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Chiefari E, Innaro N, Gervasi R, Mirabelli M, Giuliano S, Donnici A, Obiso S, Brunetti FS, Foti DP, Brunetti A. Incidental thyroid carcinoma in an endemic goiter area in Italy: histopathological features and predictors of a common finding. Endocrine 2024; 84:589-597. [PMID: 38217773 PMCID: PMC11076372 DOI: 10.1007/s12020-023-03659-2] [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: 09/13/2023] [Accepted: 12/10/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE The occurrence and histopathological features of incidental thyroid carcinoma (ITC) vary considerably among populations from different geographical regions. The aim of this study is to assess the prevalence and histopathological characteristics of ITC in patients who underwent thyroid surgery for apparently benign thyroid diseases in an endemic goiter area in Italy. METHODS A total of 649 consecutive patients (531 females and 118 males; mean age, 52.9 ± 11.0 years), who underwent thyroid surgery at the Endocrine Surgery Unit of the tertiary care "Renato Dulbecco" University Hospital (Catanzaro, Italy) in the period between years 2017 and 2022, were included in this retrospective study. A comprehensive histopathological examination was performed on surgically excised thyroid tissue. Logistic regression analysis was employed to identify potential predictors of ITC. RESULTS The histopathological examination revealed the presence of ITC in 81 patients, accounting for 12.5% of the total study population. The female to male ratio was found to be 6.4 to 1. Among the patients with ITC, 72 had papillary carcinoma (PTC), with 53 of these tumors being microcarcinomas (microPTC). Additionally, 5 patients had follicular thyroid carcinoma, 2 patients had low-risk follicular cell-derived thyroid neoplasms, 1 patient had an oncocytic carcinoma, and 1 patient had a medullary thyroid carcinoma. Logistic regression analysis demonstrated a significant association between female sex and incidental microPTC. CONCLUSIONS These findings provide further evidence of the common occurrence of ITC, typically in the form of microPTC, among individuals who undergo thyroid surgery for apparently benign thyroid diseases.
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Affiliation(s)
- Eusebio Chiefari
- Department of Health Sciences, University of "Magna Græcia" Catanzaro, 88100, Catanzaro, Italy
| | - Nadia Innaro
- Operative Unit of Endocrine Surgery, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy
| | - Rita Gervasi
- Operative Unit of Endocrine Surgery, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University of "Magna Græcia" Catanzaro, 88100, Catanzaro, Italy
| | - Stefania Giuliano
- Operative Unit of Endocrinology, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy
| | - Alessandra Donnici
- Operative Unit of Endocrinology, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy
| | - Stefania Obiso
- Operative Unit of Endocrinology, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy
| | - Francesco S Brunetti
- Department of Health Sciences, University of "Magna Græcia" Catanzaro, 88100, Catanzaro, Italy
| | - Daniela Patrizia Foti
- Department of Experimental and Clinical Medicine, University of "Magna Græcia" Catanzaro, 88100, Catanzaro, Italy
| | - Antonio Brunetti
- Department of Health Sciences, University of "Magna Græcia" Catanzaro, 88100, Catanzaro, Italy.
- Operative Unit of Endocrinology, University Hospital "Renato Dulbecco", 88100, Catanzaro, Italy.
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Hanna M, Sun B, Shekarappa R. Toxic Thyroid Adenoma Presenting as Apathetic Hyperthyroidism: A Case Report. Cureus 2024; 16:e61322. [PMID: 38947590 PMCID: PMC11213546 DOI: 10.7759/cureus.61322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
The thyroid gland is an essential endocrine organ that secretes hormones to regulate homeostasis across multiple organ systems throughout the body. It is actively regulated by the hypothalamic-pituitary-thyroid (HPT) axis, where negative feedback modulates the amounts of active hormone being released; thus, lesions that disrupt the proper functioning of this gland or its regulatory mechanisms can be destructive. Toxic thyroid adenomas are usually singular benign functioning nodules in the thyroid gland that cause thyrotoxicosis. Hyperthyroidism is commonly clinically silent, however, in most symptomatic cases, patients will be diagnosed based on abnormal laboratory findings and typical hyperthyroid symptoms. This case report examines an 81-year-old male with an extensive medical history who presented with complaints of new-onset generalized fatigue coupled with bilateral lower extremity muscle cramps. A positron emission tomography (PET) scan for other medical conditions incidentally noted mildly increased uptake in the thyroid gland, prompting a further investigation that resulted in a diagnosis of toxic thyroid adenoma. The patient responded well to treatment with methimazole and has remained in a euthyroid state.
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Affiliation(s)
- Mina Hanna
- Medicine, Trinity School of Medicine, Warner Robins, USA
| | - Bo Sun
- Medicine, Trinity School of Medicine, Warner Robins, USA
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3
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Cheng X, Fan Y, Ye W, Xu S, Wu J, Gao W, Bao J, Yu H, Zhang L. Preoperative Serum Thyroglobulin Levels Predict Radioiodine Therapy Outcome in Papillary Thyroid Microcarcinoma Patients. Horm Metab Res 2024. [PMID: 38503312 DOI: 10.1055/a-2291-0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Our previous study showed that elevated preoperative thyroglobulin (pre-Tg) level predicted the risk of developing radioiodine refractory in PTC patients. In the present study, we aimed to evaluate the prognostic value of pre-Tg in papillary thyroid microcarcinoma (PTMC). After a specific inclusion and exclusion criteria were applied, a total of 788 PTMCs were enrolled from Jiangyuan Hospital affiliated to Jiangsu Institute of Nuclear Medicine between Jan 2015 and Dec 2019. Among them, 107 PTMCs were treated with radioiodine therapy (RAIT) and the response to therapy was grouped as excellent response (ER), and non-excellent response (NER: indeterminate response, IDR and biochemical incomplete response, BIR). Multivariable logistic regression was used to identify predictors for the response of RAIT in PTMCs. Higher pre-Tg levels were detected in PTMCs with RAIT as compared with PTMCs without RAIT (p=0.0018). Higher levels of pre-Tg were also found in patients with repeated RAIT as compared with patients with single RAIT (p<0.0001). Furthermore, pre-Tg level was higher in PTMC with IDR (n=16) and much higher in BIR (n=9) as compared with patients with ER (n=82, p=0.0003) after RAIT. Multivariate analysis showed that pre-Tg level over 16.79 ng/ml [OR: 6.55 (2.10-20.39), p=0.001] was the only independent predictor for NER in PTMC with RAIT. We found that high level of pre-Tg predicted a poor RAIT outcome in PTMC. Our finding explores a prospective way in identifying high-risk PTMCs with poor response to RAIT.
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Affiliation(s)
- Xian Cheng
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Yijun Fan
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Wanzhong Ye
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Shichen Xu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Jing Wu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Wenjing Gao
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Jiandong Bao
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Huixin Yu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
| | - Li Zhang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi
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4
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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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Raymond P, Klein M, Borson-Chazot F. Summary and update on the management of differentiated thyroid cancer in 2023. ANNALES D'ENDOCRINOLOGIE 2024; 85:110-117. [PMID: 38316254 DOI: 10.1016/j.ando.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024]
Abstract
The 6-fold increase in the incidence of differentiated thyroid cancer over the past 30 years in industrialized countries can be mainly attributed to improved detection. At the same time, in addition to the excellent prognosis for low-risk cancers, improved survival in metastatic forms has been also reported, likely due to the progress made recently in the treatment of aggressive forms, for which there is now an extensive therapeutic arsenal. Today, clinical management of differentiated thyroid cancer represents a paradigm of precision oncology, with personalized, risk-adapted therapeutic strategies. This has led to therapeutic de-escalation in those forms with a good prognosis, while targeted treatments play an increasingly important role in the management of radioiodine-refractory or advanced cancers. While endocrinologists will not always have the opportunity to prescribe these treatments, they will be called on to support and monitor patients during treatment. The aim of this article is to provide an overview of treatment options for differentiated thyroid cancer in 2023.
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Affiliation(s)
- Perrine Raymond
- Service d'endocrinologie, CHRU de Brabois, rue du Morvan, Vandœuvre-lès-Nancy, France.
| | - Marc Klein
- Service d'endocrinologie, CHRU de Brabois, rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Françoise Borson-Chazot
- Fédération d'endocrinologie, hospices civils de Lyon, hôpital Louis-Pradel, 69500 Bron, France
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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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Usman M, Yao P, Luckett K, Andreadis K, Thomas R, Hickner A, Christos PJ, Tassler A, Kutler D, Kuhel W, Banuchi V. The use of thyroid isthmusectomy for management of well differentiated thyroid carcinoma - A systematic review and meta-analysis. Surg Oncol 2024; 52:102032. [PMID: 38159364 DOI: 10.1016/j.suronc.2023.102032] [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: 11/03/2023] [Revised: 11/29/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE With the growing global incidence of thyroid carcinomas, there is an increasing need for distinct guidelines for isthmus-confined carcinomas. Here, we performed the first systematic review on the topic to date, aiming to provide understanding to isthmusectomy as surgical management for well-differentiated thyroid carcinoma of the isthmus. METHODS We conducted a systematic review following the PRISMA guidelines, analyzing English-language studies from the past decade that report on thyroid isthmusectomy. Exclusion criteria included isthmusectomy performed alongside full thyroidectomy or partial thyroid lobectomy, lack of data on tumor characteristics or survival outcomes, and non-English publications where a translation was unavailable. Our review identified a total of 227 patients from seven studies. RESULTS The average 5-year overall survival and disease-free survival rates for patients with isthmus-confined PTC who underwent isthmusectomy were 100 % and 93.1 %, respectively. Similar to that of total thyroidectomy. 3.1 % of patients required completion thyroidectomy. Furthermore, isthmusectomy resulted in fewer surgical complications than total thyroidectomy. CONCLUSIONS The scarcity of studies providing detailed tumor characteristics and patient outcomes limits our ability to fully evaluate the safety and efficacy of isthmusectomy for isthmus-confined PTC. Additionally, the variable sample sizes and restricted geographic distribution of the included studies calls into questions the generalizability of their findings. Despite these limitations, the data suggest that isthmusectomy may be a viable surgical option for select patients with small, isthmus-confined PTC. In the absence of a randomized controlled trial on the noninferiority of isthmusectomy, significantly more publications are needed before strong conclusions can be drawn.
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Affiliation(s)
- Moon Usman
- NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Peter Yao
- NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Kathleen Luckett
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, NY, USA
| | - Katerina Andreadis
- Department of Population Health Science, Weill Cornell Medical College, New York, NY, USA
| | | | - Andy Hickner
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell, New York, NY, USA
| | - Paul J Christos
- Department of Population Health Science, Weill Cornell Medical College, New York, NY, USA
| | - Andrew Tassler
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - David Kutler
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - William Kuhel
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Victoria Banuchi
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA.
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Abelleira E, Jerkovich F. Dynamic risk assessment in patients with differentiated thyroid cancer. Rev Endocr Metab Disord 2024; 25:79-93. [PMID: 38015344 DOI: 10.1007/s11154-023-09857-7] [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: 11/20/2023] [Indexed: 11/29/2023]
Abstract
The current approach for patients with differentiated thyroid carcinoma should be individualized according to the risk of recurrence, and this stratification could be used to identify the risk of persistent/recurrent disease in three scenarios: preoperatively, immediately postoperatively, and during long-term follow-up. The initial risk of recurrence will tailor the management of the patient in the preoperative and immediate postoperative settings, while the dynamic risk, which considers the responses to treatment, could guide the decision-making process for remnant ablation and long-term management.This review provides a summary of the existing information regarding the dynamic risk of recurrence and recommended management for patients with differentiated thyroid cancer. The application of this approach is essential to avoid unnecessary treatments for most patients who will have a favorable prognosis. On the other hand, it allows specific therapeutic interventions for those patients at high risk of recurrence. In the future, analysis of tumor biology and prospective studies will surely improve the accuracy of recurrence risk prediction.
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Affiliation(s)
- Erika Abelleira
- Division of Endocrinology, Hospital de Clínicas José de San Martín (UBA), University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, C 1120, Argentina.
| | - Fernando Jerkovich
- Division of Endocrinology, Hospital de Clínicas José de San Martín (UBA), University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, C 1120, Argentina
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Smulever A, Pitoia F. Thirty years of active surveillance for low-risk thyroid cancer, lessons learned and future directions. Rev Endocr Metab Disord 2024; 25:65-78. [PMID: 37833520 DOI: 10.1007/s11154-023-09844-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: 10/05/2023] [Indexed: 10/15/2023]
Abstract
Active Surveillance is a non-invasive strategy designed to identify a minority of patients with low-risk papillary thyroid carcinoma who might experience clinical progression and benefit from additional definitive treatments. Global experience suggests that these tumors typically show minimal changes in size during active surveillance, often demonstrating very slow growth or even size reduction. Moreover, the rate of lymph node metastases is low and can be effectively managed through rescue surgery, without impacting cancer-related mortality. However, despite 30 years of experience demonstrating the safety and feasibility of active surveillance for appropriately selected patients, this approach seems to have limited adoption in specific contexts. This limitation can be attributed to various barriers, including disparities in access to accurate information about the indolent nature of this disease and the prevalence of a maximalist mindset among certain patients and medical settings. This review aims to revisit the experience from the last three decades, provide current insights into the clinical outcomes of active surveillance trials, and propose a systematic approach for its implementation. Furthermore, it intends to emphasize the importance of precise patient selection and provides new perspectives in the field.
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Affiliation(s)
- Anabella Smulever
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Córdoba, Buenos Aires, 2351, Argentina.
- Division of Endocrinology, Instituto de Investigaciones Médicas A. Lanari, University of Buenos Aires, Buenos Aires, Argentina.
| | - Fabian Pitoia
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Córdoba, Buenos Aires, 2351, Argentina
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Kim MJ, Moon JH, Lee EK, Song YS, Jung KY, Lee JY, Kim JH, Kim K, Park SK, Park YJ. Active Surveillance for Low-Risk Thyroid Cancers: A Review of Current Practice Guidelines. Endocrinol Metab (Seoul) 2024; 39:47-60. [PMID: 38356210 PMCID: PMC10901665 DOI: 10.3803/enm.2024.1937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
The indolent nature and favorable outcomes associated with papillary thyroid microcarcinoma have prompted numerous prospective studies on active surveillance (AS) and its adoption as an alternative to immediate surgery in managing low-risk thyroid cancer. This article reviews the current status of AS, as outlined in various international practice guidelines. AS is typically recommended for tumors that measure 1 cm or less in diameter and do not exhibit aggressive subtypes on cytology, extrathyroidal extension, lymph node metastasis, or distant metastasis. To determine the most appropriate candidates for AS, factors such as tumor size, location, multiplicity, and ultrasound findings are considered, along with patient characteristics like medical condition, age, and family history. Moreover, shared decision-making, which includes patient-reported outcomes such as quality of life and cost-effectiveness, is essential. During AS, patients undergo regular ultrasound examinations to monitor for signs of disease progression, including tumor growth, extrathyroidal extension, or lymph node metastasis. In conclusion, while AS is a feasible and reliable approach for managing lowrisk thyroid cancer, it requires careful patient selection, effective communication for shared decision-making, standardized follow-up protocols, and a clear definition of disease progression.
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Affiliation(s)
- Min Joo Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Lee
- Department of Internal Medicine, National Cancer Center, Goyang, Korea
| | - Young Shin Song
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kyong Yeun Jung
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Ji Ye Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Deparment of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Deparment of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyungsik Kim
- Deparment of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sue K. Park
- Deparment of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Integrated Major in Innovative Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
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Shaha AR, Tuttle RM. Active surveillance for micropapillary thyroid carcinoma: a clinical review. Gland Surg 2024; 13:100-107. [PMID: 38323232 PMCID: PMC10839699 DOI: 10.21037/gs-22-558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/08/2023] [Indexed: 02/08/2024]
Abstract
With the rapid rise in the incidence of micropapillary carcinoma, there is increasing concern about its overdiagnosis and overtreatment. There is considerable interest in managing patients with micropapillary carcinoma with active surveillance or deferred intervention. Various institutions around the world are practicing active surveillance. The major question remains as to who the ideal candidates are and how best to monitor these patients. This clinical review will discuss the ideal, appropriate, and inappropriate patients for active surveillance. It will also discuss the follow-up strategy for these patients and some of the adverse clinical features that will be used to decide against active surveillance. There are uncertainties as to who should be offered active surveillance. Various studies have shown approximately 10% of the patients switching to surgery primarily related to fear factor rather than increase in the tumor size or lymph node metastasis. The results of immediate surgery do raise issues related to complications of thyroid surgery and quality of life. The most ideal candidate would be patients with a tumor below 1 cm, intrathyroidal. For the patient who is a minimalist, the follow up strategy includes, ultrasound every 6 months for the first 1 or 2 years, and then every year after that. If there is a substantial change in the tumor volume or nodal metastasis, surgery should be considered, which happens in less than 10 percent of patients according to many studies. Based on existing literature and clinical experience, it appears that active surveillance is an appropriate strategy for monitoring micropapillary carcinoma.
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Affiliation(s)
- Ashok R. Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R. Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Liu Q, Song M, Zhang H. Choice of management strategy for papillary thyroid microcarcinoma: active surveillance or immediate surgery? J Cancer 2024; 15:1009-1020. [PMID: 38230222 PMCID: PMC10788711 DOI: 10.7150/jca.91612] [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: 10/28/2023] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
Overdiagnosis of papillary thyroid microcarcinoma (PTMC) is prevalent, and effective management of PTMC is an important matter. The high incidence and low mortality rate of papillary thyroid carcinoma (PTC) justify the preference for active surveillance (AS) over immediate surgery (IS), particularly in cases of low-risk PTMC. Japan began AS in the 1990s as an alternative surgical option for PTMC and it has shown promising results. The safety and efficacy of AS management in PTMC have been verified. However, AS may not be suitable for all PTMC cases. How to find the balance between the decision-making of AS and IS requires careful consideration. Therefore, we collected and analyzed the relevant evidence on the clinical strategies for PTC and discussed AS and IS from the perspectives of health, economic, and psychological aspects, to help clinicians in choosing a more appropriate clinical strategy for PTC.
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Affiliation(s)
| | | | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
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13
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Yan L, Yang Z, Li Y, Li X, Xiao J, Jing H, Luo Y. Five-year Outcome Between Radiofrequency Ablation vs Surgery for Unilateral Multifocal Papillary Thyroid Microcarcinoma. J Clin Endocrinol Metab 2023; 108:3230-3238. [PMID: 37318878 DOI: 10.1210/clinem/dgad360] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
CONTEXT Ultrasound (US)-guided radiofrequency ablation (RFA) has been considered as an alternative to surgery or active surveillance for papillary thyroid microcarcinoma (PTMC). However, little is known about the long-term outcomes of RFA in comparison with surgery for unilateral multifocal PTMC. OBJECTIVE This work aims to report the comparison between RFA vs surgery for unilateral multifocal PTMC over a more than 5-year follow-up period. METHODS This was a retrospective study at a primary care center with a median follow-up period of 72.9 months. A total of 97 patients with unilateral multifocal PTMC were treated with RFA (RFA group, n = 44) or surgery (surgery group, n = 53). In the RFA group, patients were treated by a bipolar RFA generator and an 18-gauge bipolar RF electrode with a 0.9-cm active tip. In the surgery group, patients underwent thyroid lobectomy with prophylactic central neck dissection. RESULTS During the follow-up, no statistically significant differences were found in disease progression (4.5% vs 3.8%; P = ≥.999), lymph node metastasis (2.3% vs 3.8%; P = ≥.999), persistent lesion (2.3% vs 0%; P = .272), and RFS rates (97.7% vs 96.2%; P = .673) in the RFA and surgery groups. Patients undergoing RFA had a shorter hospitalization (0 vs 8.0 [3.0] d; P < .001), shorter procedure time (3.5 [2.4] vs 80.0 [35.0] min; P < .001), lower estimated blood loss (0 vs 20.0 [15.0] mL; P < .001), and lower costs ($1768.3 [0.1] vs $2084.4 [1173.8]; P = .001) than those in the surgery group. The complication rate in the surgery group was 7.5%, whereas none of the RFA-treated patients experienced any complications (P = .111). CONCLUSION This study revealed 6-year comparable outcomes between RFA and surgery for unilateral multifocal PTMC. RFA may be a safe and effective alternative to surgery in selected patients with unilateral multifocal PTMC.
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Affiliation(s)
- Lin Yan
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhen Yang
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yingying Li
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Xinyang Li
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Jing Xiao
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - HaoYu Jing
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yukun Luo
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
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14
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Xiao J, Yan L, Li Y, Li X, Yang Z, Zhang M, Luo Y. Radiofrequency ablation for papillary thyroid cancer located in isthmus: comparison with that originated in thyroid lobe. Int J Hyperthermia 2023; 40:2266668. [PMID: 37940133 DOI: 10.1080/02656736.2023.2266668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023] Open
Abstract
PURPOSE To analyze the outcomes of radiofrequency ablation (RFA) for isthmus papillary thyroid cancer (PTC) versus PTC originating from the lobes. METHODS Patients with solitary low-risk PTC treated with RFA between July 2014 and December 2019 were retrospectively reviewed. This study was approved by our institutional review board. Of the 562 patients, 104 and 458 had PTCs located in the thyroid isthmus and thyroid lobes, respectively. Local tumor progression (LTP), LTP-free survival (LTPFS), changes in tumor volume, and complications were compared between the two groups using propensity-score matching (PSM). RESULTS The isthmic and lobar groups showed no significant differences in LTP (2.9% vs. 3.8%), new PTC (2.9% vs. 2.9%), persistent lesions (0.0% vs. 0.2%), or LTPFS after PSM. Before PSM, the two groups showed significant differences in the volume reduction ratio (VRR) of the ablated tumors at 1, 3, 24, 30, and 48 months after RFA, but no differences between the two groups were observed in tumor volume, VRR, or disappearance rate after PSM (p > .05). One patient in the isthmic group presented with coughing, while another complained of hoarseness. Complications did not differ significantly between the two groups (p > .05). CONCLUSIONS The outcomes of RFA for patients with low-risk PTC in the thyroid isthmus and thyroid lobes were similar. Therefore, RFA may serve as an alternative treatment option for patients with low-risk isthmic PTC.
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Affiliation(s)
- Jing Xiao
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Lin Yan
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Yingying Li
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Xinyang Li
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Zhen Yang
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Mingbo Zhang
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Yukun Luo
- Department of Ultrasound, the First Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
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15
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Tong M, Wang L, Gai Z, Zhu Y, Che Y. Clinical outcomes of radiofrequency ablation for solitary T1aN0M0 versus T1bN0M0 papillary thyroid carcinoma: a propensity-matched cohort study. Int J Hyperthermia 2023; 40:2257908. [PMID: 37848402 DOI: 10.1080/02656736.2023.2257908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE To conduct a cohort study comparing the treatment outcomes of radiofrequency ablation (RFA) therapy for solitary T1aN0M0 (T1a) versus T1bN0M0 (T1b) papillary thyroid carcinoma (PTC). METHODS This retrospective analysis comprised 310 patients with low-risk PTC undergoing RFA classified into T1a (n = 272) and T1b (n = 38) groups according to the tumor size. A comparative analysis between the two groups was conducted for the volume reduction ratio (VRR), volume, local tumor progression (LTP), and recurrence-free survival (RFS) before and after 1:2 propensity score matching (PSM). Cox analysis was conducted to examine the influence of several variables, including T1b, on recurrence following RFA for PTC. RESULTS The total VRR was 99.99 ± 0.11% throughout the median follow-up duration of 26 months, and the overall incidence of LTP was 2.58% (8/310). No irrecoverable complications occurred after RFA. The variations between the T1a and T1b groups following PSM were insignificant in terms of volume (p = 0.574), VRR (p = 0.574), complete disappearance rate (p = 0.210), LTP incidence (p = 1.000), and RFS rate (p = 0.610). The correlation between T1b and LTP continued to be insignificant (p = 0.686). No distant metastasis or delayed surgery occurred. CONCLUSIONS The presence of T1b did not influence the patients' prognoses following RFA for T1N0M0 PTC. After appropriate patient selection and adequate preoperative assessment, RFA has the potential to serve as an effective therapy for individuals with T1a and T1b PTC.
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Affiliation(s)
- Mengying Tong
- Department of Ultrasound, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P.R. China
| | - Linchun Wang
- Department of Ultrasound, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P.R. China
| | - Ziru Gai
- Department of Ultrasound, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P.R. China
| | - Yalin Zhu
- Department of Ultrasound, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P.R. China
| | - Ying Che
- Department of Ultrasound, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P.R. China
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16
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Durante C, Hegedüs L, Na DG, Papini E, Sipos JA, Baek JH, Frasoldati A, Grani G, Grant E, Horvath E, Hoang JK, Mandel SJ, Middleton WD, Ngu R, Orloff LA, Shin JH, Trimboli P, Yoon JH, Tessler FN. International Expert Consensus on US Lexicon for Thyroid Nodules. Radiology 2023; 309:e231481. [PMID: 37906014 DOI: 10.1148/radiol.231481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Multiple US-based systems for risk stratification of thyroid nodules are in use worldwide. Unfortunately, the malignancy probability assigned to a nodule varies, and terms and definitions are not consistent, leading to confusion and making it challenging to compare study results and craft revisions. Consistent application of these systems is further hampered by interobserver variability in identifying the sonographic features on which they are founded. In 2018, an international multidisciplinary group of 19 physicians with expertise in thyroid sonography (termed the International Thyroid Nodule Ultrasound Working Group) was convened with the goal of developing an international system, tentatively called the International Thyroid Imaging Reporting and Data System, or I-TIRADS, in two phases: (phase I) creation of a lexicon and atlas of US descriptors of thyroid nodules and (phase II) development of a system that estimates the malignancy risk of a thyroid nodule. This article presents the methods and results of phase I. The purpose herein is to show what has been accomplished thus far, as well as generate interest in and support for this effort in the global thyroid community.
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Affiliation(s)
- Cosimo Durante
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Laszlo Hegedüs
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Dong Gyu Na
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Enrico Papini
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Jennifer A Sipos
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Jung Hwan Baek
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Andrea Frasoldati
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Giorgio Grani
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Edward Grant
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Eleonora Horvath
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Jenny K Hoang
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Susan J Mandel
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - William D Middleton
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Rose Ngu
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Lisa Ann Orloff
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Jung Hee Shin
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Pierpaolo Trimboli
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Jung Hyun Yoon
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
| | - Franklin N Tessler
- From the Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy (C.D., G.G.); Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark (L.H.); Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.G.N.); Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy (E.P.); Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio (J.A.S.); Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea (J.H.B.); Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy (A.F.); Department of Radiology, Keck Hospital of USC, University of Southern California, Los Angeles, Calif (E.G.); Department of Imaging, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (E.H.); Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Md (J.K.H.); Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pa (S.J.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M.); Department of Dental Radiological Imaging, Guy's and St Thomas NHS Foundation Trust & King's College London Dental Institute, London, United Kingdom (R.N.); Department of Otolaryngology - Head and Neck Surgery, Stanford Cancer Center, Stanford University School of Medicine, Stanford, Calif (L.A.O.); Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.S.); Clinic for Endocrinology and Diabetology, Ente Ospedaliero Cantonale, Lugano, Switzerland (P.T.); Department of Radiology, Severance Hospital Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea (J.H.Y.); and Department of Radiology, The University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249 (F.N.T.)
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Ren W, Zhu Y, Wang Q, Song Y, Fan Z, Bai Y, Lin D. Deep learning prediction model for central lymph node metastasis in papillary thyroid microcarcinoma based on cytology. Cancer Sci 2023; 114:4114-4124. [PMID: 37574759 PMCID: PMC10551586 DOI: 10.1111/cas.15930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/11/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023] Open
Abstract
Controversy exists regarding whether patients with low-risk papillary thyroid microcarcinoma (PTMC) should undergo surgery or active surveillance; the inaccuracy of the preoperative clinical lymph node status assessment is one of the primary factors contributing to the controversy. It is imperative to accurately predict the lymph node status of PTMC before surgery. We selected 208 preoperative fine-needle aspiration (FNA) liquid-based preparations of PTMC as our research objects; all of these instances underwent lymph node dissection and, aside from lymph node status, were consistent with low-risk PTMC. We separated them into two groups according to whether the postoperative pathology showed central lymph node metastases. The deep learning model was expected to predict, based on the preoperative thyroid FNA liquid-based preparation, whether PTMC was accompanied by central lymph node metastases. Our deep learning model attained a sensitivity, specificity, positive prediction value (PPV), negative prediction value (NPV), and accuracy of 78.9% (15/19), 73.9% (17/23), 71.4% (15/21), 81.0% (17/21), and 76.2% (32/42), respectively. The area under the receiver operating characteristic curve (value was 0.8503. The predictive performance of the deep learning model was superior to that of the traditional clinical evaluation, and further analysis revealed the cell morphologies that played key roles in model prediction. Our study suggests that the deep learning model based on preoperative thyroid FNA liquid-based preparation is a reliable strategy for predicting central lymph node metastases in thyroid micropapillary carcinoma, and its performance surpasses that of traditional clinical examination.
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Affiliation(s)
- Wenhao Ren
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of PathologyPeking University Cancer Hospital and InstituteBeijingChina
| | - Yanli Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of PathologyPeking University Cancer Hospital and InstituteBeijingChina
| | - Qian Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of PathologyPeking University Cancer Hospital and InstituteBeijingChina
| | - Yuntao Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Head and Neck SurgeryPeking University Cancer Hospital and InstituteBeijingChina
| | - Zhihui Fan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of UltrasoundPeking University Cancer Hospital and InstituteBeijingChina
| | - Yanhua Bai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of PathologyPeking University Cancer Hospital and InstituteBeijingChina
| | - Dongmei Lin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of PathologyPeking University Cancer Hospital and InstituteBeijingChina
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Liu C, Zhao H, Xia Y, Cao Y, Zhang L, Zhao Y, Gao L, Liu R, Liu Y, Liu H, Meng Z, Liu S, Lu Y, Li X. Active surveillance versus immediate surgery: A comparison of clinical and quality of life outcomes among patients with highly suspicious thyroid nodules 1 cm or smaller in China. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106917. [PMID: 37137793 DOI: 10.1016/j.ejso.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Active surveillance (AS) is considered an alternative to immediate surgery (IS) for low-risk papillary thyroid microcarcinoma (PTMC) patients. However, it is difficult to decide between AS and IS due to limited evidence regarding risks and benefits for patients in China. METHODS This study prospectively enrolled 485 patients with highly suspicious thyroid nodules = 1 cm who chose AS and 331 patients who underwent IS during the same period. The oncological outcomes, adverse events and quality of life, were compared between the two groups. RESULTS The oncological outcomes of the IS and AS groups were similarly excellent. The IS group had significantly higher rates of temporary vocal cord paralysis (VCP) and temporary hypoparathyroidism than the AS group (2.7% vs. 0.2%, p = 0.002; 13.6% vs.1.9%, p < 0.001, respectively). The IS group had significantly more patients on hormone replacement therapy (98.4% vs. 10.9%, p < 0.001) and a significantly higher incidence of neck scarring (94.3% vs. 9.1%, p < 0.001) compared to the AS group. In the early stages, the quality of life questionnaire showed significant differences with respect to three items: voice, throat/mouth, and surgical scarring, with more complaints in the IS group. However, one year or more after surgery, the main complaint was surgical scarring. CONCLUSION In China, AS can achieve similar short-term therapeutic effects as IS. As this approach can reduce the occurrence of unfavorable events, achieve better quality of life, it is a feasible option for patients with highly suspicious thyroid nodules.
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Affiliation(s)
- Chunhao Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Hao Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yu Xia
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yue Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Liyang Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Ya Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Luying Gao
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Ruifeng Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yuewu Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Hongfeng Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Zhilan Meng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Shuzhou Liu
- Department of Otolaryngology Head and Neck Surgery, Hainan General Hospital, Hainan, 570311, China.
| | - Ying Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Xiaoyi Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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Young S, Goldfarb M. Is There an Age Threshold for Active Surveillance in Highly Suspicious Subcentimeter Thyroid Nodules? Ann Surg Oncol 2023; 30:5318-5319. [PMID: 37233953 DOI: 10.1245/s10434-023-13682-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Stephanie Young
- Department of Surgical Oncology, Center for Endocrine Tumors, Saint John's (Formerly John Wayne) Cancer Institute, Santa Monica, CA, USA
| | - Melanie Goldfarb
- Department of Surgical Oncology, Center for Endocrine Tumors, Saint John's (Formerly John Wayne) Cancer Institute, Santa Monica, CA, USA.
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20
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Abstract
From low-resolution images in the 1960s to current high-resolution technology, ultrasound has proven to be the initial imaging modality of choice for thyroid application. Point-of-care ultrasound has brought the technology to the thyroid specialist. Combined with physical examination, it provides real-time information regarding goiter, thyroid nodules, and thyroid cancer. Ultrasound-guided fine-needle aspiration biopsy has become the accepted norm, with biopsies rarely performed using palpation alone. Advantages of ultrasound-guided biopsy include precise placement of the needle within the nodule, selective sampling of areas with suspicious features, and accurate direction of the biopsy needle to actively growing viable cells in the periphery of the nodule. Education of endocrinologists in thyroid ultrasound began in the late 1990s and by 2016 more than 6000 clinicians had completed an ultrasound course. Concurrent with this rapid expansion of use of thyroid ultrasound was a rise in the diagnosis of small papillary carcinomas, which might have otherwise remained indolent and undetected. The 2009 American Thyroid Association Guidelines for the Management of Thyroid Nodules and Thyroid Cancer recommended biopsy for all solid hypoechoic nodules measuring larger than 1 cm. Attempting to decrease the frequency of biopsies of low-risk nodules, subsequent guidelines have focused on identifying and selectively biopsying those thyroid nodules at higher risk of clinically significant carcinoma based on ultrasound appearance. A major role for thyroid ultrasound has been in both preoperative staging and mapping to help determine the extent of surgery, as well as postoperative monitoring for locoregional soft tissue or lymph node metastases. With the recognition that the increase in papillary carcinoma was predominantly a result of early diagnosis of small often indolent cancers, active surveillance has become a promising management strategy for papillary thyroid microcarcinomas. Thyroid ultrasound is essential to active surveillance of thyroid cancer. Easy access to high-quality ultrasound studies is a requirement for a successful active surveillance program. Thyroid ultrasound has been used to facilitate interventional procedures, including treatment of thyroid nodules, treatment of recurrent thyroid cancer, and therapy of papillary thyroid microcarcinoma.
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Affiliation(s)
- Robert A Levine
- Department of Endocrinology, Thyroid Center of New Hampshire, Nashua, New Hampshire, USA
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21
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Kwon O, Lee S, Bae JS, Jung CK. Implications of isthmic location as a risk factor in papillary thyroid carcinoma. Gland Surg 2023; 12:952-962. [PMID: 37727333 PMCID: PMC10506121 DOI: 10.21037/gs-23-56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/12/2023] [Indexed: 09/21/2023]
Abstract
Background Papillary thyroid carcinoma (PTC) located in the isthmus generally has been known to have more extrathyroidal extension (ETE), lymph node involvement, and multifocality. The purpose of this study was to determine the clinical significance of an isthmic location of PTC. Methods The records of 160 patients who underwent a total thyroidectomy due to a single, dominant isthmic PTC were retrospectively reviewed. The characteristics of isthmic cancer were compared with those of unilateral-lobar cancer in a PTC cohort at Seoul St. Mary's hospital. After propensity score matching for age, sex, and tumor size, 160 isthmic PTCs and 800 unilateral-lobar PTCs were compared. The clinicopathologic characteristics were analyzed to evaluate the prognostic significance of an isthmic tumor location. Results The isthmic group was significantly older (49.6 vs. 46.8 years, P=0.007) and had a smaller mean tumor size (0.8±0.4 vs. 1.0±0.7 cm, P<0.001) than the unilateral-lobar group. After propensity score matching, tumor size categories, ETE, multifocality, nodal metastasis and proportion of patients with more than five metastatic lymph nodes were similar in both groups. However, N1b cases were more frequent in the unilateral-lobar group both before and after propensity score matching. In multivariate analysis, isthmic location was not correlated with gross ETE, multifocality, and higher-risk N1 disease. Younger age and more than five metastatic nodes increased the risk of PTC recurrence. However, isthmic tumor location was not significantly correlated with recurrence-free survival. Conclusions Isthmic location is not an independent risk factor for aggressive clinicopathologic features and is not related to PTC recurrence.
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Affiliation(s)
- Ohjoon Kwon
- Department of Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sohee Lee
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ja Seong Bae
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Cararo Lopes E, Sawant A, Moore D, Ke H, Shi F, Laddha S, Chen Y, Sharma A, Naumann J, Guo JY, Gomez M, Ibrahim M, Smith TL, Riedlinger GM, Lattime EC, Trooskin S, Ganesan S, Su X, Pasqualini R, Arap W, De S, Chan CS, White E. Integrated metabolic and genetic analysis reveals distinct features of human differentiated thyroid cancer. Clin Transl Med 2023; 13:e1298. [PMID: 37317665 PMCID: PMC10267429 DOI: 10.1002/ctm2.1298] [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: 03/10/2023] [Revised: 05/22/2023] [Accepted: 05/27/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Differentiated thyroid cancer (DTC) affects thousands of lives worldwide each year. Typically, DTC is a treatable disease with a good prognosis. Yet, some patients are subjected to partial or total thyroidectomy and radioiodine therapy to prevent local disease recurrence and metastasis. Unfortunately, thyroidectomy and/or radioiodine therapy often worsen(s) quality of life and might be unnecessary in indolent DTC cases. On the other hand, the lack of biomarkers indicating a potential metastatic thyroid cancer imposes an additional challenge to managing and treating patients with this disease. AIM The presented clinical setting highlights the unmet need for a precise molecular diagnosis of DTC and potential metastatic disease, which should dictate appropriate therapy. MATERIALS AND METHODS In this article, we present a differential multi-omics model approach, including metabolomics, genomics, and bioinformatic models, to distinguish normal glands from thyroid tumours. Additionally, we are proposing biomarkers that could indicate potential metastatic diseases in papillary thyroid cancer (PTC), a sub-class of DTC. RESULTS Normal and tumour thyroid tissue from DTC patients had a distinct yet well-defined metabolic profile with high levels of anabolic metabolites and/or other metabolites associated with the energy maintenance of tumour cells. The consistency of the DTC metabolic profile allowed us to build a bioinformatic classification model capable of clearly distinguishing normal from tumor thyroid tissues, which might help diagnose thyroid cancer. Moreover, based on PTC patient samples, our data suggest that elevated nuclear and mitochondrial DNA mutational burden, intra-tumour heterogeneity, shortened telomere length, and altered metabolic profile reflect the potential for metastatic disease. DISCUSSION Altogether, this work indicates that a differential and integrated multi-omics approach might improve DTC management, perhaps preventing unnecessary thyroid gland removal and/or radioiodine therapy. CONCLUSIONS Well-designed, prospective translational clinical trials will ultimately show the value of this integrated multi-omics approach and early diagnosis of DTC and potential metastatic PTC.
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Affiliation(s)
- Eduardo Cararo Lopes
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of Molecular Biology and BiochemistryRutgers UniversityPiscatawayNew JerseyUSA
| | - Akshada Sawant
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Dirk Moore
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of Biostatistics and EpidemiologyRutgers School of Public HealthPiscatawayNew JerseyUSA
| | - Hua Ke
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Fuqian Shi
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Saurabh Laddha
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Ying Chen
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Anchal Sharma
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Jake Naumann
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Jessie Yanxiang Guo
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of MedicineRobert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
- Department of Chemical BiologyRutgers Ernest Mario School of PharmacyPiscatawayNew JerseyUSA
| | - Maria Gomez
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Maria Ibrahim
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Tracey L. Smith
- Rutgers Cancer Institute of New JerseyNewarkNew JerseyUSA
- Division of Cancer BiologyDepartment of Radiation OncologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | | | - Edmund C. Lattime
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of Surgery, Robert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Stanley Trooskin
- Department of Surgery, Robert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Shridar Ganesan
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of MedicineRobert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Xiaoyang Su
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of MedicineRobert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Renata Pasqualini
- Rutgers Cancer Institute of New JerseyNewarkNew JerseyUSA
- Division of Cancer BiologyDepartment of Radiation OncologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Wadih Arap
- Rutgers Cancer Institute of New JerseyNewarkNew JerseyUSA
- Division of Hematology/OncologyDepartment of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Subhajyoti De
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Chang S. Chan
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of MedicineRobert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Eileen White
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of Molecular Biology and BiochemistryRutgers UniversityPiscatawayNew JerseyUSA
- Ludwig Princeton Branch, Ludwig Institute for Cancer ResearchPrinceton UniversityPrincetonNew JerseyUSA
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23
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Deguelte S, Colas PA, Guerin C, Leboulleux S, Najah H, Lifante JC. Extent of thyroidectomy: When should hemithyroidectomy be performed? Recommendations from the Francophone Association for Endocrine Surgery, the French Society of Endocrinology and the French Society of Nuclear Medicine. J Visc Surg 2023:S1878-7886(23)00077-2. [PMID: 37150665 DOI: 10.1016/j.jviscsurg.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
These recommendations, drawn from current data in the medical literature, incorporate the risks of hemithyroidectomy (HT) and total thyroidectomy (TT) and clarify the place of these two procedures in clinical settings. Discussions leading to a consensus were then assessed by the Francophone Association for Endocrine Surgery (Association francophone de chirurgie endocrinienne [AFCE]), along with the French Society of Endocrinology (Société française d'endocrinologie [SFE]), and the French Society of Nuclear Medicine (Société française de médecine nucléaire [SFMN]). The complication rate was twice as high after TT compared to HT. Total thyroidectomy requires life-long thyroid hormone supplementation, whereas such supplementation is required in only 30% of patients after HT. When surgery is indicated for Bethesda category II nodules, and in the absence of any indication for surgery on the contralateral lobe, HT is recommended. In patients with thyroid cancer (TC)≤1cm requiring surgical management or TC≤2cm, in the absence of risk factors for TC and in the absence of pre- or intraoperative detection of extrathyroidal extension, lymph node metastases (cN0) and/or suspected contra-lateral disease, HT is the preferred technique as long as the patient accepts the possibility of TT which might be required when aggressive forms of cancer are detected on definitive cytohistology (extrathyroidal extension, lymphovascular invasion, high-grade histology). For TC measuring between 2 and 4cm, the debate between HT and TT remains open today, although some surgeons tend to prefer TT. In patients with TC>4cm, macroscopic lymph node involvement (cN1), signs of extrathyroidal extension or predisposing factors for TC, TT is the treatment of choice.
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Affiliation(s)
- Sophie Deguelte
- Department of endocrine, digestive and oncological surgery, Robert-Debré university hospital, Reims, France; EA 3797, Reims medical school, 51095 Reims, France; Reims medical school, university of Champagne-Ardennes, Reims, France.
| | - Pierre Antoine Colas
- Department of general, visceral and endocrine surgery, Pitié-Salpêtrière university hospital, 75013 Paris, France
| | - Carole Guerin
- Department of endocrine surgery, CHU de la Conception, Aix-Marseille university, Marseille, France
| | - Sophie Leboulleux
- Department of Endocrinology, diabetology, Nutrition and Therapeutic Education, Hôpitaux Universitaires de Genève, Switzerland
| | - Haythem Najah
- Department of digestive and endocrine surgery, university hospital of Bordeaux, Bordeaux, France
| | - Jean Christophe Lifante
- Health services and performance research lab (EA 7425 HESPER) and EA 3738 CICLY, université Lyon 1, Claude-Bernard, 69921 Lyon, France; Department of endocrine surgery , hospices civils de Lyon, groupement hospitalier Sud, 69495 Pierre-Bénite, France
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24
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Klarich S, White H. Can ultrasound strain elastography (USE) improve management of suspicious thyroid nodules measuring <10 mm? A systematic review. Radiography (Lond) 2023; 29:661-667. [PMID: 37148707 DOI: 10.1016/j.radi.2023.04.015] [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: 01/24/2023] [Revised: 03/08/2023] [Accepted: 04/17/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Current UK guidelines state that suspicious thyroid nodules <10 mm do not require FNA. These are often followed up with serial ultrasound scans. Ultrasound Strain Elastography (USE) could provide a more accurate alternative and preclude the need for follow-up. Can USE identify nodules at greater risk of malignancy and streamline patient management? METHODS Systematic review methodology used. Inclusion criteria are: - Population: patients with suspicious thyroid nodules <10 mm.- Intervention: USE.- Comparator: Ultrasound features of nodules.- Outcome measure: FNA or surgical removal of nodules. Searches performed on 6 commercial databases, along with grey literature anddissertation databases. The QUADAS-2 diagnostic study checklist used for quality assessment. RESULTS 8 studies included and a narrative analysis performed due to heterogeneity of results. The mean USE sensitivity is 74.3%, mean specificity 80.5%. Mean overall ultrasound sensitivity is 80.4%, specificity 71.0%. Results suggest that USE is not superior to ultrasound for detecting malignancy. Some study limitations, particularly the heterogeneity of reporting the ultrasound features preclude meaningful conclusion from being drawn. CONCLUSION USE is more accurate at identifying benign nodules than ultrasound. Nodules appearing benign on USE could be excluded from serial ultrasound follow-up. No significant difference was found between USE and ultrasound at identifying malignant nodules. IMPLICATIONS FOR PRACTICE As FNA is not recommended for suspicious thyroid nodules <10 mm, these are often followed up with multiple scans and clinician reviews. This increases pressure on healthcare systems and uncertainty for the patient. This review shows that USE is more accurate at identifying benign nodules than ultrasound alone, meaning that these nodules could potentially be excluded from serial follow up. This would streamline patient management, freeing-up vital resources in ENT and ultrasound departments.
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Affiliation(s)
- S Klarich
- Walsall Healthcare NHS Trust, Imaging Department, Walsall Manor Hospital, Moat Road, Walsall, WS2 9PS, United Kingdom.
| | - H White
- Department of Radiography, Birmingham City University, City South Campus, Westbourne Road, Edgbaston, Birmingham, B15 3TN, United Kingdom.
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Yan L, Liu Y, Li W, Zhu Y, Wang J, Zhang M, Tang J, Che Y, Wang H, Wang S, Luo Y. Long-term Outcomes of Ultrasound-guided Thermal Ablation for the Treatment of Solitary Low-risk Papillary Thyroid Microcarcinoma: A Multicenter Retrospective Study. Ann Surg 2023; 277:846-853. [PMID: 36727947 DOI: 10.1097/sla.0000000000005800] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To report more than 5-year outcomes of ultrasound-guided thermal ablation (TA) for patients with solitary low-risk papillary thyroid microcarcinoma (PTMC) in a large multicenter cohort. BACKGROUND TA, including radiofrequency ablation (RFA) and microwave ablation (MWA) have been used in patients with low-risk PTMC who refuse surgery or active surveillance. However, its clinical value remains controversial. MATERIALS AND METHODS This retrospective multicenter study included 474 patients with solitary low-risk PTMC treated with TA (357 for RFA; 117 for MWA) from 4 centers and followed up for at least 5 years. Disease progression including lymph node metastasis and recurrent tumors, volume reduction rate (VRR), tumor disappearance rate, complications, and delayed surgery were assessed. RFA and MWA outcomes were compared using propensity score matching. RESULTS During the median follow-up period of 77.2 months, disease progression incidence, lymph node metastasis, and recurrent tumors rates were 3.6%, 1.1%, and 2.5%, respectively. Age below 40 years old, male sex, Hashimoto thyroiditis, and tumor size were not independent factors associated with disease progression by Cox analysis. The median VRR was 100% and 471 tumors disappeared radiographically. Eight patients experienced transient voice change (1.7%) which recovered within 3 months. None of the patients underwent delayed surgery because of anxiety. After 1:1 matching, no significant differences were found in the disease progression, VRR, tumor disappearance rate, or complications between RFA and MWA subgroups. CONCLUSION This multicenter study revealed that TA was an effective and safe treatment for patients with solitary low-risk PTMC, which could be offered as a treatment option for the management for low-risk PTMC.
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Affiliation(s)
- Lin Yan
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ying Liu
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - WenHui Li
- Depart of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - YaLin Zhu
- Department of Ultrasound, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jinling Wang
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - Mingbo Zhang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Tang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ying Che
- Department of Ultrasound, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hui Wang
- Depart of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shurong Wang
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - Yukun Luo
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
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26
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Yan L, Li Y, Li XY, Xiao J, Tang J, Luo Y. Clinical outcomes of ultrasound-guided radiofrequency ablation for solitary T1N0M0 papillary thyroid carcinoma: A retrospective study with more than 5 years of follow-up. Cancer 2023. [PMID: 37060239 DOI: 10.1002/cncr.34802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/13/2023] [Accepted: 03/29/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Ultrasound-guided radiofrequency ablation (RFA) has been used in patients with papillary thyroid carcinoma (PTC) who refuse surgery or active surveillance. However, the long-term outcomes are still limited. This study aimed to evaluate the clinical outcomes of RFA for solitary T1N0M0 PTC in a large cohort over a more than 5-year follow-up period. METHODS This retrospective study included 358 patients with solitary T1N0M0 PTC who were treated with RFA and followed for at least 5 years. The bipolar RFA procedure was performed using hydrodissection technique, transisthmic approach, and moving-shot technique. The primary outcomes were disease progression, including lymph node metastasis (LNM), recurrent tumor, persistent tumor, and distant metastasis. The secondary outcomes were volume reduction rate, complete disappearance rate, complications, and delayed surgery. RESULTS During a mean follow-up period of 75.5 ± 9.7 months, the overall disease progression was 5.0%. The incidence of LNM, recurrent tumor, and persistent tumor was 1.4%, 3.1%, and 0.6%, respectively. There were no significant differences in the disease progression (5.0% vs. 5.5%, p = 1.000), LNM (1.3% vs. 1.8%, p = .568), recurrent tumor (3.3% vs. 1.8%, p = .872), persistent tumors (0.3% vs. 1.8%, p = .284), and 5-year recurrence-free survival rates (95.4% vs. 96.4%, p = .785) in the T1a and T1b groups. Volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. No complications occurred. No patients underwent delayed surgery because of anxiety. CONCLUSIONS RFA is an effective and safe alternative for patients with T1N0M0 PTC and can offer a minimally invasive curative option for patients who refuse surgery or active surveillance. PLAIN LANGUAGE SUMMARY During a mean follow-up period of 75.5 ± 9.7 months, the overall papillary thyroid carcinoma disease progression was 5.0%. The volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. The T1a and T1b groups had similar incidence of disease progression and 5-year recurrence-free survival rates. No patients experienced complications or underwent delayed surgery because of anxiety.
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Affiliation(s)
- Lin Yan
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yingying Li
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin Yang Li
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing Xiao
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Tang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yukun Luo
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
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27
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Smulever A, Pitoia F. Conservative management of low-risk papillary thyroid carcinoma: a review of the active surveillance experience. Thyroid Res 2023; 16:6. [PMID: 36907911 PMCID: PMC10009928 DOI: 10.1186/s13044-023-00148-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/22/2023] [Indexed: 03/14/2023] Open
Abstract
The detection of low-risk thyroid carcinoma has increased in recent decades, although disease-specific mortality remained without changes. The high prevalence of occult carcinomas in autopsy studies, and hence the underlying indolent course of this entity, prompted the emergence of active surveillance as an alternative approach to these tumors. This strategy aims to recognize the minority group of patients who will develop clinical progression and probably benefit from deferred surgery. Experience around the world has shown that during active surveillance these tumors are mostly unchanged in size, with very-slow growth and even a decrease in diameter. Moreover, the rates of lymph node metastases were low and easily handled by rescue surgery, and distant metastases have not been reported. Given the high prevalence of small thyroid carcinomas and the excellent outcomes for observation, active surveillance provides a safe and feasible alternative in properly selected patients with low-risk thyroid cancer.
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Affiliation(s)
- Anabella Smulever
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, Argentina
| | - Fabian Pitoia
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, Argentina.
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Cararo-Lopes E, Sawant A, Moore D, Ke H, Shi F, Laddha S, Chen Y, Sharma A, Naumann J, Guo JY, Gomez M, Ibrahim M, Smith TL, Riedlinger GM, Lattime EC, Trooskin S, Ganesan S, Su X, Pasqualini R, Arap W, De S, Chan CS, White E. Integrated metabolic and genetic analysis reveals distinct features of primary differentiated thyroid cancer and its metastatic potential in humans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.09.23287037. [PMID: 36945575 PMCID: PMC10029066 DOI: 10.1101/2023.03.09.23287037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Differentiated thyroid cancer (DTC) affects thousands of lives worldwide every year. Typically, DTC is a treatable disease with a good prognosis. Yet, some patients are subjected to partial or total thyroidectomy and radioiodine therapy to prevent local disease recurrence and metastasis. Unfortunately, thyroidectomy and/or radioiodine therapy often worsen(s) the quality of life and might be unnecessary in indolent DTC cases. This clinical setting highlights the unmet need for a precise molecular diagnosis of DTC, which should dictate appropriate therapy. Here we propose a differential multi-omics model approach to distinguish normal gland from thyroid tumor and to indicate potential metastatic diseases in papillary thyroid cancer (PTC), a sub-class of DTC. Based on PTC patient samples, our data suggest that elevated nuclear and mitochondrial DNA mutational burden, intratumor heterogeneity, shortened telomere length, and altered metabolic profile reflect the potential for metastatic disease. Specifically, normal and tumor thyroid tissues from these patients had a distinct yet well-defined metabolic profile with high levels of anabolic metabolites and/or other metabolites associated with the energy maintenance of tumor cells. Altogether, this work indicates that a differential and integrated multi-omics approach might improve DTC management, perhaps preventing unnecessary thyroid gland removal and/or radioiodine therapy. Well-designed, prospective translational clinical trials will ultimately show the value of this targeted molecular approach. TRANSLATIONAL RELEVANCE In this article, we propose a new integrated metabolic, genomic, and cytopathologic methods to diagnose Differentiated Thyroid Cancer when the conventional methods failed. Moreover, we suggest metabolic and genomic markers to help predict high-risk Papillary Thyroid Cancer. Both might be important tools to avoid unnecessary surgery and/or radioiodine therapy that can worsen the quality of life of the patients more than living with an indolent Thyroid nodule.
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Alexander K, Lee SYC, Georgiades S, Constantinou C. The "not so good" thyroid cancer: a scoping review on risk factors associated with anxiety, depression and quality of life. J Med Life 2023; 16:348-371. [PMID: 37168306 PMCID: PMC10165516 DOI: 10.25122/jml-2022-0204] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/10/2023] [Indexed: 05/13/2023] Open
Abstract
The incidence of thyroid cancer has increased in recent years, leading to a growing number of survivors facing lifelong consequences. This scoping review investigated anxiety, depression, and quality of life (QoL) in thyroid cancer survivors compared to the general population, those with benign pathology, and survivors of other types of cancers. Moreover, we aimed to identify the risk factors associated with anxiety, depression, and QoL in thyroid cancer patients. A total of 727 articles were identified through PubMed, ProQuest, Cochrane, and Google Scholar databases, and 68 articles that met the criteria were selected for data extraction. Thyroid cancer survivors have a poorer QoL compared to the general population, population with benign pathology, and survivors of other types of cancer associated with worse clinical outcomes. The main risk factors are grouped into socioeconomic factors, disease-specific factors, management factors, comorbidities, and patient perceptions. Effective communication between the patient and the medical team and behavioral interventions may reduce these risks. Despite the common perception of thyroid cancer as a "good cancer," the findings of this review demonstrate the need to address the risk factors associated with increased anxiety, depression, and lower QoL in survivors.
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Affiliation(s)
- Kyle Alexander
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Sum-Yu Christina Lee
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Stelios Georgiades
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Constantina Constantinou
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
- Corresponding Author: Constantina Constantinou, Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus. E-mail:
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Fung YY, Chung D, Clark JR, Low THH, Palme CE, Wykes J, Elliott MS. Comparative analysis of pre-operative ultrasound and histopathology in small papillary thyroid carcinoma in the era of active surveillance. ANZ J Surg 2023; 93:902-906. [PMID: 36852861 DOI: 10.1111/ans.18353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/19/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Contemporary management of small papillary thyroid carcinomas (PTC) includes active surveillance (AS) as a number of these tumours are indolent. Overseas studies have reported AS in tumours up to 15 mm. This study aims to look at an Australian cohort of patients who have had surgery for non-incidental PTCs and analyse their pre-operative ultrasound and histopathology data to investigate potential issues that might arise in the era of AS. METHODS Retrospective review of 82 patients who had surgical removal of PTCs ≤15 mm in diameter. Pre-operative ultrasound imaging was reviewed by an experienced sonologist and histopathology data was obtained from medical records. The AS risk stratification framework by Brito et al. was used to determine those who were feasible for AS based on ultrasound findings. RESULTS Review of pre-operative ultrasounds demonstrated there were 68 (82.9%) patients who were shown to be either appropriate or ideal for AS. On review of histopathology, 49 (69%) patients had at least one adverse pathological risk factor. This is more than half of the patients that were originally identified as candidates for AS. CONCLUSION Our study has revealed a large proportion were suitable for AS but when compared with histopathological guidelines there was a high incidence of adverse pathological features found. This discrepancy indicates that although the guidelines are important, there are unknown pathological variables that need to be considered in patients selected for AS.
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Affiliation(s)
- Yuen Yin Fung
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - David Chung
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan R Clark
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Tsu-Hui Hubert Low
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia
| | - Carsten E Palme
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia
| | - James Wykes
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia
| | - Michael S Elliott
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia
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Liu Q, Ma B, Song M, Sun W, Zhang H. Age-dependent changes in the prognostic advantage of papillary thyroid cancer in women: A SEER-based study. Clin Endocrinol (Oxf) 2023. [PMID: 36806120 DOI: 10.1111/cen.14896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Papillary thyroid cancer (PTC) is more prevalent in women, and women show a better prognosis than men; however, the factors contributing to this prognostic difference are confounding. Therefore, we aimed to investigate the effect of the interaction between sex and age on the prognosis of PTC. METHODS A total of 108,459 patients with PTC were retrospectively analysed, and Cox-regression models were used to assess differences in disease specific survival (DSS) by sex, with inverse probability of treatment weighting (IPTW) to control for between-group differences in prognosis by sex due to age change. Restricted cubic splines were used to analyse prognostic differences between sexes for papillary thyroid microcarcinoma (PTMC) and PTC. Multiple mediation analyses were used to assess the direct or indirect effect of sex on DSS. RESULTS The DSS was higher for women than men (98.6% vs. 95.4%, χ2 = 458.57, p < .001). After IPTW adjustment, the DSS of women was better than that of men (HR = 0.67, 0.60-0.76). In the subgroup analysis, women had an advantage in DSS across most age intervals (crude HR = 0.166 [0.082-0.337], p < .001, IPTW-adjusted HR = 0.331 [0.161-0.681], p < .001). The difference between the two gradually narrowed with increasing age, and the prognosis of women was better than that of men in PTMC, while this advantage was not obvious in PTC. CONCLUSIONS The overall PTC prognosis of women is better than that of men, but the prognostic advantage of women diminishes with age and tumour growth. These differences in prognosis may be due to some indirect factors caused by different sexes.
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Affiliation(s)
- Qi Liu
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Bing Ma
- Department of Clinical Epidemiology and Evidence-Based Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Mingyuan Song
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Wei Sun
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
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Fu C, Cui Y, Li J, Wang Y, Si C, Cui K. The feasibility of decreasing the thresholds for biopsy in Kwak and C TIRADSs. Front Oncol 2023; 13:1027802. [PMID: 36845721 PMCID: PMC9945266 DOI: 10.3389/fonc.2023.1027802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023] Open
Abstract
Objectives To estimate the feasibility of decreasing the original thresholds for biopsy in the Kwak Thyroid Imaging Reporting and Data System (Kwak TIRADS) and Chinese Thyroid Imaging Reporting and Data System (C TIRADS). Methods This retrospective study included 3,201 thyroid nodules from 2,146 patients with a pathological diagnosis. We lowered the original fine-needle aspiration (FNA) thresholds with the TR4a-TR5 in Kwak and C TIRADSs and calculated the ratio of additional benign-to-malignant nodules being biopsied (RABM). If the RABM is less than 1, the decreased FNA thresholds could be accepted and used to the modified TIRADSs (modified C and Kwak TIRADSs). Then, we estimated and compared the diagnostic performance between the modified TIRADS and the original TIRADS to determine if the decreased thresholds could be an effective strategy. Results A total of 1,474 (46.0%) thyroid nodules were diagnosed as malignant after thyroidectomy. The TR4c-TR5 in Kwak TIRADS and TR4b-TR5 in C TIRADS had a rational RABM (RABM < 1). The modified Kwak TIRADS had higher sensitivity, a positive predictive value, a negative predictive value, lower specificity, an unnecessary biopsy rate, and a missed malignancy rate compared with the original Kwak TIRADS (94.1% vs. 42.6%, 59.4% vs. 44.6%, 89.9% vs. 52.8%, 45.0% vs. 54.9%, 40.6% vs. 55.4%, and 10.1% vs. 47.1%, respectively, P < 0.05 for all). Similar trends were seen in the modified C TIRADS versus the original C TIRADS (95.1% vs. 38.7%, 61.7% vs. 47.8%, 92.3% vs. 55.0%, 49.7% vs. 64.0%, 38.3% vs. 52.2%, and 7.7% vs. 44.9%, respectively, P < 0.05 for all). Conclusions The biopsy of all nodules with TR4C-TR5 in the Kwak TIRADS and TR4B-TR5 in the C TIRADS might be an effective strategy. This paper contributes to the contradiction concerning whether to perform FNA for the nodules smaller than 10 mm.
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Affiliation(s)
- Chao Fu
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yiyang Cui
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Wang
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Caifeng Si
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kefei Cui
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,*Correspondence: Kefei Cui,
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Liu L, Jia C, Li G, Shi Q, Du L, Wu R. Nomogram incorporating preoperative clinical and ultrasound indicators to predict aggressiveness of solitary papillary thyroid carcinoma. Front Oncol 2023; 13:1009958. [PMID: 36798828 PMCID: PMC9927212 DOI: 10.3389/fonc.2023.1009958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
Objective To construct a nomogram based on preoperative clinical and ultrasound indicators to predict aggressiveness of solitary papillary thyroid carcinoma (PTC). Methods Preoperative clinical and ultrasound data from 709 patients diagnosed with solitary PTC between January 2017 and December 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with PTC aggressiveness, and these factors were used to construct a predictive nomogram. The nomogram's performance was evaluated in the primary and validation cohorts. Results The 709 patients were separated into a primary cohort (n = 424) and a validation cohort (n = 285). Univariate analysis in the primary cohort showed 13 variables to be associated with aggressive PTC. In multivariate logistic regression analysis, the independent predictors of aggressive behavior were age (OR, 2.08; 95% CI, 1.30-3.35), tumor size (OR, 4.0; 95% CI, 2.17-7.37), capsule abutment (OR, 2.53; 95% CI, 1.50-4.26), and suspected cervical lymph nodes metastasis (OR, 2.50; 95% CI, 1.20-5.21). The nomogram incorporating these four predictors showed good discrimination and calibration in both the primary cohort (area under the curve, 0.77; 95% CI, 0.72-0.81; Hosmer-Lemeshow test, P = 0.967 and the validation cohort (area under the curve, 0.72; 95% CI, 0.66-0.78; Hosmer-Lemeshow test, P = 0.251). Conclusion The proposed nomogram shows good ability to predict PTC aggressiveness and could be useful during treatment decision making. Advances in knowledge Our nomogram-based on four indicators-provides comprehensive assessment of aggressive behavior of PTC and could be a useful tool in the clinic.
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Affiliation(s)
- Long Liu
- Department of Ultrasound, Shanghai General Hospital of Nanjing Medical University, Shanghai, China,Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao Jia
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gang Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiusheng Shi
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lianfang Du
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Wu
- Department of Ultrasound, Shanghai General Hospital of Nanjing Medical University, Shanghai, China,Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,*Correspondence: Rong Wu,
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Abstract
Recently, the incidence of thyroid carcinoma has been increasing rapidly worldwide. This is interpreted as an increase in the incidental detection of small papillary thyroid carcinomas by the widespread use of high-resolution imaging techniques such as ultrasonography. However, the mortality rates of thyroid carcinoma have not changed, suggesting that small papillary thyroid carcinomas may be overdiagnosed and overtreated. Active surveillance management has been introduced from Japan since the 1990s, as one of the measures to prevent overtreatment of low-risk papillary thyroid microcarcinoma. Based on the favorable outcomes, active surveillance has been gradually adopted worldwide as an alternative to immediate surgery. The management should be carried out with strict eligibility criteria and close monitoring for cancer progression, under a multidisciplinary team. In addition, an adequate shared decision-making is mandatory for individual patients. Papillary thyroid microcarcinomas with clinically apparent lymph node metastasis, distant metastasis, or invasion to adjacent organs should have surgery.
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Affiliation(s)
- Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
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Cohen SM, Noel JE, Baroody M, Orloff LA. Prognostication of papillary thyroid microcarcinoma based on preoperative ultrasound. Front Endocrinol (Lausanne) 2023; 14:1101705. [PMID: 36793279 PMCID: PMC9922900 DOI: 10.3389/fendo.2023.1101705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/04/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Diagnosis of papillary thyroid microcarcinoma, defined as papillary thyroid carcinoma measuring 1cm or less in greatest diameter, has increased with improvements in ultrasound technology and widespread familiarity and utilization. Given the indolent course of papillary thyroid carcinoma, active surveillance is considered an acceptable alternative to surgical resection for select patients. Candidacy for active surveillance is determined by a number of patient and tumor characteristics. Specifically, the location of the tumor within the thyroid gland plays one of the key roles in decision making. Here we evaluate characteristics of the primary tumor and distance to the thyroid capsule in association with locoregional metastases to help guide risk assessment. METHODS Retrospective chart review of all thyroid surgeries performed by two surgeons at one medical center from 2014-2021 to evaluate characteristics of papillary thyroid microcarcinoma on preoperative ultrasound that are associated with locoregional metastatic disease. RESULTS Our data show a sensitivity of 65% and specificity of 95% for identifying regional metastases in papillary thyroid microcarcinoma using preoperative ultrasound. We found no correlation between regional metastasis and size of tumor, distance to thyroid capsule or trachea, tumor contour, or presence of autoimmune thyroiditis. Nodules in the superior or midpole were associated with central or lateral neck metastases, whereas nodules in the isthmus or inferior pole were only associated with central neck metastases. CONCLUSIONS Active surveillance may be a reasonable option for even those papillary thyroid microcarcinomas adjacent to the thyroid capsule.
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Advances in Endocrine Surgery. Surg Oncol Clin N Am 2023; 32:199-220. [PMID: 36410918 DOI: 10.1016/j.soc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent changes in the landscape of endocrine surgery include a shift from total thyroidectomy for almost all patients with papillary thyroid cancer to the incorporation of thyroid lobectomy for well-selected patients with low-risk disease; minimally invasive parathyroidectomy with, and potentially without, intraoperative parathyroid hormone monitoring for patients with well-localized primary hyperparathyroidism; improvement in the management of parathyroid cancer with the incorporation of immune checkpoint blockade and/or targeted therapies; and the incorporation of minimally invasive techniques in the management of patients with benign tumors and selected secondary malignancies of the adrenal gland.
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Leboulleux S, Lamartina L, Lecornet Sokol E, Menegaux F, Leenhardt L, Russ G. SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules : Follow-up: How and how long? ANNALES D'ENDOCRINOLOGIE 2022; 83:407-414. [PMID: 36283461 DOI: 10.1016/j.ando.2022.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians, surgeons, and other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the follow-up of thyroid nodules, low-grade tumors and microcarcinomas.
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Affiliation(s)
- Sophie Leboulleux
- Service d'Endocrinologie, Hôpitaux Universitaires de Genève, 4 Rue Gabrielle Perret-Gentil, 1205 Genève, Switzerland.
| | - Livia Lamartina
- Endocrine Oncology, Gustave Roussy and University Paris Saclay, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | | | - Fabrice Menegaux
- Endocrine Surgery Department, Pitié-Salpêtrière Hospital APHP, Institute of Cancer IUC, Sorbonne University GRC N°16, 83 Boulevard de l'Hôpital, 75013 Paris, France; Centre de Pathologie et d'Imagerie, 14 Avenue René Coty, 75014 Paris, France
| | - Laurence Leenhardt
- Thyroid and Endocrine Tumors Department, Pitié Salpêtrière Hospital, APHP, Institute of Cancer IUC, Sorbonne University, 83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Gilles Russ
- Centre de Pathologie et d'Imagerie, 14 Avenue René Coty, 75014 Paris, France; Thyroid and Endocrine Tumors Department, Pitié-Salpêtrière Hospital APHP, Institute of Cancer IUC, Sorbonne University GRC N°16, 83 Boulevard de l'Hôpital, 75013 Paris, France
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Ho AS, Kim S, Zalt C, Melany ML, Chen IE, Vasquez J, Mallen-St. Clair J, Chen MM, Vasquez M, Fan X, van Deen WK, Haile RW, Daskivich TJ, Zumsteg ZS, Braunstein GD, Sacks WL. Expanded Parameters in Active Surveillance for Low-risk Papillary Thyroid Carcinoma: A Nonrandomized Controlled Trial. JAMA Oncol 2022; 8:2796440. [PMID: 36107411 PMCID: PMC9478884 DOI: 10.1001/jamaoncol.2022.3875] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/08/2022] [Indexed: 08/28/2023]
Abstract
Importance Unlike for prostate cancer, active surveillance for thyroid cancer has not achieved wide adoption. The parameters by which this approach is feasible are also not well defined, nor is the effect of patient anxiety. Objective To determine if expanded size/growth parameters for patients with low-risk thyroid cancer are viable, as well as to assess for cohort differences in anxiety. Design, Setting, and Participants This prospective nonrandomized controlled trial was conducted at a US academic medical center from 2014 to 2021, with mean [SD] 37.1 [23.3]-month follow-up. Of 257 patients with 20-mm or smaller Bethesda 5 to 6 thyroid nodules, 222 (86.3%) enrolled and selected treatment with either active surveillance or immediate surgery. Delayed surgery was recommended for size growth larger than 5 mm or more than 100% volume growth. Patients completed the 18-item Thyroid Cancer Modified Anxiety Scale over time. Interventions Active surveillance. Main Outcomes and Measures Cumulative incidence and rate of size/volume growth. Results Of the 222 patients enrolled, the median (IQR) age for the study population was 46.8 (36.6-58) years, and 76.1% were female. Overall, 112 patients (50.5%) underwent treatment with active surveillance. Median tumor size was 11.0 mm (IQR, 9-15), and larger tumors (10.1-20.0 mm) comprised 67 cases (59.8%). One hundred one (90.1%) continued to receive treatment with active surveillance, 46 (41.0%) had their tumors shrink, and 0 developed regional/distant metastases. Size growth of more than 5 mm was observed in 3.6% of cases, with cumulative incidence of 1.2% at 2 years and 10.8% at 5 years. Volumetric growth of more than 100% was observed in 7.1% of cases, with cumulative incidence of 2.2% at 2 years and 13.7% at 5 years. Of 110 patients who elected to undergo immediate surgery, 21 (19.1%) had equivocal-risk features discovered on final pathology. Disease severity for all such patients remained classified as stage I. Disease-specific and overall survival rates in both cohorts were 100%. On multivariable analysis, immediate surgery patients exhibited significantly higher baseline anxiety levels compared with active surveillance patients (estimated difference in anxiety scores between groups at baseline, 0.39; 95% CI, 0.22-0.55; P < .001). This difference endured over time, even after intervention (estimated difference at 4-year follow-up, 0.50; 95% CI, 0.21-0.79; P = .001). Conclusions and Relevance The results of this nonrandomized controlled trial suggest that a more permissive active surveillance strategy encompassing most diagnosed thyroid cancers appears viable. Equivocal-risk pathologic features exist in a subset of cases that can be safely treated, but suggest the need for more granular risk stratification. Surgery and surveillance cohorts possess oppositional levels of worry, elevating the importance of shared decision-making when patients face treatment equivalence. Trial Registration ClinicalTrials.gov Identifier: NCT02609685.
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Affiliation(s)
- Allen S. Ho
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sungjin Kim
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia Zalt
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle L. Melany
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Irene E. Chen
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joan Vasquez
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon Mallen-St. Clair
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M. Chen
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Missael Vasquez
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xuemo Fan
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Welmoed K. van Deen
- Center for Outcomes Research and Education, Division of Health Sciences Research, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert W. Haile
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Timothy J. Daskivich
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zachary S. Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Glenn D. Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wendy L. Sacks
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Ward LS, Scheffel RS, Hoff AO, Ferraz C, Vaisman F. Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:522-532. [PMID: 36074944 PMCID: PMC10697645 DOI: 10.20945/2359-3997000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
Increasingly sensitive diagnostic methods, better understanding of molecular pathophysiology, and well-conducted prospective studies have changed the current approach to patients with thyroid cancer, requiring the implementation of individualized management. Most patients with papillary thyroid carcinoma (PTC) are currently considered to have a low risk of mortality and disease persistence/recurrence. Consequently, current treatment recommendations for these patients include less invasive or intensive therapies. We used the most recent evidence to prepare a position statement providing guidance for decisions regarding the management of patients with low-risk PTC (LRPTC). This document summarizes the criteria defining LRPTC (including considerations regarding changes in the TNM staging system), indications and contraindications for active surveillance, and recommendations for follow-up and surgery. Active surveillance may be an appropriate initial choice in selected patients, and the criteria to recommend this approach are detailed. A section is dedicated to the current evidence regarding lobectomy versus total thyroidectomy and the potential pitfalls of each approach, considering the challenges during long-term follow-up. Indications for radioiodine (RAI) therapy are also addressed, along with the benefits and risks associated with this treatment, patient preparation, and dosage. Finally, this statement presents the best follow-up strategies for LRPTC after lobectomy and total thyroidectomy with or without RAI.
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Affiliation(s)
- Laura Sterian Ward
- Laboratório de Genética Molecular do Câncer, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Rafael Selbach Scheffel
- Unidade de Tireoide, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
- Departamento de Farmacologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Ana O Hoff
- Unidade de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (Icesp), Universidade de São Paulo (USP), São Paulo, SP, Brasil
| | - Carolina Ferraz
- Divisão de Endocrinologia, Departamento de Medicina, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Faculdade de Ciências Médicas da Santa Casa, São Paulo, SP, Brasil
| | - Fernanda Vaisman
- Serviço de Oncologia Endócrina, Instituto Nacional do Câncer do Rio de Janeiro (Inca), Rio de Janeiro, RJ, Brasil,
- Faculdade de Medicina, Serviço de Endocrinologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Papachristos A, Do K, Tsang VH, Sywak M, Gill AJ, Sidhu S, Clifton-Bligh RJ, Glover A, Gild ML. Outcomes of Papillary Thyroid Microcarcinoma Presenting with Palpable Lateral Lymphadenopathy. Thyroid 2022; 32:1086-1093. [PMID: 35703333 DOI: 10.1089/thy.2022.0109] [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: 11/12/2022]
Abstract
Purpose: Papillary thyroid microcarcinoma (PTMC) is typically indolent in nature, allowing management with active surveillance protocols. Occasionally, a more aggressive phenotype can present and may lead to poor outcomes such as patients presenting with clinically significant lateral lymphadenopathy (cN1b). Prior analysis of the outcomes of this cohort is largely from papillary thyroid cancer (PTC) (>1 cm) or from institutions where use of radioactive iodine (RAI) is limited. Hence, we aim to describe the outcomes of patients with PTMC who presented with palpable cN1b disease, treated with total thyroidectomy and RAI. Methodology: We performed a retrospective cohort study. Outcomes of patients with PTMC who presented with palpable lateral lymph node (LN) metastases (microPTC cN1b) treated between 1997 and 2020 at Royal North Shore Hospital were compared with two control groups' outcomes: patients with clinically detected PTMC without evidence of involved LNs (microPTC cN0) and with larger PTC (>10 mm) who presented with palpable lateral lymphadenopathy (larger PTC cN1b). We assessed clinicopathological variables, postoperative risk stratification, rates of disease recurrence, reoperative surgery, and structural disease-free survival (DFS). Results: In total, 1534 PTMCs were diagnosed following thyroid surgery in the study period; of these, 157 (10%) were clinically detected microPTC cN0 and 26 microPTC cN1b (1.7%). There were 138 patients in the larger PTC cN1b control group. All cN1b patients were treated with total thyroidectomy and adjuvant RAI. Mean size of the largest LN deposit was similar between the microPTC cN1b and larger PTC cN1b groups (23 vs. 27 mm, p = 0.11). Patients with microPTC cN1b were more likely to have biochemical or structural persistence or recurrence compared with microPTC cN0 (19%, 5/26 vs. 3.8%, 6/157, p = 0.002) but less likely than larger PTC cN1b patients (19%, 5/26 vs. 42%, 58/138, p = 0.04). All patients in the microPTC cN1b group who had an excellent response to initial therapy (85%, 22/26) were disease free at last follow-up. The rate of reoperation was similar for the microPTC cN1b and microPTC cN0 groups (4%, 1/26 vs. 2%, 3/157, p = 0.461) and significantly lower than the larger PTC cN1b group (4%, 1/26 vs. 26%, 36/138, p = 0.002). Five-year DFS estimates were significantly better for microPTC cN1b patients than for larger PTC cN1b patients (94% vs. 59%, p = 0.001). Conclusions: MicroPTC cN1b patients treated with thyroidectomy and adjuvant RAI have inferior clinical outcomes compared with microPTC cN0 patients but have better outcomes than their larger PTC cN1b counterparts with respect to disease persistence and recurrence. Response to initial therapy provides valuable prognostication in microPTC cN1b patients: if these patients had an excellent response to initial treatment, they achieved long-term DFS in this series.
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Affiliation(s)
- Alexander Papachristos
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kimchi Do
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Venessa H Tsang
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Stan Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Roderick J Clifton-Bligh
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Matti L Gild
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Lindner K, Iwen KA, Kußmann J, Fendrich V. Predictive Factors for Bilateral Disease in Papillary Microcarcinoma: A Retrospective Cohort Study. Curr Oncol 2022; 29:6010-6017. [PMID: 36135042 PMCID: PMC9497734 DOI: 10.3390/curroncol29090473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Based on risk stratification, the therapeutic options in papillary microcarcinoma (PTMC) can be active surveillance or surgery. Multifocal tumor occurrence can be decisive in determining the treatment strategy. The objective of this study was to identify risk factors for bilateral tumor occurrence in PTMC to enable individual therapy planning. Methods: A total of 545 PTMC patients who underwent thyroidectomy from 2008 to 2020 were retrieved. Univariate and multivariate analyses were performed to evaluate risk factors for bilateral PTMC. Results: 25.1% (n = 137) of all patients had multifocal PTMC, and 13.2% (n = 72) bilateral PTMC, respectively. In contrast to the maximum tumor size, the total tumor size significantly influenced a bilateral tumor manifestation (median total tumor size 5 mm versus 8.5 mm for bilateral PTMC, p < 0.001). A cut-off level for the total tumor size of >10 mm resulted in a sensitivity and specificity of 29.2% and 94.7%, respectively, in predicting a bilateral tumor manifestation, AUC 0.680 (95% CI, 0.611−0.748, p < 0.001). A cut-off of >4 tumors showed a sensitivity of 99.4% and a specificity of 97.5%, AUC 0.897 (95% CI, 0.870−0.924, p < 0.001) in predicting bilaterality. Conclusion: We could demonstrate for the first time that a total tumor size of >10 mm and more than four tumors significantly increased the risk of bilateral PTMC tumor involvement. These findings enable a risk-adjusted patient treatment.
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Affiliation(s)
- Kirsten Lindner
- Department of Endocrine Surgery, Lakumed, Krankenhausstr. 2, 84137 Vilsbiburg, Germany
| | - K. Alexander Iwen
- Department of Internal Medicine I, University Hospital Schleswig-Holstein Campus Lübeck & Institute for Endocrinology and Diabetes–Molecular Endocrinology, Center of Brain Behavior and Metabolism CBBM, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Jochen Kußmann
- Department of Endocrine Surgery, Schoen Clinic, Dehnhaide 120, 22081 Hamburg, Germany
| | - Volker Fendrich
- Department of Endocrine Surgery, Schoen Clinic, Dehnhaide 120, 22081 Hamburg, Germany
- Correspondence: ; Tel.: +49-40-2092-7101
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Hwangbo Y, Choi JY, Lee EK, Ryu CH, Cho SW, Chung EJ, Hah JH, Jeong WJ, Park SK, Jung YS, Kim JH, Kim MJ, Kim SJ, Kim YK, Lee CY, Lee JY, Lee YJ, Yu HW, Park DJ, Ryu J, Park YJ, Lee KE, Moon JH. A Cross-Sectional Survey of Patient Treatment Choice in a Multicenter Prospective Cohort Study on Active Surveillance of Papillary Thyroid Microcarcinoma (MAeSTro). Thyroid 2022; 32:772-780. [PMID: 35698288 DOI: 10.1089/thy.2021.0619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Active surveillance (AS) is offered as a choice to patients with low-risk papillary thyroid microcarcinoma (PTMC). This study aimed to identify patient and physician factors associated with the choice of AS. Methods: We conducted a cross-sectional survey of patients with low-risk PTMC who were enrolled in a prospective study comparing outcomes following AS and surgery. Patients completed a questionnaire to assess their prior knowledge of the disease, considerations in the decision-making process, and reasons for choosing the treatment. We also surveyed 19 physician investigators about their disease management preferences. Variables affecting the patients' choice of AS, including patients' characteristics and their decision-making process, were analyzed in a multivariable analysis. Results: The response rate of the patient survey was 72.8% (857/1177). Among the patients who responded to the survey, 554 patients (128 male; mean age 49.4 ± 11.6 years; response rate 73.4%) with low-risk PTMC chose AS (AS group), whereas 303 patients (55 male; 46.6 ± 10.7 years; 71.8%) chose immediate surgery (iOP group). In the AS group, 424 patients (76.5%) used a decision aid, and 144 (47.5%) used it in the iOP group. The choice of AS was associated with the following variables: patient age >50 years (odds ratio 1.713 [confidence interval, CI 1.090-2.690], p = 0.020), primary tumor size ≤5 mm (odds ratio 1.960 [CI 1.137-3.379], p = 0.015), and consulting an endocrinologist (odds ratio 114.960 [CI 48.756-271.057], p < 0.001), and use of a decision aid (odds ratio 2.469 [CI 1.320-4.616], p = 0.005). The proportion of patients who were aware of AS before their initial consultation for treatment decision was higher in the AS group than in the iOP group (64.6% vs. 56.8%). Family members were reported to have influenced the treatment decisions more in the iOP group (p = 0.025), whereas the AS group was more influenced by information from the media (p = 0.017). Physicians' attitudes regarding AS of low-risk PTMC tended to be more favorable among endocrinologists than surgeons and all became more favorable as the study progressed. Conclusions: Emerging evidence suggests that physicians' attitudes and communication tools influence the treatment decision of low-risk PTMC patients. Support is needed for patient-centered decision making. (Clinical trial No: NCT02938702).
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Affiliation(s)
- Yul Hwangbo
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Republic of Korea
| | - Eun Kyung Lee
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Chang Hwan Ryu
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Sun Wook Cho
- Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Eun-Jae Chung
- Department of Otorhinolaryngology, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Jeong Hun Hah
- Department of Otorhinolaryngology, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Republic of Korea
| | - Sue K Park
- Department of Preventive Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Yuh-Seog Jung
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Ji-Hoon Kim
- Department of Radiology, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Min Joo Kim
- Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Su-Jin Kim
- Department of Surgery, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Yeo Koon Kim
- Department of Radiology, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Republic of Korea
| | - Chang Yoon Lee
- Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Ji Ye Lee
- Department of Radiology, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - You Jin Lee
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Republic of Korea
| | - Do Joon Park
- Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Junsun Ryu
- Center for Thyroid Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Republic of Korea
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Hughes DT, Reyes-Gastelum D, Ward KC, Hamilton AS, Haymart MR. Barriers to the Use of Active Surveillance for Thyroid Cancer Results of a Physician Survey. Ann Surg 2022; 276:e40-e47. [PMID: 33074908 PMCID: PMC8549720 DOI: 10.1097/sla.0000000000004417] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this study was to determine physician-reported use of and barriers to active surveillance for thyroid cancer. SUMMARY BACKGROUND DATA It is not clear whether active surveillance for thyroid cancer is widely used. METHODS Surgeons and endocrinologists identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles County were surveyed between 2018 and 2019. Multivariable weighted logistic regression analyses were conducted to determine physician acceptance and use of active surveillance. Results: Of the 654 eligible physicians identified, 448 responded to the survey (69% response rate). The majority (76%) believed that active surveillance was an appropriate management option, but only 44% used it in their practice. Characteristics of physicians who stated that active surveillance was appropriate management, but did not report using it included more years in practice (reference group <10 years in practice): 10 to 19 years [odds ratio, OR 0.50 [95% confidence interval, CI 0.28-0.92]; 20 to 29 years [OR 0.31 (95% CI 0.15-0.62)]; >30 years [OR 0.30 (95% CI 0.15-0.61)] and higher patient volume 11 to 30 patients per year [OR 0.39 (95% CI 0.21 -0.70)] and >50 patients per year [OR 0.33 (95% CI 0.16-0.71)] compared to < 10, with no significant difference in those seeing 31 to 50 patients. Physicians reported multiple barriers to implementing active surveillance including patient does not want (80.3%), loss to follow-up concern (78.4%), more patient worry (57.6%), and malpractice lawsuit concern (50.9%). CONCLUSION AND RELEVANCE Despite most physicians considering active surveillance to be appropriate management, more than half are not using it. Addressing existing barriers is key to improving uptake.
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Affiliation(s)
- David T Hughes
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - David Reyes-Gastelum
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Megan R Haymart
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Gao L, Li X, Liu C, Liu R, Shi X, Ma L, Zhao H, Xia Y, Jiang Y. What Are the Characteristics of Papillary Thyroid Microcarcinoma Prone to High-Volume Lateral Lymph Node Metastasis? - An Analysis of 2981 Consecutive Cases. J INVEST SURG 2022; 35:1519-1525. [PMID: 35610088 DOI: 10.1080/08941939.2022.2075494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To identify candidate factors for predicting high-volume lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC). METHODS We retrospectively studied 2981 patients with PTMC who underwent thyroidectomy from 2013 to 2016. LLNM was identified by histopathology. Patients with different LLNM statuses were compared according to clinical, sonographic and pathological parameters. A multivariate logistic model was established to predict high-volume LLNM (number of metastatic lymph nodes >5). RESULTS High-volume LLNM of PTMC was independently associated with age < 40 years (OR = 1.791, P = 0.023), male sex (OR = 2.401, p = 0.001), tumor size > 0.5 cm (OR = 4.839, p < 0.001), extrathyroidal extension (OR = 2.097, p = 0.007) and microcalcification (OR = 2.894, p = 0.002). These five factors were incorporated together to develop a multivariate analysis, which showed good predictive ability (AUC = 0.78, 95% CI 0.72-0.83), with a sensitivity of 80.0% and a specificity of 61.4%. Moreover, more level II or V lateral regions were involved in patients with high-volume LLNM than in those with small-volume LLNM (69.2% vs. 25.0%, p < 0.001; 10.8% vs. 4.7%, p < 0.001). CONCLUSION Multilevel LLNM tended to be more common in patients with PTMC who had high-volume LLNM. The high-volume LLNM rates of patients with PTMC with age < 40 years, male sex, tumor size > 0.5 cm, extrathyroidal extension and microcalcification were relatively higher than those without. These findings may be useful for identifying patients at higher high-volume LLNM risk who may require more aggressive treatment or intensive follow-up management.
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Affiliation(s)
- Luying Gao
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyi Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunhao Liu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruifeng Liu
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinlong Shi
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liyuan Ma
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Zhao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Xia
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxin Jiang
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Stan MN, Papaleontiou M, Schmitz JJ, Castro MR. Nonsurgical Management of Thyroid Nodules: The Role of Ablative Therapies. J Clin Endocrinol Metab 2022; 107:1417-1430. [PMID: 34953163 PMCID: PMC9016471 DOI: 10.1210/clinem/dgab917] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/02/2022]
Abstract
CONTEXT After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma surgery or radioactive iodine (RAI) (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (eg, scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks. CASES We present 4 cases of thyroid lesions causing concern (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients' attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation [RFA] being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects, and conclude with a simplified description of how these procedures are performed. CONCLUSION Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules, while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.
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Affiliation(s)
- Marius N Stan
- Correspondence: Marius N. Stan, Division of Endocrinology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John J Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Sonographic assessment of minor extrathyroidal extension of papillary thyroid microcarcinoma involving the posterior thyroid capsule. Eur Radiol 2022; 32:6090-6096. [PMID: 35380227 DOI: 10.1007/s00330-022-08765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study aimed to determine sonographic features and clinical significance of minor extrathyroidal extension (ETE) to the posterior thyroid capsule in papillary thyroid microcarcinoma (PTMC) patients. METHODS We retrospectively reviewed the records of 506 PTMC patients consisting of 151 patients with minor ETE and 355 patients without ETE. Significant clinicoradiologic features associated with ETE were identified by logistic regression analyses. The diagnostic performance of sonographic features, including the presence of capsular abutment, capsular abutment degree (< 25%, 25-50%, ≥ 50%), and protrusion, were assessed for the diagnosis of posterior minor ETE. Interobserver agreement was calculated. RESULTS PTMC patients with posterior minor ETE were more likely to have lymphovascular invasion and lateral neck lymph node metastasis (OR = 2.636, 95%CI: 1.754, 3.963 and OR = 2.897, 95%CI: 1.069, 7.848). Regarding the diagnostic performance, the capsular abutment yielded the highest sensitivity (81.5%), followed by ≥ 25% abutment, protrusion, and ≥ 50% abutment (57.0%, 21.9%, and 4.6%, respectively), with similar levels of diagnostic accuracy (71.3-75.1%). The specificity was highest for the sonographic feature of ≥ 50% abutment (99.7%), followed by protrusion, ≥ 25% abutment, and capsular abutment (97.8%, 82.0%, and 68.7%, respectively). Abutment assessment had a moderate interobserver agreement (K = 0.705), and abutment degree and protrusion assessment had a fair and slight interobserver agreement (K = 0.553 and 0.287). CONCLUSIONS Sonographic features of posterior capsular abutment are sensitive and reliable for diagnosis of posterior minor ETE and are associated with lymphovascular invasion and lateral neck lymph node metastasis in PTMC patients. The assessment of posterior minor ETE is important for considering candidates for active surveillance among PTMC patients. KEY POINTS • PTMC patients with posterior minor ETE were more likely to have lymphovascular invasion and lateral neck lymph node metastasis. • Sonographic features of posterior capsular abutment are sensitive and reliable for the diagnosis of posterior minor ETE. • The assessment of posterior minor ETE is important for considering candidates for active surveillance among PTMC patients.
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Pasqual E, Sosa JA, Chen Y, Schonfeld SJ, Berrington de González A, Kitahara CM. Trends in the Management of Localized Papillary Thyroid Carcinoma in the United States (2000-2018). Thyroid 2022; 32:397-410. [PMID: 35078347 PMCID: PMC9048184 DOI: 10.1089/thy.2021.0557] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: In response to evidence of overdiagnosis and overtreatment of papillary thyroid carcinoma (PTC), the 2009 and 2015 American Thyroid Association (ATA) adult guidelines recommended less extensive surgery (lobectomy vs. total thyroidectomy) and more restricted use of postsurgical radioactive iodine (RAI) in management of PTC at low risk of recurrence. In 2015, active surveillance was suggested as a viable option for some <1-cm PTCs, or microcarcinomas. The 2015 ATA pediatric guidelines similarly shifted toward more restricted use of RAI for low-risk PTCs. The impact of these recommendations on low-risk adult and pediatric PTC management remains unclear, particularly after 2015. Methods: Using data from 18 Surveillance, Epidemiology, and End Results (SEER) U.S. registries (2000-2018), we described time trends in reported first-course treatment (total thyroidectomy alone, total thyroidectomy+RAI, lobectomy, no surgery, and other/unknown) for 105,483 patients diagnosed with first primary localized PTC (without nodal/distant metastases), overall and by demographic and tumor characteristics. Results: The declining use of RAI represented the most pronounced change in management of PTCs <4 cm (44-18% during the period 2006-2018), including microcarcinomas (26-6% during the period 2007-2018). In parallel, an increasing proportion of PTCs were managed with total thyroidectomy alone (35-54% during the period 2000-2018), while more subtle changes were observed for lobectomy (declining from 23% to 17% during the period 2000-2006, stabilizing, and then rising from 17% to 24% during the period 2015-2018). Use of nonsurgical management did not meaningfully change over time, impacting <1% of microcarcinomas annually during the period 2000-2018. Similar treatment trends were observed by sex, age, race/ethnicity, metropolitan vs. nonmetropolitan residence, and insurance status. For pediatric patients (<20 years), use of RAI peaked in 2009 (59%), then decreased markedly to 11% (2018), while use of total thyroidectomy alone and, to a lesser extent, lobectomy increased. No changing treatment trends were observed for ≥4-cm PTCs. Conclusions: The declining use of RAI in management of low-risk adult and pediatric PTC is consistent with changing recommendations from the ATA practice guidelines. Post-2015 trends in use of lobectomy and nonsurgical management of low-risk PTCs, particularly microcarcinomas, were more subtle than expected; however, these trends may change as evidence regarding their safety continues to emerge.
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Affiliation(s)
- Elisa Pasqual
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yingxi Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Sara J. Schonfeld
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Cari M. Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Address correspondence to: Cari M. Kitahara, PhD, MHS, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rm. 7E-456, Bethesda, MD 20892, USA
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Escalante DA, Anderson KG. Workup and Management of Thyroid Nodules. Surg Clin North Am 2022; 102:285-307. [DOI: 10.1016/j.suc.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Newman SK, Harries V, Wang L, McGill M, Ganly I, Girshman J, Tuttle RM. Invasion of a Recurrent Laryngeal Nerve from Small Well-Differentiated Papillary Thyroid Cancers: Patient Selection Implications for Active Surveillance. Thyroid 2022; 32:164-169. [PMID: 34714169 PMCID: PMC8861915 DOI: 10.1089/thy.2021.0310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: The success of an active surveillance management approach to low-risk papillary thyroid cancer (PTC) is heavily dependent on proper patient selection. For example, primary tumors located in a subcapsular position immediately adjacent to the trachea or a recurrent laryngeal nerve (RLN) are considered to be inappropriate for active surveillance. Since preoperative imaging cannot reliably rule out extrathyroidal extension or reveal the full course of the RLN relative to the thyroid gland, it is important for clinicians to understand subcapsular tumor locations and minimum tumor sizes that are most likely to be associated with gross invasion of the RLNs. Methods: We assessed the medical records of 123 patients treated at Memorial Sloan Kettering Cancer Center (MSK) between 1986 and 2015 who had a primary PTC tumor demonstrating gross extrathyroidal extension to either the right or left RLN. Thirty patients with a primary tumor ≤2 cm in diameter demonstrating extrathyroidal extension into an RLN were included in the analysis. Results: Gross invasion of an RLN by tumors ≤2 cm is a rare event that was seen in only 0.8% (35/4334) of patients with PTC who underwent initial thyroid surgery at MSK between 1986 and 2015. Gross RLN invasion was associated with subcapsular PTC tumors located in either the right paratracheal area (60%), left paratracheal area (36.7%), or right lateral posterior lobe area not adjacent to the trachea (3.3%). Only a quarter of the patients had imaging findings suggestive of extrathyroidal extension and only 30% had clinically apparent vocal paresis/paralysis on preoperative examination. Invasion of the RLN was not observed for primary tumors <0.9 cm in diameter, regardless of tumor location. Conclusions: Well-differentiated PTC tumors ≥0.9 cm in maximal diameter that are located in the right paratracheal, left paratracheal, and right lateral posterior lobe subcapsular positions are usually not appropriate for active surveillance even in the absence of definitive evidence for nerve invasion on preoperative imaging or vocal cord examination. Patient selection for active surveillance management should take into account not only the size and growth rate of a tumor but also its location in relation to the expected course of RLNs.
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Affiliation(s)
- Samantha K. Newman
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Victoria Harries
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Wang
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marlena McGill
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey Girshman
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R. Michael Tuttle
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Address correspondence to: R. Michael Tuttle, MD, Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, USA
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Zhang L, Zhang GP, Zhan WW, Zhou W. The feasibility and efficacy of ultrasound-guided percutaneous laser ablation for multifocal papillary thyroid microcarcinoma. Front Endocrinol (Lausanne) 2022; 13:921812. [PMID: 36060950 PMCID: PMC9428260 DOI: 10.3389/fendo.2022.921812] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility and efficacy of percutaneous laser ablation (PLA) for patients with multifocal papillary thyroid microcarcinoma (PTMC). MATERIALS AND METHODS A cohort of patients who underwent ultrasound (US)-guided PLA for primary PTMC were enrolled in this study. The patients were divided into a multifocal PTMC (multi-PTMC) group and a unifocal PTMC (uni-PTMC) group. Before PLA, conventional US and contrast-enhanced ultrasound (CEUS) were performed to evaluate the PTMC and cervical lymph nodes. The operation time, energy, power, amount of isolation liquid, and complications during PLA were recorded. Patients were followed up at 2 days, 1 month, 3 months, and 6 months, and every 6 months after that. Volume reduction rate (VRR), local tumor recurrence, and lymph node metastasis after PLA were observed. RESULTS The study included 12 patients with 26 PTMCs and 60 patients with 60 PTMCs. The operation time, total energy, and amount of isolation liquid in the multi-PTMC group were more than those in the uni-PTMC group (p = 0.000, 0.007, and 0.020, respectively). The mean follow-up durations in multi-PTMC and uni-PTMC groups were 19.75 ± 11.46 months (6-36 months) and 16.33 ± 10.01 months (4-40 months), with a similar VRR of the ablated lesions in the two groups. One and three cases with newly developed PTMCs were observed in the multi-PTMC group and the uni-PTMC group during follow-up, respectively. There was no regrowth of treated lesions, lymph node metastasis, or distant metastasis. At the end of the follow-up, all the ablated lesions in the two groups completely disappeared or only remained scar strips. CONCLUSION PLA is a safe and effective technique for treating multifocal PTMC, which might be an alternative technique for patients who are not eligible or are unwilling to undergo surgery.
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