Observing micopapillary thyroid cancers

Reconceptualize tall-cell variant papillary thyroid microcarcinoma: From a "sonographic histology" perspective

OBJECTIVE

This study aimed to examine the relationship between sonographic features and histological manifestations in the tall-cell variant of papillary thyroid microcarcinoma (TCV-PTMC), thus proposing the concept of "sonographic histology" and examine its value in the clinical management of the aggressive tall-cell variant.

METHODS

This study retrospectively included 104 participants who were admitted to Peking University Third Hospital from 2015 to 2022 and were histopathologically confirmed as having TCV-PTMC or classical PTMC. We mainly compared the general characteristics, sonographic characteristics, and pathological specimens between the two cohorts.

RESULTS

Hypoechoic nodules with a localized central isoechoic lesion and hypoechoic halo around nodules were most often observed in TCV-PTMC, which correlated with circumferentially distributed tumor epithelium and densely distributed tumor stroma histopathologically. Additionally, TCV-PTMC showed nodules with a more regular margin and less microcalcification than classical PTMC, which led to an underestimation of the risk of TCV-PTMC.

CONCLUSION

The good association between the ultrasound echo pattern and tissue cell arrangement was defined as sonographic histology in this study and can be applied in the preoperative identification of TCV-PTMC. This concept may provide novel insight for the identification of special subtypes of thyroid tumors and may modify pitfalls of the Thyroid Imaging Reporting and Data System in aggressive variants of microcarcinoma.

The global burden of thyroid cancer and its attributable risk factor in 195 countries and territories: A systematic analysis for the Global Burden of Disease Study

Background

Thyroid cancer is a growing threat to human health. Few studies have explored trends of thyroid cancer and relationships with social development factors. In this study, we explored the trend and relationship based on GBD.

Methods

By using GBD study, we obtained detailed data of thyroid cancer. Incidence, mortality and DALY were used to assess epidemiological characteristics. ASR and EAPC were used to estimate the trend.

Results

Globally, the incidence significantly increased from 1990 to 2017, especially in high‐income regions. Males and middle SDI region demonstrated a higher increase of age‐standardized incidence rates. Unlike incidence trend, mortality trend showed a minor increase, and even showed a decreasing trend in some regions such as Eastern Sub‐Saharan Africa. Additionally, the DALY trend also demonstrated a slightly increase with an EAPC of 0.77 (95% CI 0.73–0.81). More significant increase of DALY was found in males, middle SDI region and high‐income Asia Pacific. The incidence of thyroid cancer peaked in middle‐aged people, while the mortality and DALY peaked in elder‐aged. Moreover, the proportion of thyroid cancer deaths contributable to high BMI was highest in developed countries and middle‐aged people.

Conclusions

Thyroid cancer is a public health problem worldwide. Over‐diagnosis might be partly responsible for its rising trend. It remains us to revise the guidelines to avoid unnecessary burdens. Moreover, we should pay attention to the risk factors of thyroid cancer. More targeted measures should be formulated to improve potential environmental and lifestyle‐related factors which might contribute to rising trend of thyroid cancer.

Comparison of treatment efficacy 1 and 2 years after thyroid remnant ablation with 1110 versus 5550 MBq of iodine-131 in patients with intermediate-risk differentiated thyroid cancer

BACKGROUND

Radioiodine ablation may be associated with improved survival in patients with intermediate-risk follicular cell differentiated thyroid cancer (FCDTC). The aim of this study was to compare ablation efficacy of 1110 versus 5500 MBq of iodine-131 (I) in FCDTC patients with intermediate risk.

METHODS

Thirty-nine patients with intermediate-risk FCDTC (T3N0, T1-2N1b and T1-3N1a) were treated with 1110 MBq of I and compared with 43 age-matched and sex-matched patients who received 5550 MBq of I. Patients with invasive histology, extensive lymph node involvement, and preablation thyroglobulin (Tg) of more than 100 ng/ml were excluded from the study. All patients underwent total or near total thyroidectomy with or without lymph node dissection. Response to treatment was evaluated 1 and 2 years after I treatment.

RESULTS

We studied four male and 78 female patients, age range 21-69 years. Preablation Tg level was 12.7±17.8 and 15.8±22.6 ng/ml in patients in the low-dose and high-dose groups, respectively (P=0.48). Anti-Tg antibody level as well as T and N staging were not significantly different in the two groups (P>0.2). One and 2 years after treatment, an excellent response was noted in 19 and 22 patients in the low-dose group and in 16 and 23 patients in the high-dose group, respectively (P>0.3). Using logistic regression analysis, preablation Tg was the only significant factor in the prediction of an incomplete response 2 years after therapy.

CONCLUSION

1110 MBq of I was as effective as 5550 MBq of I in the treatment of FCDTC patients with intermediate risk 1 and 2 years after therapy.

Treatment decision making in early-stage papillary thyroid cancer

OBJECTIVE

The purpose of this study was to develop an in-depth understanding of papillary microcarcinoma (PMC) patients' decision-making process when offered options of surgery and active surveillance.

METHODS

Fifteen PMC patients and 6 caregivers participated in either a focus group or individual interview. Focus groups were segmented by patients' treatment choice. Primary themes were identified in transcripts using thematic text analysis.

RESULTS

Four themes emerged from the surgery subsample: (1) Decision to undergo thyroidectomy quickly and with a sense of urgency; (2) Perception of PMC as a potentially life-threatening disease; (3) Fear of disease progression and unremitting uncertainty with active surveillance; and (4) Surgery as a means of control and potential cure. Three themes emerged from the active surveillance subsample: (1) View of PMC as a common, indolent, and low-risk disease; (2) Concerns about adjusting to life without a thyroid and becoming reliant on hormone replacement medication; and (3) Openness to reconsidering surgery over the long run. Two themes were identified that were shared by participants from both subsamples: (1) Deep level of trust and confidence in physician and cancer center; and (2) Use of physician and internet as primary sources of disease and treatment-related information.

CONCLUSIONS

Several factors influenced participants' treatment choice, with similarities and differences noted between surgery and active surveillance subsamples. Many of the emergent themes are consistent with research on decision making among localized prostate cancer patients. Findings suggest that participants from both PMC treatment subsamples are motivated to reduce illness and treatment-related uncertainty.

Current Management of Low Risk Differentiated Thyroid Cancer and Papillary Microcarcinoma

Each year, the proportion of thyroid cancer patients presenting with low risk disease is increasing. Moreover, the definition of low risk thyroid cancer is expanding and several histological subtypes beyond papillary microcarcinomas are now classified as low risk disease. This shift in the landscape of thyroid cancer presentation is forcing clinicians to critically re-evaluate whether or not traditional management paradigms that were effective in treating intermediate and high risk disease are applicable to these low risk patients. Here we review the definition of low risk disease, examine the various histological subtypes that are considered low risk in the 2015 American Thyroid Association guidelines for the management of thyroid nodules and thyroid cancer, and review our current approach to the management of these low risk tumours.

The changing incidence of thyroid cancer

During the past few decades, the incidence of thyroid cancer has increased substantially in many countries, including the USA. The rise in incidence seems to be attributable both to the growing use of diagnostic imaging and fine-needle aspiration biopsy, which has led to enhanced detection and diagnosis of subclinical thyroid cancers, and environmental factors. The latest American Thyroid Association (ATA) practice guidelines for the management of adult patients with thyroid nodules and differentiated thyroid cancer differ substantially from the previous ATA guidelines published in 2009. Specifically, the problems of overdiagnosis and overtreatment of a disease that is typically indolent, where treatment-related morbidity might not be justified by a survival benefit, now seem to be acknowledged. As few modifiable risk factors for thyroid cancer have been established, the specific environmental factors that have contributed to the rising incidence of thyroid cancer remain speculative. However, the findings of several large, well-designed epidemiological studies have provided new information about exposures (such as obesity) that might influence the development of thyroid cancer. In this Review, we describe the changing incidence of thyroid cancer, suggest potential explanations for these trends, emphasize the implications for patients and highlight ongoing and potential strategies to combat this growing clinical and public health issue.

A cost-effectiveness comparison between early surgery and non-surgical approach for incidental papillary thyroid microcarcinoma

BACKGROUND

The issue of whether all incidental papillary thyroid microcarcinoma (PTMC) should be managed by early surgery (ES) has been questioned and there is a growing acceptance that a non-surgical approach (NSA) might be more appropriate. We conducted a cost-effectiveness analysis comparing the two strategies in managing incidental PTMC.

METHODS

Our base case was a hypothetical 40-year-old female diagnosed with a unifocal intra-thyroidal 9 mm PTMC. The PTMC was considered suitable for either strategy. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between ES and NSA after 20 years. Outcome probabilities, utilities and costs were derived from the literature. The threshold for cost-effectiveness was set at USD 50,000/quality-adjusted life year (QALY). A further analysis was done for patients < 40 and ≥ 40 years. Sensitivity and threshold analyses were used to examine model uncertainty.

RESULTS

Each patient who adopted NSA over ES cost an extra USD 682.54 but gained an additional 0.260 QALY. NSA was cost saving (i.e. less costly and more effective) up to 16 years from diagnosis and remained cost-effective from 17 years onward. In the sensitivity analysis, NSA remained cost-effective regardless of patient age (< 40 and ≥ 40 years), complications, rates of progression, year cycle and discount rate. In the threshold analysis, none of the scenarios that could have changed the conclusion appeared clinically likely.

CONCLUSIONS

For a selected group of incidental PTMC, adopting NSA was not only cost saving in the initial 16 years but also remained cost effective thereafter. This was irrespective of patient age, complication rate or rate of PTMC progression.

Papillary thyroid microcarcinoma: an over-treated malignancy?

BACKGROUND

The clinical importance of papillary thyroid microcarcinoma (PTMC) remains controversial, with current guidelines suggesting that thyroid lobectomy alone is sufficient. The purpose of this study was to identify population-level treatment patterns in the USA for PTMC.

METHODS

Patients with PTMC in SEER (1998-2010) were included; demographic, clinical (extent of surgery, administration of post-operative radioactive iodine [RAI]), and pathologic characteristics were examined. Outcomes of interest were 5- and 10-year overall survival (OS) and disease-specific survival (DSS).

RESULTS

The cohort consisted of 29,512 patients. Mean age at diagnosis was 48.5 years; mean tumor size was 0.53 cm. Overall, 73.4 % of patients underwent total thyroidectomy, and RAI was administered to 31.3 %. In multivariate analysis, total thyroidectomy was more frequently performed in patients with multifocal (odds ratio [OR] 2.55), 'regional', or 'distant' PTMC (OR 2.90 and 2.59). Non-operative management was associated with male patients (OR 4.24) and those aged ≥65 years (OR 6.31). Post-operative RAI was associated with multifocal PTMC (OR 2.57). Overall, 5- and 10-year DSS was 99.6 and 99.3 %, respectively, with no difference in DSS between patients who underwent partial versus total thyroidectomy. OS of patients with PTMC who underwent any thyroid operation was similar to that of the general population of the USA.

CONCLUSIONS

An increasing number of patients are undergoing total thyroidectomy and RAI for PTMC. While there may be a subset of patients for whom more aggressive therapy is indicated, many patients with PTMC may be over-treated, with no demonstrable benefit to survival.

[Total thyroidectomy with lymph node dissection of the central compartment for node-positive, capsular invasive papillary thyroid cancer: video contribution]

The aim of radical oncological surgery for nodal metastasized papillary thyroid cancer is, as for other oncological interventions in visceral surgery, the anatomy-related implementation of the concept of en bloc (no touch) resection of the organ bearing the primary tumor together with the first lymph node station, while the structures of the aerodigestive tract, the recurrent laryngeal nerves and parathyroid glands are preserved. The surgical technique is demonstrated in detail with the help of a video of the operation and which is available on-line, the advantages and disadvantages of the technique are discussed.

Differentiated thyroid cancer-personalized therapies to prevent overtreatment

The concept of individualized therapy is rapidly gaining recognition in the management of patients with differentiated thyroid cancer (DTC). This Review provides an overview of the most important elements of this paradigm shift in DTC management and discusses the implications for clinical practice. In the majority of patients with DTC who have an inherently good prognosis, the extent of surgery, the dosage of (131)I therapy and the use of levothyroxine therapy are all aspects suitable for individualization, on the basis of both the stage of disease and the response to treatment. In individuals with advanced disease, newer imaging techniques, advances in (131)I therapy and the use of targeted molecular therapies (such as multitargeted kinase inhibitors) have provided new options for the personalized care of patients, for whom until recently no effective therapies were available. Individualized therapies could reduce adverse effects, including the sometimes debilitating hypothyroidism that used to be required before initiation of (131)I treatment, and major salivary gland damage, a common and unpleasant side effect of (131)I therapy. Highly individualized interdisciplinary treatment of patients with DTC might lead to improved outcomes with reduced severity and frequency of complications and adverse effects. However, in spite of ongoing research, personalized therapies remain in their infancy.