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Han B, Hao S, Wu J, Fang J, Han Z. Predictive features of central lymph node metastasis in papillary thyroid microcarcinoma: Roles of active surveillance in over-treatment. Front Med (Lausanne) 2022; 9:906648. [PMID: 36226144 PMCID: PMC9548607 DOI: 10.3389/fmed.2022.906648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background Low-risk papillary thyroid microcarcinoma (PTMC) without clinically evident lymph nodes, extrathyroidal expansions, and distant metastases may be candidates for active monitoring. Objective The purpose of this research is to identify risk factors for papillary thyroid microcarcinoma (PTMC) metastasis to central cervical lymph nodes (CLNM) and to discuss the viability of an active surveillance strategy to minimize unnecessary therapy for patients. Methods This single-center retrospective study was conducted on the data and medical records of the patients who were diagnosed with PTMC and underwent surgery at the Baotou Cancer Hospital, China, between January 1, 2018, and December 31, 2019. Both lobectomy and complete thyroid resections were performed, and central lymph node dissections (CLND) were used in all patients. Comparisons and analyses were conducted on the preoperative ultrasound (US) characteristics, the post-operation pathological results, and lymph node metastasis. Results We analyzed 172 patients with PTMC with average age 48.32 ± 10.59 years old, with 31 males and 142 females. US testing showed 74 (43.0%) patients had suspicious lymph nodes; 31 (41.9%) had capsular invasion and 52 (30.2%) patients were confirmed to have CLNM. Based on logistic regression analysis, central lymph node metastasis was shown to be more common in individuals with PTMC who were older than 45 years old, male, and had tumors that lacked micro-calcification on US imaging. Postoperative pathology assessments suggested that 58 cases (33.7%) were more suitable candidates for active surveillance cohorts. Conclusions While active surveillance might benefit many PTMC patients, treatments for the patients should also encompass occult lymph node metastasis, especially in patients with over 45 years old, male, tumor without micro-calcification in the US imaging. Furthermore, the prediction of lymph nodes in the central cervical via the preoperative US and the PTMC risk stratification accuracy need to be improved. Our findings showed about 30% of the patients with PTMC had no active surveillance high-risk factors but required surgical treatment. Fear of cancer in the PTMC patients, although informed of the details, is still the main reason for choosing surgical treatment over active surveillance.
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Affiliation(s)
- Bo Han
- Department of General Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Head and Neck Surgery, Baotou Cancer Hospital, Baotou, China
| | - Sen Hao
- Department of Head and Neck Surgery, Baotou Cancer Hospital, Baotou, China
| | - Jixiang Wu
- Department of General Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jugao Fang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhengxue Han
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
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Management of Sonographically Suspicious Thyroid Nodules 1 cm or Smaller and Candidacy for Active Surveillance: Experience of a Tertiary Center in China. Endocr Pract 2021; 27:903-911. [PMID: 33607263 DOI: 10.1016/j.eprac.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Our objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm. METHODS We retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE). RESULTS Of the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a >50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P < .05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months). CONCLUSIONS IS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.
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3
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Ho AS, Luu M, Barrios L, Chen I, Melany M, Ali N, Patio C, Chen Y, Bose S, Fan X, Mallen-St Clair J, Braunstein GD, Sacks WL, Zumsteg ZS. Incidence and Mortality Risk Spectrum Across Aggressive Variants of Papillary Thyroid Carcinoma. JAMA Oncol 2021; 6:706-713. [PMID: 32134428 DOI: 10.1001/jamaoncol.2019.6851] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance While well-differentiated papillary thyroid carcinoma (WDPTC) outcomes have been well characterized, the prognostic implications of more aggressive variants are far less defined. The rarity of these subtypes has led to their consolidation as intermediate risk for what are in fact likely heterogeneous diseases. Objective To analyze incidence, clinicopathologic characteristics, and outcomes for aggressive variants of papillary thyroid carcinoma (PTC). Design, Setting, and Participants This cohort study used data from 2000 to 2016 from hospital-based and population-based US cancer registries to analyze aggressive PTC variants, including diffuse sclerosing (DSV), tall-cell (TCV), insular, and poorly differentiated (PDTC) subtypes. These variants were compared against WDPTC and anaplastic cases. Data analysis was conducted from January 2019 to October 2019. Main Outcomes and Measures Age-adjusted incidence was calculated via annual percentage change (APC) using the weighted least-squares method. Overall survival and disease-specific survival were analyzed via Cox regression. Propensity-score matching was used to adjust survival analyses for clinical and demographic covariates. Results Collectively, 5447 aggressive PTC variants were identified (including 415 DSV, 3339 TCV, 362 insular, and 1331 PDTC cases), as well as 35 812 WDPTC and 2249 anaplastic cases. Over the study period, a substantial increase in aggressive variant incidence was observed (APC, 9.1 [95% CI, 7.33-10.89]; P < .001), surpassing the relative increases observed in WDPTC (APC, 5.1 [95% CI, 3.98-6.12]; P < .001) and anaplastic cases (APC, 1.9 [95% CI, 0.75-3.05]; P = .003; parallelism P < .007). Survival varied markedly based on histologic subtype, with a wide spectrum of mortality risk noted; 10-year overall survival was 85.4% (95% CI, 84.6%-86.3%) in WDPTC, 79.2% (95% CI, 73.6%-85.3%) in DSV, 71.9% (95% CI, 68.4%-75.6%) in TCV, 45.1% (95% CI, 40.2%-50.6%) in PDTC, 27.9% (95% CI, 20.0%-38.9%) in the insular variant, and 8.9% (95% CI, 7.5%-10.6%) in anaplastic cases (P < .001). These differences largely persisted even after adjusting for inherent differences in baseline characteristics by multivariable Cox regression and propensity-score matching. Conclusions and Relevance An upsurge in aggressive PTC incidence was observed at a rate beyond that seen in WDPTC or anaplastic thyroid carcinoma. Moreover, long-term survival outcomes for aggressive PTC subgroups exhibit heterogeneous clinical behavior and a wide range of mortality risk, suggesting that treatment should be tailored to specific histologic subtypes. Given increasing prevalence and disparate outcomes, further investigation to identify optimal therapeutic strategies is needed in these diverse, understudied populations.
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Affiliation(s)
- Allen S Ho
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Luu
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Biostatistics and Bioinformatics Research Center, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Laurel Barrios
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
| | - Irene Chen
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle Melany
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nabilah Ali
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrysanta Patio
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yufei Chen
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shikha Bose
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xuemo Fan
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon Mallen-St Clair
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Glenn D Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wendy L Sacks
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zachary S Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California.,Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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Pusztaszeri MP, Tamilia M, Payne RJ. Active surveillance for low-risk small papillary thyroid cancer in North American countries: past, present and future (bridging the gap between North American and Asian practices). Gland Surg 2020; 9:1685-1697. [PMID: 33224846 DOI: 10.21037/gs-20-389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Papillary thyroid cancer (PTC) is increasingly being diagnosed worldwide; yet the mortality remains very low, suggesting widespread overdiagnosis. While traditional management of PTC includes thyroid surgery, sometimes followed by radioactive iodine treatment, there is a global trend towards more conservative approaches for patients who are considered as the lowest risk of recurrence or death from their disease. Active surveillance (AS), once called watchful waiting, involves close follow-up, with the intention to intervene if the cancer progresses, or on patient request. The Kuma Hospital in Japan was the first to introduce AS as an alternative to immediate thyroid surgery for low-risk papillary thyroid microcarcinomas (PTMC, <1 cm) in 1993. Accumulated evidence over the years has shown that AS is a safe and effective approach in select patients, with a low rate of cancer progression during AS. Consequently, the Japanese Clinical Guidelines for treatment of thyroid tumor approved AS as a first-line management for patients with asymptomatic PTMC in 2010. Subsequently, the latest 2015 American Thyroid Association guidelines endorsed AS as an alternative approach to immediate surgery for cytologically confirmed very low-risk PTC. However, the acceptance, feasibility and results of AS in patients with low-risk PTC outside of Japan are still largely unknown. Most guidelines recommend that thyroid nodules <1 cm should not be aspirated but instead monitored regardless of the ultrasonographic characteristics. In essence, these patients are also being subjected to AS. Specific recommendations and the role of molecular testing for the optimal selection of PTMC patients for an AS management approach are not well established. Furthermore, research is needed to assess the long-term clinical and psychosocial outcomes in patients with larger tumor sizes (>1 cm) who undergo screening and diagnosis according to the North American guidelines and practices. The first Canadian prospective observational study launched in 2016 is intended to complement the existing data for AS of small low-risk PTC (≤2 cm) and may provide insight into the different approaches in North American and Asian practices. This review intends to summarize the development and the rationale of AS for PTMC and highlights significant differences between North American and Japanese practices.
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Affiliation(s)
- Marc P Pusztaszeri
- Department of Pathology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Michael Tamilia
- Division of Endocrinology & Metabolism, Jewish General Hospital, McGill University, Montreal, Canada
| | - Richard J Payne
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, Montreal, Canada
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5
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Rangel L, Volpi LM, Stabenow E, Steck JH, Volpi E, Russell JO, Tufano RP. Radiofrequency for benign and malign thyroid lesions. World J Otorhinolaryngol Head Neck Surg 2020; 6:188-193. [PMID: 33073215 PMCID: PMC7548387 DOI: 10.1016/j.wjorl.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 12/27/2022] Open
Abstract
Background Thermal ablation of thyroid nodules is new modality for the management of the benign and malign lesions. This minimally invasive treatment is performed as an outpatient, local anesthetic, single professional procedure that can treat neoplastic lesions without removing normal thyroid tissue and thus avoiding hypothyroidism. Method A comprehensive review of the most relevant literature regarding the thermal ablation of benign and malign nodules was performed in order to currently define its role on the management of the nodular thyroid disease. The data was divided into benign and malign literature. Results The benign nodules can be effectively treated by radiofrequency ablation (RFA) but some limitation exists regarding the nodule's size but not nodules characteristics. The RFA of primary malign tumors of the thyroid recently demonstrated positive and safe long-term follow-up and encouraged additional investigation and possibly a definitive role in the management of these low risk nodules. Conclusion RFA is a safe, cost-effective minimally invasive procedure that avoids thyroid tissue removal while destroying neoplastic one thus, preventing hypothyroidism.
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Affiliation(s)
| | | | | | | | | | - Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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6
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Ho AS, Luu M, Barrios L, Balzer BL, Bose S, Fan X, Walgama E, Mallen-St Clair J, Alam U, Shafqat I, Lin DC, Chen Y, Van Eyk JE, Maghami EG, Braunstein GD, Sacks WL, Zumsteg ZS. Prognostic Impact of Histologic Grade for Papillary Thyroid Carcinoma. Ann Surg Oncol 2020; 28:1731-1739. [PMID: 32808161 DOI: 10.1245/s10434-020-09023-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade. METHODS We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed. RESULTS Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01). CONCLUSIONS Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.
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Affiliation(s)
- Allen S Ho
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Michael Luu
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Biostatistics and Bioinformatics Research Center, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Laurel Barrios
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bonnie L Balzer
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shikha Bose
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Xuemo Fan
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Evan Walgama
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon Mallen-St Clair
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Usman Alam
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Iram Shafqat
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - De-Chen Lin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yufei Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer E Van Eyk
- Advanced Clinical Biosystems Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ellie G Maghami
- Division of Head and Neck Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Glenn D Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Wendy L Sacks
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zachary S Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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7
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8
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Active surveillance of low-risk papillary thyroid cancer: A meta-analysis. Surgery 2020; 167:46-55. [DOI: 10.1016/j.surg.2019.03.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 12/21/2022]
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9
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Ho AS, Luu M, Zalt C, Morris LG, Chen I, Melany M, Ali N, Patio C, Chen Y, Mallen St.-Clair J, Braunstein GD, Sacks WL, Zumsteg ZS. Mortality Risk of Nonoperative Papillary Thyroid Carcinoma: A Corollary for Active Surveillance. Thyroid 2019; 29:1409-1417. [PMID: 31407637 PMCID: PMC7476400 DOI: 10.1089/thy.2019.0060] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Active surveillance is established as an alternative to surgery for papillary thyroid microcarcinomas, but inclusion criteria and mortality risk for pursuing a nonsurgical approach have not been clearly defined. To gauge the feasibility of expanding active surveillance thresholds, we investigated the effects of increasing size and age on disease-specific survival (DSS) in a large nonoperative thyroid cancer cohort, compared against a matched group of surgical patients. Methods: Papillary thyroid carcinoma patients staged T1-4N0M0 were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 1975 and 2015, stratified by nonsurgical and surgical management. Propensity score matching was performed to adjust for imbalances in covariates. Multivariable models were constructed using restricted cubic splines to model nonlinear relationships of age and tumor size with DSS. Results: Overall, 1453 nonoperative patients and 54,718 surgical patients met the inclusion criteria. Collectively, increasing age and size after certain thresholds independently led to greater differences in DSS between nonsurgical and surgical patients. For younger ages (14-55 years), surgical approach compared with nonsurgical approach was not associated with any difference in the 10-year DSS among 0-4 cm cancers (99.8% vs. 100%, p = 0.470), 4.1-6 cm cancers (98.8% vs. 100%, p = 0.599), or >6 cm cancers (97.3% vs. 100%, p = 0.718). Older patients with larger tumors (>75 years, >6 cm) demonstrated the greatest difference in DSS (48.1% vs. 91.3%, p < 0.001). Similar results were found when applying propensity score matching. For age, restricted cubic spline plots showed minimal relative survival hazard in nonoperative cases beginning after age 60 years, with a change point illustrating acceleration in relative hazard beyond age 72 years. For size, relative survival hazard was observed after 2.0 cm and increased slowly with nodule growth up to an inflection point of 4.5 cm. Beyond this, mortality risk escalated with each additional year without plateau. Conclusions: Increasing age and size lead to progressively greater mortality risk without surgery, but only beyond certain thresholds. We define escalating gradients at which a nonsurgical approach may be deemed appropriate, and beyond which survival benefits from surgery become apparent. Such findings reconcile controversial observations regarding age and size in active surveillance and further reshape evolving treatment paradigms in thyroid cancer.
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Affiliation(s)
- Allen S. Ho
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Address correspondence to: Allen S. Ho, MD, Department of Surgery, Cedars-Sinai Medical Center, 8635 West Third Street, Suite 590W, Los Angeles, CA 90048
| | - Michael Luu
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Biostatistics and Bioinformatics Research Center, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia Zalt
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
| | - Luc G.T. Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Irene Chen
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle Melany
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nabilah Ali
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrysanta Patio
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yufei Chen
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Department of Surgery, and Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon Mallen St.-Clair
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Glenn D. Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wendy L. Sacks
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zachary S. Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Zachary S. Zumsteg, MD, Department of Radiation Oncology, Cedars-Sinai Medical Center, SOCCI AC1004, 8700 Beverly Blvd, Los Angeles, CA 90048
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10
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Stadler TM, Morand GB, Rupp NJ, Freiberger SN, Broglie MA. [Benefits of Molecular Analyses in Thyroid Carcinoma]. PRAXIS 2019; 108:535-540. [PMID: 31185849 DOI: 10.1024/1661-8157/a003240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Benefits of Molecular Analyses in Thyroid Carcinoma Abstract. The widespread access to neck ultrasonography has led to high detection rates of thyroid nodules, whose vast majority will remain clinically silent. In daily practice it is a challenge to filter out the thyroid nodules that require medical attention. This is usually achieved by a combination of sonomorphologic criteria and fine-needle aspiration cytology. In recent years, there is a trend toward deescalation in diagnostic and therapeutic measures for thyroid nodules. Some authors even advocate active surveillance instead of surgical approaches for very low-risk thyroid carcinoma. This approach requires an accurate assessment of the malignant potential of each thyroid nodule. As recent studies have allowed better understanding of molecular pathogenesis of thyroid cancer, the mutational profile of thyroid nodules has emerged as a new tool for assessment of thyroid nodules. Its exact clinical application in daily routine remains, however, unclear.
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Affiliation(s)
- Thomas M Stadler
- 1 Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich
| | - Grégoire B Morand
- 1 Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich
| | - Niels J Rupp
- 2 Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich
| | - Sandra N Freiberger
- 2 Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich
| | - Martina A Broglie
- 1 Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich
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11
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Rovira A, Nixon IJ, Simo R. Papillary microcarcinoma of the thyroid gland: current controversies and management. Curr Opin Otolaryngol Head Neck Surg 2019; 27:110-116. [PMID: 30844924 DOI: 10.1097/moo.0000000000000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To highlight recent advances in our understanding of the nature of micropapillary thyroid carcinoma (mPTC), its evaluation and options of management based on risk. RECENT FINDINGS A dramatic increase of the incidence of papillary thyroid carcinoma has been reported worldwide during recent decades, specifically those smaller than 10 mm (mPTC). Although not taking into consideration other risk factors for aggressiveness when describing tumours by their size, most of these newly diagnosed mPTC are indolent and active surveillance can be considered as valid option for their management. SUMMARY An increasing number of patients with mPTC will be encountered in clinical practice. Although it is difficult to assess the aggressiveness of a tumour on size criteria, less than a total thyroidectomy and active surveillance can be considered for the majority of patients with mPTC. Further trials should be performed to prove this as a valid option of management in the majority of these patients.
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Affiliation(s)
- Aleix Rovira
- Department of Otorhinolaryngology - Head and Neck Surgery, Head, Neck and Thyroid Oncology Unit, Guy's and St Thomas NHS Foundation Trust, London
| | - Iain J Nixon
- Department of Otolaryngology Head and Neck Surgery, NHS Lothian, Edinburgh
| | - Ricard Simo
- Department of Otorhinolaryngology - Head and Neck Surgery, Head, Neck and Thyroid Oncology Unit, Guy's and St Thomas' Hospital, London, UK
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