RAS-mutant ITNs under AS and find that most demonstrate stability over time. Of the resected RAS-mutant nodules, most were benign; of the cancers, most were ATA low-risk. Immediate surgical resection of all RAS-mutant ITNs appears to be a low-value practice. Further research is needed to help define cases most appropriate for AS or immediate surgery.
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Affiliation(s)
- Hannah J Sfreddo
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth S Koh
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Karena Zhao
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christina E Swartzwelder
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Brian R Untch
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer L Marti
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jared Dublin
- Department of Otolaryngology, NYU School of Medicine, New York, New York, USA
| | - Ronald S Wang
- Department of Otolaryngology, NYU School of Medicine, New York, New York, USA
| | - Rong Xia
- Department of Pathology, NYU School of Medicine, New York, New York, USA
| | - Jean-Marc Cohen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ronald Ghossein
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Babak Givi
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jay O Boyle
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James A Fagin
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Le K, Jin L, Zhong F, Huang X, Zhou L, Zhou J, Xie L. Tumor growth manifested in two-fifths of low-risk papillary thyroid microcarcinoma patients during active surveillance: data from a tertiary center in China. Front Endocrinol (Lausanne) 2024; 15:1359621. [PMID: 38577570 PMCID: PMC10991742 DOI: 10.3389/fendo.2024.1359621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/21/2024] [Indexed: 04/06/2024] Open
Abstract
Purpose To assess tumor growth using tumor doubling rate (TDR) during active surveillance (AS) in China. Methods Between January 2016 and June 2020, a total of 219 patients with low-risk papillary thyroid microcarcinoma (PTMC) (aged 23-75 years) were consecutively enrolled in the AS program. Results Four sections of TDR, >0.5, 0.1~0.5, -0.1~0.1 and <-0.1, corresponded with four categories of tumor volume kinetics: rapid growth, slow growth, stable, and decreased size. We found that 10.5% of PTMCs exhibited rapid growth, 33.33% exhibited slow growth, 26.48% were stable, and 29.68% decreased in size. Tumor growth was associated with two factors: age and volume of PTMC at diagnosis. 85.72% of elderly patients (≥ 61 years old) had tumors that remained stable or even shrank and rapidly growing tumors were not found in them. When the volume was small (≤14.13 mm3), the proportion of rapid growth was high (41.67%), whereas when the volume was large (> 179.5 mm3), the proportion of non-growth was 68.75%. Conclusion TDR may be a better metric for evaluating tumor growth in observational PTMCs. A certain proportion of PTMCs grow during the period of AS and tumor growth was associated with age and volume of PTMC at initial diagnosis. Therefore, how to block tumor growth during the AS period, especially for young patients and patients with early-stage PTMC (size ≤ 5 mm), will be a new challenge.
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Affiliation(s)
- Kehao Le
- Department of Head and Neck Surgery, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lei Jin
- Department of Head and Neck Surgery, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fangfang Zhong
- Department of Head and Neck Surgery, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaojuan Huang
- Department of Nuclear Medicine, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Liang Zhou
- Department of Head and Neck Surgery, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiamin Zhou
- Department of Technology, Hangzhou KuaikuaiKangfu Technology Co., LTD, Hangzhou, Zhejiang, China
| | - Lei Xie
- Department of Head and Neck Surgery, the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Zhu P, Zhang Q, Wu Q, Shi G, Wang W, Xu H, Zhang L, Qian M, Hegarty J. Barriers and Facilitators to the Choice of Active Surveillance for Low-Risk Papillary Thyroid Cancer in China: A Qualitative Study Examining Patient Perspectives. Thyroid 2023. [PMID: 36719782 DOI: 10.1089/thy.2022.0347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background: Internationally, several clinical practice guidelines recommend active surveillance as a nonsurgical management strategy for select patients with low-risk papillary thyroid carcinoma. However, patient's decision making when choosing active surveillance as a management approach is not well understood. Thus, our aim was to examine the barriers and facilitators to selecting active surveillance among patients with low-risk papillary thyroid carcinoma in China. Methods: Thirty-nine participants diagnosed with low-risk papillary thyroid carcinoma were purposively recruited between July and November 2021 for semistructured interviews; 24 of whom rejected and 15 patients chose "active surveillance" as a management approach in our sample. Inductive content analysis illustrated emerging themes. Audit trails, member checks, and thematic discussions were used to assert rigor. Results: Barriers and facilitators were classified as patient-related, disease-related, and external factors. Patient-related factors included patient's knowledge, attitudes, and emotions. Disease-related factors included the response to having cancer, the constant state of being diseased, and perceived value of the thyroid gland. External factors included the residual effects of surgery, the active surveillance protocol, and physicians' recommendations. Conclusions: Patient's acceptability of the active surveillance as a management approach are complex with many influencing factors. The public acceptance of active surveillance as a disease management approach needs to be improved, through the presentation of active surveillance as an evidence-based and optimized dynamic management strategy. Clinicians must address their patients' psychological struggles when patients choose active surveillance and patients require more attention and supportive intervention.
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Affiliation(s)
- Pingting Zhu
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
- Jiangsu Key Laboratory of Zoonosis, Yangzhou, P. R. China
| | - Qianqian Zhang
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
- Department of Anesthesia and Perioperative Medicine, the First Affiliated Hospital with Nanjing Medical University, Nanjing, P. R. China
| | - Qiwei Wu
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
| | - Guanghui Shi
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
| | - Wen Wang
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
| | - Huiwen Xu
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
| | - Li Zhang
- Department of General Surgery, the First Affiliated Hospital with Xuzhou Medical University, Xuzhou, P. R. China
| | - Meiyan Qian
- Department of Nursing, School of Nursing and Public Health, Yangzhou University, Yangzhou, P. R. China
| | - Josephine Hegarty
- Department of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland
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Wang Z, Guan H. Hear the Patient's Voice Regarding Implementation of Thyroid Cancer Active Surveillance in China. Thyroid 2023. [PMID: 36792936 DOI: 10.1089/thy.2023.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Zhuoying Wang
- Department of Head and Neck Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P.R. China
| | - Haixia Guan
- Department of Endocrinology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, P.R. China
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Ye L, Hu L, Liu W, Luo Y, Li Z, Ding Z, Hu C, Wang L, Zhu Y, Liu L, Ma X, Kong Y, Huang L. Capsular extension at ultrasound is associated with lateral lymph node metastasis in patients with papillary thyroid carcinoma: a retrospective study. BMC Cancer 2021; 21:1250. [PMID: 34800991 PMCID: PMC8605523 DOI: 10.1186/s12885-021-08875-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In patients with papillary thyroid cancer (PTC), cervical lymph node metastasis (LNM) must be carefully assessed to determine the extent of lymph node dissection required and patient prognosis. Few studies attempted to determine whether the ultrasound (US) appearance of the primary thyroid tumor could be used to predict cervical lymph node involvement. This study aimed to identify the US features of the tumor that could predict cervical LNM in patients with PTC. METHODS This was a retrospective study of patients with pathologically confirmed PTC. We evaluated the following US characteristics: lobe, isthmus, and tumor size; tumor position; parenchymal echogenicity; the number of lesions (i.e., tumor multifocality); parenchymal and lesional vascularity; tumor margins and shape; calcifications; capsular extension; tumor consistency; and the lymph nodes along the carotid vessels. The patients were grouped as no LNM (NLNM), central LNM (CLNM) alone, and lateral LNM (LLNM) with/without CLNM, according to the postoperative pathological examination. RESULTS Totally, 247 patients, there were 67 men and 180 women. Tumor size of > 10 mm was significantly more common in the CLNM (70.2%) and LLNM groups (89.6%) than in the NLNM group (45.4%). At US, capsular extension > 50% was most common in the LLNM group (35.4%). The multivariable analysis revealed that age (OR = 0.203, 95%CI: 0.095-0.431, P < 0.001) and tumor size (OR = 2.657, 95%CI: 1.144-6.168, P = 0.023) were independently associated with CLNM compared with NLNM. In addition, age (OR = 0.277, 95%CI: 0.127-0.603, P = 0.001), tumor size (OR = 6.069, 95%CI: 2.075-17.75, P = 0.001), and capsular extension (OR = 2.09, 95%CI: 1.326-3.294, P = 0.001) were independently associated with LLNM compared with NLNM. CONCLUSION Percentage of capsular extension at ultrasound is associated with LLNM. US-guided puncture cytology and eluent thyroglobulin examination could be performed as appropriate to minimize the missed diagnosis of LNM.
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Affiliation(s)
- Lei Ye
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China.
| | - Lei Hu
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Weiyong Liu
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China.
| | - Yuanyuan Luo
- Department of Laboratory, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Zhe Li
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Zuopeng Ding
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Chunmei Hu
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Lin Wang
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Yajuan Zhu
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Le Liu
- Department of Ultrasound, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, No. 1, Tianehu Road, Hefei, 230036, Anhui, China
| | - Xiaopeng Ma
- Department of Surgery, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Yuan Kong
- Department of Surgery, Division of Life Science and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Liangliang Huang
- Department of Pathology, Division of Life Science and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
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Management of Low-Risk Thyroid Cancers: Is Active Surveillance a Valid Option? A Systematic Review of the Literature. J Clin Med 2021; 10:jcm10163569. [PMID: 34441866 PMCID: PMC8397017 DOI: 10.3390/jcm10163569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/01/2023] Open
Abstract
Thyroid cancer is the most common endocrine malignancy, representing 2.9% of all new cancers in the United States. It has an excellent prognosis, with a five-year relative survival rate of 98.3%.Differentiated Thyroid Carcinomas (DTCs) are the most diagnosed thyroid tumors and are characterized by a slow growth rate and indolent course. For years, the only approach to treatment was thyroidectomy. Active surveillance (AS) has recently emerged as an alternative approach; it involves regular observation aimed at recognizing the minority of patients who will clinically progress and would likely benefit from rescue surgery. To better clarify the indications for active surveillance for low-risk thyroid cancers, we reviewed the current management of low-risk DTCs with a systematic search performed according to a PRISMA flowchart in electronic databases (PubMed, Web of Science, Scopus, and EMBASE) for studies published before May 2021. Fourteen publications were included for final analysis, with a total number of 4830 patients under AS. A total of 451/4830 (9.4%) patients experienced an increase in maximum diameter by >3 mm; 609/4830 (12.6%) patients underwent delayed surgery after AS; metastatic spread to cervical lymph nodes was present in 88/4213 (2.1%) patients; 4/3589 (0.1%) patients had metastatic disease outside of cervical lymph nodes. Finally, no subject had a documented mortality due to thyroid cancer during AS. Currently, the American Thyroid Association guidelines do not support AS as the first-line treatment in patients with PMC; however, they consider AS to be an effective alternative, particularly in patients with high surgical risk or poor life expectancy due to comorbid conditions. Thus, AS could be an alternative to immediate surgery for patients with very-low-risk tumors showing no cytologic evidence of aggressive disease, for high-risk surgical candidates, for those with concurrent comorbidities requiring urgent intervention, and for patients with a relatively short life expectancy.
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