Is the management of thyroid nodules and differentiated thyroid cancer in accordance with recent consensus guidelines? - Results of a national survey

Use of thyroid hormones in hypothyroid and euthyroid patients: a THESIS* survey of Belgian specialists *THESIS: treatment of hypothyroidism in Europe by specialists: an international survey

Background

Hypothyroidism is a topic that continues to provoke debate and controversy with regards to specific indications, type of thyroid hormone substitution and efficacy. We investigated the use of thyroid hormones in clinical practice in Belgium, a country where currently only levothyroxine (LT4) tablet formulations are available.

Method

Members of the Belgian Endocrine Society were invited to respond to an online questionnaire. Results were compared with those from other THESIS surveys.

Results

Eighty (50%) of the invited 160 individuals, completed the questionnaire. LT4 was the first treatment of choice for all respondents. As secondary choice, some also prescribed liothyronine (LT3) and LT4 + LT3 combinations (2 and 7 respondents, respectively). Besides hypothyroidism, 34 and 50% of respondents used thyroid hormones for infertile euthyroid TPOAb positive women and the treatment of a growing non-toxic goiter, respectively. Had alternative formulations of LT4 to tablets been available (soft gel or liquid L-T4), 2 out of 80 (2.5%) participants would consider them for patients achieving biochemical euthyroidism but remaining symptomatic. This proportion was higher in case of unexplained poor biochemical control of hypothyroidism (13.5%) and in patients with celiac disease or malabsorption or interfering drugs (10%). In symptomatic euthyroid patients, 20% of respondents would try combined LT4 + LT3 treatment. Psychosocial factors were highlighted as the main contributors to persistent symptoms.

Conclusions

LT4 tablets is the preferred treatment for hypothyroidism in Belgium. A minority of the respondents would try combined LT4 + LT3 in symptomatic but biochemically euthyroid patients. Thyroid hormones are prescribed for euthyroid infertile women with thyroid autoimmunity and patients with non-toxic goiter, a tendency noted in other European countries, despite current evidence of lack of benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13044-022-00121-9.

Papillary microcarcinoma of the thyroid gland: current controversies and management

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.

Practice patterns in the management of patients with differentiated thyroid cancer in Ontario Canada 2000-2008

BACKGROUND

The extent of treatment for differentiated thyroid cancer remains controversial. The objective of this study was to describe the variations in practice prior to diagnosis and for the first year after diagnosis, including the investigations, the extent of surgery and the use of RAI 131, for all patients with thyroid cancer (TC) treated Jan 1 2000 to Dec 2008 across Ontario Canada.

METHOD

Population-based study of all patients who had a therapeutic surgical procedure for TC based on the data holdings of the Institute of Clinical Investigative Sciences (ICES) linking the Ontario Cancer Registry to the Ontario Health Insurance Plan and to the Canadian Institutes of Health Information. The analysis includes comparisons between health care utilization/geographic regions and between treating specialties. The study population was 12957 patients.

RESULTS

There was a 112% increase in case detection over 9 years. Overall the initial (index) surgery was less-than-total thyroidectomy (LTT) in 37.6% and 63.4% of the patients who had total thyroidectomy (TT) as an index surgery went on to adjuvant RAI, however there was wide variation in all aspects of patient care across the province, between Local Health Networks and between surgical specialties.

CONCLUSION

In Ontario, there was wide variation for most aspects of the management of TC and, as the incidence of TC is increasing at least 7% per year in females, these data provide a foundation for future discussions, the provision of health care services and research.

Have 2006 ATA practice guidelines affected the treatment of differentiated thyroid cancer in the United States?

BACKGROUND

There is wide variability in the degree of adherence to guideline recommendations among caregivers. Our aim was to determine the clinical impact of the 2006 guidelines from the American Thyroid Association (ATA) on the management of differentiated thyroid cancer (DTC) in the United States.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database (2004-2009) was employed. Patients were divided into two groups based on receipt of care before (DTC 04-06) and after (DTC 07-09) the release of the 2006 ATA guidelines. Adherence was determined with a chi-square test and binary logistic regression. Survival was analyzed with the Kaplan-Meier method and log-rank test.

RESULTS

A total of 12,816 patients with DTC were identified between 2004 and 2006, and 14,514 between 2007 and 2009 (DTC 07-09). Adherence to Recommendation 26 (surgery) tended to increase in DTC 07-09 (82.2% vs. 83.2%, p=0.083). Factors associated with discordant practice among the DTC 07-09 group were older age, treatment in the Northeast, having more than one primary cancer, tumor size >4 cm, and follicular and Hürthle cell histologies. Factors associated with accordance were treatment in the Midwest, level II-VI metastases, having lymph nodes examined, AJCC Stage III, and presenting with distant metastases. Patients treated in accordance with Recommendation 26 showed prolonged disease-specific survival (p<0.001). A trend toward more adherence to Recommendation 27 (lymphadenectomy) was observed over time (68.4% vs. 69.7%, p=0.065). Adherence to Recommendation 27 was not associated with disease-specific survival (p=0.539). Less discordance from guidelines was seen for cancers that were 2.1-4 cm, extrathyroidal, and greater than Stage I. Overall accordance with Recommendation 32 (radioactive iodine [RAI] ablation) increased in DTC 07-09 compared to DTC 04-06 (61.7% vs. 57.5% respectively, p<0.001), and this was associated with improved disease-specific survival in DTC 07-09 (p<0.001). Predictors of care discordant with guidelines were patient age ≥ 65 years, living in the Northeast, and not undergoing total thyroidectomy. Factors associated with RAI use in accordance with guidelines were married status, treatment in the South, and having more than one lymph node examined.

CONCLUSIONS

Care in accordance with evidence-based guidelines for DTC is associated with improved patient outcomes. Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.

Limited adequacy of thyroid cancer patient follow-up at a Canadian tertiary care centre

BACKGROUND

We sought to evaluate the adequacy of follow-up of thyroid cancer patients at a Canadian centre.

METHODS

We mailed a survey to the family physicians of thyroid cancer patients and analyzed the findings relative to follow-up guidelines published by the American Thyroid Association (ATA). Statistical significance between early and late follow-up patterns was analyzed using the χ(2) test.

RESULTS

Our survey response rate was 56.2% (91 of 162). The time from operation ranged from 1.24-7.13 (mean 3.96) years, and 87.9% of patients had undergone a physical exam within the previous year. Only 37.4% and 14% of patients had a serum thyroglobulin measurement within 6 and between 6 and 12 months before the survey, respectively. Thyroid simulating hormone (TSH) levels were measured within the prior 6 months in 67% of patients and between 6 and 12 months in 13.2%. The TSH levels were suppressed (< 0.1 μIU/L) in 24.2% of patients, 0.1-2 μIU/L in 44% and greater than 2 μIU/L in 17.6%. Ultrasonography was the most common imaging test performed.

CONCLUSION

There is significant variation in the follow-up patterns of patients with thyroid cancer, and there is considerable deviation from current ATA guidelines.

An examination of recently revised differentiated thyroid cancer guidelines

PURPOSE OF REVIEW

To examine the most recent changes in published guidelines by various organizations for the treatment of patients with differentiated thyroid cancer. This document provides a comparison of recommendations for common topics currently found in available thyroid cancer care guidelines.

RECENT FINDINGS

Recent changes to guidelines have focused on controversial topics, including extent of thyroidectomy based on tumor size, prophylactic central neck dissection, use of radioactive iodine, and degree of thyrotropin suppression. Regional variations between guidelines exist. Adherence to thyroid cancer guidelines at national levels is less than ideal.

SUMMARY

Guidelines for the management of differentiated thyroid cancer should continue to reflect minor regional variations in thyroid cancer treatment based on factors unique to that population while remaining otherwise similar to ensure optimal state-of-the-art patient care and outcomes. In the future, individual patient molecular information will likely play an important role in assessing the risk of tumor recurrence and overall survival. Consideration of multiple patient and tumor factors will allow thyroid cancer specialists to use a risk-adapted approach to patient care, from both a surgical and medical standpoint, to ensure optimal patient outcomes on an individual basis and at a disease level.

Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes

BACKGROUND

Papillary microcarcinoma (PMC) of the thyroid generally follows a benign clinical course. However, treatment strategies remain controversial. According to our previous retrospective review of 178 patients with PMC who underwent surgery between 1976 and 1993, the most significant risk factors affecting cancer-specific survival were clinical symptoms at presentation due to invasion or metastasis. Distant metastasis and cancer-specific death were never seen postoperatively for 148 cases (83%) of asymptomatic PMC without clinically apparent (>or=1 cm) lymph node metastasis or recurrent nerve palsy. Based on these results, we identified three biologically different types of PMC that should be treated differently. Type I comprises incidentally detected PMC without any symptoms, which is harmless and the lowest-risk cancer. Conservative follow-up with ultrasonography every 6 or 12 months is feasible. Type II involves the early stage of the usual low-risk papillary carcinoma. This can be treated by lobectomy when increasing size is noted during conservative follow-up. Type III comprises clinically symptomatic PMC, representing a high-risk cancer. Immediate wider resection followed by radioiodine treatment and suppression of thyroid-stimulating hormone is recommended.

METHODS

Since 1995, we have been conducting a prospective clinical trial of nonsurgical observation for asymptomatic PMC. As of 2008, 230 of 244 candidates (94%) have decided to accept this policy, whereas 56 patients underwent surgery for symptomatic PMC between 1976 and 2006.

RESULTS

Nonsurgical observation for a mean of 5 (range, 1-17) years for 300 lesions of asymptomatic PMC revealed that 22 (7%) had increased in size, 269 (90%) were unchanged, and 9 (3%) had decreased. No patients developed extrathyroidal invasion or distant metastasis. Three patients (1%) who developed apparent lymph node metastasis and nine patients (4%) in whom tumor increased in size eventually received surgery after 1-12 years of follow-up. No recurrences have been identified postoperatively. Conversely, 10-year cause-specific survival for symptomatic PMC was 80%. Multivariate analysis identified extrathyroidal invasion, large lymph node metastasis (>or=2 cm), and poorly differentiated component as significantly related to adverse outcomes.

CONCLUSIONS

Nonsurgical observation seems to represent an attractive alternative to surgery for asymptomatic PMC. Almost 95% of asymptomatic PMC patients are type I, and another 5% are type II and can be treated with conservative surgery. A small number of PMCs with bulky lymph node metastasis or extrathyroidal invasion are high-risk type III and require aggressive treatment.

ATA practice guidelines for the treatment of differentiated thyroid cancer: were they followed in the United States?

BACKGROUND

The aim of this study was to benchmark national practice patterns against American Thyroid Association guidelines for thyroidectomy, lymphadenectomy, and radioactive iodine (RAI) for differentiated thyroid cancer (DTC).

METHODS

A cross-sectional analysis of patients with DTC in Surveillance, Epidemiology, and End Results was performed. Outcomes were practice accordance with guidelines for extent of surgery and RAI treatment. Predictors of accordance were identified.

RESULTS

A total of 52,964 patients with DTC were included. Seventy-six percent were women, and 83% white. There was 71% accordance with surgery recommendations; among these, 15% underwent central lymphadenectomy, 31% had RAI but no lymphadenectomy, and 25% had RAI and lymphadenectomy. The highest accordance with guidelines was for patients aged <45 years with stage II disease (80%); the lowest accordance was for patients aged > or = 45 years with stage II disease (52%). Patients aged >65 years and of black race had the lowest accordance (P < .001).

CONCLUSIONS

Variation in practice suggests variation in the quality of care for DTC. Greater dissemination of evidence-based recommendations is needed for elderly and minority patients.

Is there an increased incidence of surgically removed thyroid carcinoma in Belgium ten years after Chernobyl? A study of hospital discharge data

In order to provide some answers to the much debated subject of the consequences of the Chernobyl accident, this study attempts to measure the incidence of surgically removed thyroid cancers in Belgium ten years following the explosion. The analysis was made from the hospital discharge data between 1993 and 1998. It offers the advantage of national coverage in spite of certain validity limits. The results show an increase in surgically removed thyroid cancers, which is not, however, evident in the more susceptible younger generation who were involved at the time of the accident. Furthermore, the geographic distribution of the incidence is more marked in the south of the country, unaffected by the radioactive iodine contamination of 1986, which was more prevalent in the east of the country. The study of the type of surgery involved shows a rise in the proportion of total thyroidectomies. These findings are in favour of the hypothesis of a causal effect linking the increased incidence of thyroid cancers to medical practice and surgery in particular and not to the consequence of the possible contamination.