Management of Recurrent Well-Differentiated Thyroid Carcinoma in the Neck: A Comprehensive Review

Differentiated Thyroid Cancer after Thyroidectomy

The widespread use of neck US and other imaging modalities has contributed to a phenomenon of increased detection of differentiated thyroid cancer (DTC). Most of these cancers remain indolent, without requiring surgical intervention. Nonetheless, a subset of patients who require surgical treatment experience subsequent disease recurrence. This most commonly occurs in the cervical lymph nodes and thyroid bed, followed by distant metastasis to the lungs and bones. Because imaging is an integral part of postoperative surveillance, radiologists play a central role in the detection of recurrent tumors and in guiding treatment in these patients. US is the primary imaging modality used for postoperative evaluation. Other modalities such as CT, MRI, radioactive iodine imaging, and PET/CT aid in the accurate diagnosis and characterization of recurrent disease. Therefore, radiologists must have a thorough understanding of the utility of these imaging techniques and the imaging characteristics of recurrent DTC when interpreting these multimodality studies. The interpretation of imaging findings should also be correlated with the clinical status of patients and their biochemical markers to minimize interpretative errors. The authors present a broad overview of the postoperative evaluation of DTC, including its initial primary management, staging, and prognostication; clinical risk stratification for recurrent disease; postoperative surveillance with imaging and evaluation of biochemical markers; and management of recurrent DTC. Published under a CC BY 4.0 license. Supplemental material is available for this article.

Predicting factors and clinical outcome of biochemical incomplete response in middle eastern differentiated thyroid carcinoma

PURPOSE

The aim of this study was evaluate biochemical incomplete response (BIR) in Middle Eastern differentiated thyroid cancer (DTC), identify factors that could predict BIR before radioactive iodine (RAI) ablation and to investigate the long-term clinical outcome of DTC patient exhibiting BIR to initial therapy.

METHODS

We retrospectively evaluated 1286 DTCs from Middle Eastern ethnicity who underwent total thyroidectomy and RAI therapy. Demograpic and clinico-pathological factors predicting BIR were evaluated. The outcome of these patients was analyzed using primary outcome of structural disease and disease-free survival (DFS).

RESULTS

With a median follow-up of 10 years, 266 (20.7%) patients had BIR. High pre-ablation stimulated thyroglobulin (presTg), presence of lymph node metastasis, male gender and delayed initial RAI therapy (≥3 months) after thyroidectomy were significant independent predictors of BIR. Upon evaluating long-term clinical outcomes in 266 patients with BIR, we found 36.8% of patients developed structural disease. Male sex (OR = 1.56; 95% CI = 1.05-2.30; p = 0.0272) and increasing Tg after initial therapy (OR = 4.25; 95% CI = 1.93-10.82; p = 0.0001) were independent risk factors for structural disease in patients with BIR. DFS was significantly worse if both these risk factors existed concomitantly (p < 0.0001).

CONCLUSION

To achieve the fair efficacy of RAI therapy, early prediction of BIR before RAI ablation is desirable. Our finding of the clinico-pathological factors (high presTg level, LNM, delayed RAI therapy and male gender) could serve as easy and robust early predictors of BIR. In addition, DTC patients exhibiting BIR had a high risk of structural disease and hence personalized management approach would be preferable for BIR patients to ensure best clinical outcome.

Ablation of Primary and Recurrent Thyroid Cancer: Current and Future Perspectives

Thyroid cancer is the most common endocrine malignancy, and its incidence is increasing, driven in part by the advent of ultrasound, and subsequent increased detection of small, early thyroid cancers. Yet even for small tumors, thyroidectomy with lymph node dissection remains standard of care. Specific to well-differentiated thyroid cancer, surgery has come under scrutiny as a possible overtreatment, in light of stable and favorable survival rates even as guidelines have allowed fewer radical resections and lymph node dissections over time. Moreover, thyroid cancer unfortunately has a known recurrence rate regardless of therapy, and surgical re-intervention for local structural recurrence is eventually limited by scar. Radioactive iodine therapy, another accepted treatment, is minimally invasive but can only treat patients with iodine-avid tumors. For all of these reasons, image-guided thermal ablation has emerged as a valuable complementary tool as a thyroid-sparing, parathyroid-sparing, voice-sparing, repeatable, minimally invasive outpatient focal therapy for both primary and recurrent well-differentiated thyroid cancers. However, the data are still evolving, and this represents a new patient cohort for some interventional radiologists. Therefore, the goal of this review is to discuss the technique and evidence for ablation of patients with thyroid cancer.

Ultrasound-guided radiofrequency ablation for the treatment of papillary thyroid carcinoma: a review of the current state and future perspectives

Papillary thyroid carcinoma (PTC) is a highly prevalent cancer that typically exhibits indolent behavior and is associated with a favorable prognosis. The treatment of choice is surgical intervention; however, this approach carries the risk of complications, including scarring and loss of thyroid function. Although active surveillance can mitigate the risk of PTC overtreatment, the possibility of tumor growth and metastasis can elicit anxiety among patients. Ultrasoundguided thermal ablation has emerged as a safe and effective alternative for individuals who are ineligible for or decline surgery. This article provides a review of the clinical research on radiofrequency ablation as a treatment for PTC, offering a thorough examination of its efficacy, safety, and future perspectives.

Thyroid Cancer: A Review

Importance

Approximately 43 720 new cases of thyroid carcinoma are expected to be diagnosed in 2023 in the US. Five-year relative survival is approximately 98.5%. This review summarizes current evidence regarding pathophysiology, diagnosis, and management of early-stage and advanced thyroid cancer.

Observations

Papillary thyroid cancer accounts for approximately 84% of all thyroid cancers. Papillary, follicular (≈4%), and oncocytic (≈2%) forms arise from thyroid follicular cells and are termed well-differentiated thyroid cancer. Aggressive forms of follicular cell-derived thyroid cancer are poorly differentiated thyroid cancer (≈5%) and anaplastic thyroid cancer (≈1%). Medullary thyroid cancer (≈4%) arises from parafollicular C cells. Most cases of well-differentiated thyroid cancer are asymptomatic and detected during physical examination or incidentally found on diagnostic imaging studies. For microcarcinomas (≤1 cm), observation without surgical resection can be considered. For tumors larger than 1 cm with or without lymph node metastases, surgery with or without radioactive iodine is curative in most cases. Surgical resection is the preferred approach for patients with recurrent locoregional disease. For metastatic disease, surgical resection or stereotactic body irradiation is favored over systemic therapy (eg, lenvatinib, dabrafenib). Antiangiogenic multikinase inhibitors (eg, sorafenib, lenvatinib, cabozantinib) are approved for thyroid cancer that does not respond to radioactive iodine, with response rates 12% to 65%. Targeted therapies such as dabrafenib and selpercatinib are directed to genetic mutations (BRAF, RET, NTRK, MEK) that give rise to thyroid cancer and are used in patients with advanced thyroid carcinoma.

Conclusions

Approximately 44 000 new cases of thyroid cancer are diagnosed each year in the US, with a 5-year relative survival of 98.5%. Surgery is curative in most cases of well-differentiated thyroid cancer. Radioactive iodine treatment after surgery improves overall survival in patients at high risk of recurrence. Antiangiogenic multikinase inhibitors and targeted therapies to genetic mutations that give rise to thyroid cancer are increasingly used in the treatment of metastatic disease.

Wire-guided localization and surgical resection of non-palpable recurrent of thyroid carcinoma: A STROBE-compliant, retrospective cohort study

BACKGROUND

Information on hook-wire guided (HWG) surgery for non-palpable thyroid carcinoma (TC), locoregional-recurrent disease (LRRD) is scarce. We analyze the results of HWG resection compared with the traditional procedure.

METHODS

Cohort study performed between January 2016 and December 2020. Patients with TC and non-palpable LRRD were included. A "Standard cohort", patients with non-HWG resection and "HWG cohort", with HWG resection of LRRD were defined. Surgical morbidity, re-recurrent/progressive disease (RRD), and re-recurrence-free survival (RRFS) were defined.

RESULTS

43 and 23 patients were assigned to the Standard or HWG cohorts, respectively. Complications occurred in 28 % and 17.3 % of cases, in control or HWG cohorts, respectively. HWG cohort, size of primary TC, 131I dose >150 mCi, and thyroglobulin level >1 ng/ml at detection of LRRD were associated with RRD. HWG cohort, thyroglobulin level at LRRD, 131I treatment, and dose were associated with RRFS.

CONCLUSIONS

HWG surgery of non-palpable TC LRRD had improved results regarding surgical morbidity, RRD, and RRFS.

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.