Active surveillance in low risk papillary thyroid carcinoma

Implementing active surveillance for low-risk thyroid carcinoma into clinical practice: collaborative recommendations for Latin America

The incidence of thyroid cancer is increasing globally, but mortality rates have remained steady. Many patients with thyroid cancer have low-risk, nonmetastatic intrathyroidal tumors smaller than 2 cm. Active surveillance has shown benefits in these patients, but the adoption of this approach remains below standard in Latin America. The purpose of this article is to identify ways to improve the incorporation of active surveillance into clinical practice for patients with low-risk thyroid carcinoma in Latin America, taking into consideration cultural and geographic factors. Current recommendations include three steps involving patient participation. The first step, which consists of the initial clinical examination, has eight factors requiring special attention. Anxiety must be managed while considering individual, disease-related, cognitive, and environmental aspects. Terms like "overdiagnosis", "incidentaloma," and "overtreatment" must be explained to the patient. Implementing precise terminology contributes to adequate disease perception, substantially reducing stress and anxiety. Clarifying the nonprogressive nature of thyroid cancer helps dispel myths surrounding the disease. The second step includes advice about procedures and guidelines for patients who choose active surveillance. Flexible monitoring techniques should be implemented, with regular check-ins scheduled based on patient needs. Reasons for adjusting treatment must be clearly communicated to the patient, and changes in preference regarding active surveillance should be considered in advance. The third step includes assistance during follow-up. Patients must be educated about ultrasound results and receive surgical indications from specialized physicians. The effectiveness of active surveillance can be reinforced by explaining to the patients the dynamics of changes in nodule size using clear and concise visual aids.

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.

Regulatory role of Chitinase 3-like 1 gene in papillary thyroid carcinoma proved by integration analyses of single-cell sequencing with cohort and experimental validations

Papillary thyroid carcinoma (PTC) is one of the most common thyroid carcinomas. The gross extrathyroidal extension and extensive metastases of PTC lead to high rates of recurrence and poor clinical outcomes. However, the mechanisms underlying PTC development are poorly understood. In this study, using single-cell RNA sequencing, the transcriptome profiles of two PTC patients were addressed, including PTC1 with low malignancy and good prognosis and PTC2 with high malignancy and poor prognosis. We found that epithelial subcluster Epi02 was the most associated with the malignant development of PTC cells, with which the fold change of Chitinase 3-like 1 (CHI3L1) is on the top of the differentially expressed genes between PTC1 and PTC2 (P < 0.001). However CHI3L1 is rarely investigated in PTC as far. We then studied its role in PTC with a series of experiments. Firstly, qRT-PCR analysis of 14 PTC patients showed that the expression of CHI3L1 was positively correlated with malignancy. In addition, overexpression or silencing of CHI3L1 in TPC-1 cells, a PTC cell line, cultured in vitro showed that the proliferation, invasion, and metastasis of the cells were promoted or alleviated by CHI3L1. Further, immunohistochemistry analysis of 110 PTC cases revealed a significant relationship between CHI3L1 protein expression and PTC progression, especially the T (P < 0.001), N (P < 0.001), M stages (P = 0.007) and gross ETE (P < 0.001). Together, our results prove that CHI3L1 is a positive regulator of malignant development of PTC, and it promotes proliferation, invasion, and metastasis of PTC cells. Our study improves understanding of the molecular mechanisms underlying the progression of PTC and provides new insights for the clinical diagnosis and treatment of PTC.

Comparative analysis of pre-operative ultrasound and histopathology in small papillary thyroid carcinoma in the era of active surveillance

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.

Efficacy and safety of ultrasound-guided radiofrequency ablation for low-risk papillary thyroid microcarcinoma in patients aged 55 years or older: a retrospective study

PURPOSE

To evaluate the efficacy and safety of radiofrequency ablation for low-risk papillary thyroid microcarcinoma (PTMC) in patients aged 55 years or older.

METHODS

This retrospective study included 95 patients aged 55 years or older who underwent radiofrequency ablation (RFA) for PTMCs between June 2014 and January 2019. Incidence and duration of postoperative complications were recorded and evaluated. Tumor volume and volume reduction rate (VRR) changes were calculated. Patients were also closely monitored for tumor recurrence, regrowth, and lymph node metastasis.

RESULTS

All nodules were completely ablated. The mean initial volume of the ablated thyroid nodules was 107.27 ± 99.10 mm³, and the volume decreased significantly during the follow-up time. The VRR in 1st, 3rd, 6th, 12th, 18th, 24th and 36th month were -591.64 ± 623.65%, -170.89 ± 319.51%, 9.74 ± 128.43%, 77.99 ± 45.26%, 99.35 ± 3.61%, 99.45 ± 3.05% and 99.78 ± 1.54%, respectively. No patient had any life-threatening complications. One patient had lymph node metastasis and one had a recurrence; both underwent a second radiofrequency ablation treatment and achieved satisfactory treatment results.

CONCLUSIONS

Our study suggests that radiofrequency ablation is a safe and effective option for low-risk PTMC in patients aged 55 years or older who are at a high risk of general anesthesia and postoperative complications or those who refuse surgery.

Thyroid Microcarcinoma in Pediatric Population in Romania

Thyroid microcarcinoma in pediatric population in Romania Non-medullary thyroid cancer (TC) is the most common endocrine malignancy, with an increasing incidence in the recent years, due to the increase of the thyroid microcarcinoma. Thyroid microcarcinoma (mTC) is defined, according to WHO criteria, as ≤1 cm dimension thyroid carcinoma, being a rare disease in children population. In adults, the current guidelines recommend a limited surgical approach. In children, however, there are no specific guidelines for mTC. Due to the scarcity of these tumors, mTC in children have largely been understudied, to our knowledge with only one previous publication reporting on the outcomes of a large historic series of patients with mTC from the USA. In Romania, the incidence of TC is rising, one of the reason may be the effect of Chernobyl nuclear accident in the past and the iodine deficiency. The purpose of this study was to describe the characteristics and outcome of children diagnosed with mTC in Romania diagnosed from 1 January 2000 to 31 December 2018. During the study period we identified 77 cases of differentiated TC (papillary and follicular) and of these 20 cases (19.4%) were mTC. The mTC represented roughly one fifth of our nationwide pediatric population diagnosed in the last 20 years, the majority of cases being recorded in adolescents aged between 15–18 years. Although patients with apparently more unfavorable local phenotype were identified, this was not reflected in the outcome of the patients in terms of remission of the disease and survival. Our study illustrates the heterogeneity of the real-life practice with respect to the pediatric mTC, and underscores the need for carefully designed multicenter international studies, including larger cohorts of patients in order to provide the data required for establishing evidence based uniform protocols. The European Reference Networks (ERN), such as the ERN for Rare Endocrine Diseases (Endo-ERN) provides an ideal platform to initiate such collaborative studies.

Ultrasound-Guided Radiofrequency Ablation Versus Surgical Resection for the Treatment of T1bN0M0 Papillary Thyroid Carcinoma in Different Age Groups

PURPOSE

We aimed to compare the efficacy and safety of radiofrequency ablation (RFA) to that of surgical resection (SR) in patients with T1bN0M0 papillary thyroid carcinoma (PTC) in different age groups.

METHODS

Totally, 204 patients with an isolated, solitary, intrathyroidal T1bN0M0 PTC, who underwent either RFA (n=94) or SR (n=110) between April 2014 and December 2019, were retrospectively enrolled and were divided into two subgroups according to age (<45 years, ≧45 years). Patients with pathologically aggressive or advanced lesions were excluded from the study. Tumor progression and procedural complications were the primary and secondary endpoints, respectively. Tumor recurrence in situ, newly discovered tumors, lymph node involvement, or distant metastases indicated tumor progression. Complications included pain, fever, voice change, choking, numbness in the limbs, and cardiac events. Incidence rates of all endpoint events were compared between different age subgroups.

RESULTS

There were no significant differences in age, sex, and tumor size between the treatment groups. While the RFA group incurred less cost and experienced significantly shorter operative duration than the SR group, no significant differences were observed in incidences of both tumor progression and complications. Further, subgroup analysis of patients <45 years versus those ≧45 years showed no significant differences in the incidence of tumor progression and complications within or between different treatment groups. Older patients in the SR group incurred higher hospital costs than younger counterparts, but this difference was not observed in the RFA group.

CONCLUSIONS

Our results indicated that RFA had a similar prognosis as that of SR but was associated with lower overall cost in both young (<45 years) and middle-aged patients (≧45 years) with T1bN0M0 PTC. Therefore, RFA may be an effective and safe alternative to surgery for the treatment of patients with T1bN0M0 PTC.