Active Surveillance Outcomes of Patients with Low-Risk Papillary Thyroid Microcarcinoma According to Levothyroxine Treatment Status

A comprehensive prediction model for central lymph node metastasis in papillary thyroid carcinoma with Hashimoto's thyroiditis: BRAF may not be a valuable predictor

Purpose

Papillary thyroid carcinoma (PTC) frequently coexists with Hashimoto's thyroiditis (HT), which poses challenges in detecting central lymph node metastasis (CLNM) and determining optimal surgical management. Our study aimed to identify the independent predictors for CLNM in PTC patients with HT and develop a comprehensive prediction model for individualized clinical decision-making.

Patients and methods

In this retrospective study, a total of 242 consecutive PTC patients who underwent thyroid surgery and central lymph node dissection between February 2019 and December 2021 were included. 129 patients with HT were enrolled as the case group and 113 patients without HT as control. The results of patients' general information, laboratory examination, ultrasound features, pathological evaluation, and BRAF mutation were collected. Multivariate logistic regression analysis was used to identify independent predictors, and the prediction model and nomogram were developed for PTC patients with HT. The performance of the model was assessed using the receiver operating characteristic curve, calibration curve, decision curve analysis, and clinical impact curve. In addition, the impact of the factor BRAF mutation was further evaluated.

Results

Multivariate analysis revealed that gender (OR = 8.341, P = 0.013, 95% CI: 1.572, 44.266), maximum diameter (OR = 0.316, P = 0.029, 95% CI: 0.113, 0.888), multifocality (OR = 3.238, P = 0.010, 95% CI: 1.319, 7.948), margin (OR = 2.750, P = 0.046, 95% CI: 1.020, 7.416), and thyrotropin receptor antibody (TR-Ab) (OR = 0.054, P = 0.003, 95% CI: 0.008, 0.374) were identified as independent predictors for CLNM in PTC patients with HT. The area under the curve of the model was 0.82, with accuracy, sensitivity, and specificity of 77.5%, 80.3% and 75.0%, respectively. Meanwhile, the model showed satisfactory performance in the internal validation. Moreover, the results revealed that BRAF mutation cannot further improve the efficacy of the prediction model.

Conclusion

Male, maximum diameter > 10mm, multifocal tumors, irregular margin, and lower TR-Ab level have significant predictive value for CLNM in PTC patients with HT. Meanwhile, BRAF mutation may not have a valuable predictive role for CLNM in these cases. The nomogram constructed offers a convenient and valuable tool for clinicians to determine surgical decision and prognostication for patients.

A Prospective Clinical Trial of Radiofrequency Ablation in Patients with Low-Risk Unifocal Papillary Thyroid Microcarcinoma Favoring Active Surveillance Over Surgery

Background: Active surveillance (AS) of papillary thyroid microcarcinomas (PTMC) is emerging as an alternative to immediate surgery. While thermal ablation has also shown promise for low-risk PTMC, it has not been prospectively studied in patients appropriate for AS. This study aimed to evaluate the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) for tumor control and quality of life (QoL) management in patients with PTMC who favored AS over immediate surgery. Methods: This prospective clinical trial was conducted at a single tertiary referral hospital from 2018 to 2021. Of 227 adult patients aged ≤60 years with low-risk unifocal PTMC favoring AS over immediate surgery, 100 patients underwent RFA for their management. The primary endpoint was the disease progression rate, and secondary endpoints were technical success, volume reduction rate (VRR), complication rates, and QoL. Results: The median age of the study population was 42 years (range, 27-59 years), and 83% (83/100, [CI: 66.1-100]) were female. The median follow-up was 30 months (range, 12-56 months). All 100 patients underwent RFA with technical success. Most of the ablation zones showed continuous volume reduction, and 95.9% (94/98, [CI: 77.5-100.0]) showed complete disappearance at the last follow-up. The median VRR was 100.0% at 1-year follow-up and persisted throughout the last follow-up. The cumulative disease progression rate among 98 patients who underwent at least 1-year follow-up was 3.1% (3/98, [CI: 0.6-9.0]); one patient had lymph node metastasis (treated with surgery), and two patients had new PTMC (1 treated with RFA, 1 ongoing AS). Major complications were not observed. Psychological (baseline vs. last follow-up, 7.3 vs. 8.0, p = 0.002) and social (8.0 vs. 8.7, p = 0.005) QoL scores significantly improved during follow-up without compromising physical QoL (8.6 vs. 8.5, p = 0.99). Conclusions: RFA can be a reasonable strategy for effectively and safely controlling tumors and improving QoL in non-elderly patients with low-risk PTMC appropriate for AS. Clinical Trial registration: This trial is registered with ClinicalTrials.gov: NCT03432299.

Tumor volume-doubling rate is negatively associated with patient age in papillary thyroid microcarcinomas under active surveillance

BACKGROUND

Active surveillance of low-risk papillary thyroid microcarcinomas has gained popularity worldwide as a management strategy. We previously reported that young age was associated with tumor enlargement by ≥3 mm. Here, we used the tumor volume-doubling rate to study the age-related tumor volume dynamics of papillary thyroid microcarcinomas under active surveillance.

METHODS

Between 2005 and 2019, 2,896 patients diagnosed with low-risk papillary thyroid microcarcinomas underwent active surveillance. We excluded patients who underwent ultrasound examination fewer than 4 times, had coexisting Graves' disease, or were treated with levothyroxine at the time of diagnosis, and we enrolled 2,129 patients for this study. We divided them into 3 subsets based on the age at diagnosis: young (<40 years), middle-aged (40-59 years), and elderly (≥60 years). The tumor volume-doubling rate was calculated based on ultrasound-derived tumor sizes and the respective examination date for each patient.

RESULTS

Overall, 140 patients (6.6%) had moderate or rapid growth (tumor volume-doubling rate ≥0.3/year), and the incidence significantly decreased with advanced age (P < .01): 11.3%, 7.1%, and 5.0% in the young, middle-aged, and elderly groups, respectively. Tumor regression (tumor volume-doubling rate <0/year) was detected in 1,200 patients (56.4%), and the incidence significantly increased with age (P < .01): 44.6%, 55.3%, and 60.0% in the young, middle-aged, and elderly groups, respectively. On multivariate analysis, both the ≥60 years and 40 to 59 years age groups were independent negative predictors of papillary thyroid microcarcinoma enlargement and positive predictors of tumor regression.

CONCLUSION

Tumor volume-doubling rate analysis demonstrated that the incidence of tumor enlargement decreased and that of tumor regression increased with advancing age in patients with papillary thyroid microcarcinomas.

Differentiated thyroid cancer: a focus on post-operative thyroid hormone replacement and thyrotropin suppression therapy

PURPOSE

This review focuses on post-operative thyroid hormone replacement and thyrotropin suppression therapy in patients with differentiated thyroid cancer.

METHODS

A clinical review.

RESULTS

Differentiated thyroid cancers (DTC), including papillary and follicular thyroid cancers, have an excellent prognosis and their management leverages a unique set of clinical tools arising from homology to the normal thyroid follicular cell. Surgery is the cornerstone of initial management, and post-operative care often requires thyroid hormone replacement therapy, which may be approached with the intent of physiologic normalization or used pharmacologically to suppress TSH as part of a DTC treatment.

CONCLUSION

Management of DTC and approaches to TSH suppression are tailored to an individual's risk of DTC recurrence and are adjusted to a patient's clinical status and comorbidities over time with the goal of mitigating risk and maximizing benefit.

Thirty years of active surveillance for low-risk thyroid cancer, lessons learned and future directions

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.

Active Surveillance for Low-Risk Thyroid Cancers: A Review of Current Practice Guidelines

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.

Ultrasound-guided thermal ablation for papillary thyroid microcarcinoma: the devil is in the details

Thermal ablation (TA) has harvested favorable outcomes in treating low-risk papillary thyroid microcarcinoma (PTMC). Preoperative assessment, intraoperative procedures and postoperative follow-up are all closely linked with the success and safety of TA on PTMC. However, many details in these aspects have not been systematically reviewed. This review firstly described the influence of preoperative assessment, especially for the risk of lymph node metastasis (LNM), as well as the molecular testing on the selection of TA for PTMC. Besides, we also summarized the experiences in treating special PTMC cases by TA, like multifocal lesions, PTMC located in the isthmus or adjacent to the dorsal capsule. At last, we discussed the follow-up strategies, the influence of the thyroid-stimulating hormone (TSH) level on the prognosis of PTMCs, and the management for recurrent cases. In conclusion, the procedures during the entire perioperative period should be standardized to improve the outcomes of TA in treating PTMC patients.