Patients' View on the Management of Papillary Thyroid Microcarcinoma: Active Surveillance or Surgery

Ultrasound and gene-guided microwave ablation vs. surgery for low-risk papillary thyroid carcinoma: a prospective observational cohort study

Objective

This prospective observational cohort real-world study evaluates and compares the efficacy and prognosis of ultrasound (US) and gene-based microwave ablation (MWA) and surgical treatment in patients with low-risk papillary thyroid carcinoma (PTC), emphasizing the influence of genetic mutations on low-risk patient selection.

Background

MWA, a minimally invasive technique, is increasingly recognized in the management of PTC. While traditional criteria for ablation focus on tumor size, number, and location, the impact of genetic mutations on treatment efficacy remains underexplored.

Methods

A total of 201 patients with low-risk PTC without metastasis were prospectively enrolled. All patients underwent US and next-generation sequencing to confirm low-risk status. Patients chose either ablation or surgery and were monitored until November 2024. Efficacy and complications were assessed using thyroid US and contrast-enhanced US.

Results

The median follow-up of this study is 12 months. There is no significant difference between the ablation group (3.0%) and the surgery group (1.0%) in disease free survival (P = 0.360). However, the surgery group exhibited a significantly higher complication rate, particularly for temporary hypoparathyroidism (P < 0.001). Ablation offers notable advantages, including shorter treatment duration, faster recovery, less intraoperative blood loss, and reduced costs (P < 0.001), while maintaining favorable safety and comparable efficiency.

Conclusions

For patients with low-risk genetic mutations, ablation provides comparable efficacy and disease free survival to surgery, with significant benefits in safety, recovery, and overall cost. Guided by US and next-generation sequencing, precise patient selection enhances the potential of ablation as a promising, minimally invasive alternative to surgery in the management of low-risk PTC .

The 2024 revised clinical guidelines on the management of thyroid tumors by the Japan Association of Endocrine Surgery

The Japan Association of Endocrine Surgery published the first edition of the "Clinical guidelines on the management of thyroid tumors" in 2010 and the revised edition in 2018. The guideline presented herein is the English translation of the revised third edition, issued in 2024. The aim is to enhance health outcomes for patients suffering from thyroid tumors by facilitating evidence-based shared decision-making between healthcare providers and patients, as well as standardizing the management of thyroid tumors. The focus is on adult patients with thyroid tumors, addressing clinically significant issues categorized into areas such as an overview of the diagnosis and treatment of thyroid nodules, treatment strategies by histological type, radioactive iodine therapy, treatment of advanced differentiated carcinoma, pharmacotherapy, and complications and safety management associated with thyroid surgery. Thirty-two clinical questions were established in these areas. Following a comprehensive search of the literature and systematic review to evaluate the overall evidence, we aimed to present optimal recommendations by considering the balance of benefits and harms from the patient's perspective. We integrated evidence and clinical experience to determine the "Certainty of evidence" and "Strength of recommendations". Based on these, we illustrated overall flows of care as "Clinical algorithms". Necessary background knowledge of diseases and established clinical procedures for understanding the recommendations are presented in "Notes", while information that may be clinically useful but for which evidence remains insufficient is included in "Columns", based on the current state of evidence. Finally, future challenges for the next revision are presented as "Future research questions".

Outcomes and effectiveness of active surveillance for low-risk papillary thyroid carcinoma: a systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the outcomes and effectiveness of active surveillance (AS) in patients with low-risk papillary thyroid carcinoma (PTC) and compare them to those of immediate surgery (IS).

METHODS

A systematic review and meta-analysis, including 14 comparative studies and 7 noncomparative studies, was conducted, encompassing a total of 9,397 patients.

RESULTS

AS was associated with lower rates of familial history of thyroid cancer, multiplicity, and overall mortality compared to IS. The disease progression rate during AS was 14.53% (95% CI, 9.59-21.43%), and the delayed surgery rate was 14.91% (95% CI, 8.35-25.21%). No thyroid cancer-related mortality was observed in either the AS and IS groups. Clinicopathological characteristics showed no significant differences between delayed surgery and IS, except for higher rates of extrathyroidal extension and multiplicity in the delayed surgery group. Overall complication and recurrence rates were higher in the delayed surgery group than in the IS group. Quality of life and anxiety levels were similar between AS and IS, except for interest in sex, where AS was more beneficial.

CONCLUSION

AS is a feasible and reliable option for managing low-risk PTC, with a relatively low rate of disease progression and no thyroid cancer-related mortality. However, AS should be undertaken with caution, given the higher rates of overall complications and recurrence in the delayed surgery group compared to the IS group. Further studies with larger sample sizes and long-term follow-up are needed to clarify the role and effectiveness of AS.

Delayed Tracheal Perforation After Microwave Ablation of Papillary Thyroid Microcarcinoma: A Case Report and Literature Review

Microwave ablation (MWA) is a relatively new, well-tolerated, minimally invasive approach, developed in recent years as an alternative to surgery for low-risk papillary thyroid microcarcinoma (PTMC). We describe an 81-year-old patient with unifocal PTMC who refused active surveillance and underwent percutaneous MWA. Two weeks after the procedure, the patient presented dyspnea and cough, and delayed tracheal perforation was confirmed by computed tomography. Conservative therapy was chosen as the initial treatment, and the tracheal defect was confirmed healing successfully 1 month later. Radiologists should be aware of the possibility of delayed tracheal perforation following MWA even in the absence of unusual intraoperative events.

Safety and Feasibility of US-guided Microwave Ablation for the Treatment of Bethesda III Thyroid Nodules with Negative Eight-Gene Panel Mutational Profile

Purpose To evaluate the safety and efficacy of US-guided thermal ablation in the treatment of Bethesda III thyroid nodules with negative eight-gene panel testing results. Materials and Methods This retrospective single-center study included patients with thyroid nodules diagnosed as Bethesda category III (atypia of undetermined significance) at fine-needle aspiration biopsy and with negative eight-gene testing results who were treated with US-guided microwave ablation (MWA) between July 2020 and September 2023. Incidence of complications, technical success rate (TSR), volume reduction rate (VRR), nodule recurrence, and thyroid function were evaluated over a follow-up period of 2 years. Data before and after MWA were compared using variance analysis and the Cochran-Mantel-Haenszel χ2 test. Results A total of 101 Bethesda III nodules were detected in 95 patients (mean ± SD age, 47.08 years ±14.63; 79 female patients, 16 male patients), all of which were completely ablated (100% TSR). Two patients experienced mild neck swelling and pressure sensation after the minimally invasive operation, and the incidence of postoperative complications was 2% (two of 95). None of the patients experienced tumor recurrence or progression. At 2-year follow-up, the mean VRR of the ablated area was 90.88% ± 13.59 in 15 patients; 87% (13 of 15) of these patients had a 100% VRR. There was no evidence of a difference in thyroid function before and after MWA from 1 to 24 months (P = .15-.99). Conclusion US-guided MWA was safe and effective for the treatment of Bethesda III thyroid nodules with negative eight-gene panel testing results. Keywords: Ablation Techniques, Radiation Therapy/Oncology, Head/Neck, Thyroid, Safety, Observer Performance Published under a CC BY 4.0 license.

Long-term outcomes of active surveillance for low-risk papillary thyroid carcinoma: Progression patterns and tumor calcification

INTRODUCTION

Active surveillance (AS) for low-risk papillary thyroid carcinoma (PTC) is acknowledged as a valid management strategy. While older age is identified as a favorable factor for progression, long-term evidence is scarce and lifelong monitoring has been deemed essential. This study investigated progression patterns and tumor calcification under long-term AS and explored the possibility of ending follow-up.

MATERIALS AND METHODS

A total of 650 patients with low-risk PTC who chose AS were enrolled. Progression was defined as either tumor enlargement (≥3 mm from initiation) or development of clinically apparent lymph node metastasis.

RESULTS

The median observation period was 8 years; 45.2% were under surveillance for ≥10 years. Overall, 80 patients (12.3%) exhibited progression. Median age and observation period at the time of progression were 55 and 4 years, respectively. Only 2 patients showed progression after 15 years of follow-up and 5 patients showed progression after reaching 80 years old. Among 71 patients experiencing tumor enlargement, surgery was performed immediately in 32 patients. The remaining 39 patients continued surveillance, but only 5 demonstrated ongoing enlargement thereafter. Of 40 surgeries due to progression, 36 were conducted within the first 10 years. The degree of calcification correlated with age and observation periods. No progression occurred after the development of rim calcification.

CONCLUSIONS

Progression during AS was extremely rare in older patients with long-term surveillance and in tumors with rim calcification. It may be feasible to consider ending scheduled surveillance visits for these patients. Instances of progression halting after enlargement are not uncommon.

Ultrasound-guided percutaneous radiofrequency ablation versus surgery for solitary T1N0M0 papillary thyroid carcinoma in the danger triangle

OBJECTIVES

To compare the safety and efficiency of ultrasound-guided percutaneous radiofrequency ablation (RFA) and surgical resection (SR) for thyroid papillary carcinoma (PTC) in the danger triangle area.

METHODS

The clinical data of 298 patients who underwent either percutaneous RFA or SR for PTC in the thyroid danger triangle at our hospital between January 2018 and April 2020 were retrospectively analyzed. Propensity score matching is employed to regulate for confounding factors. All patients undergoing ablation were treated using a strategy that combined sufficient paratracheal fluid isolation with a low-power, short electrode. Disease progression was analyzed in patients with T1N0M0 PTC (T1a and T1b) employed in Kaplan‒Meier curves. Treatment parameters and the rates of local recurrence, distant metastasis, and complications are recorded and compared.

RESULTS

Of 182 eligible patients who were included, 91 were in the RFA (age 44.84 ± 13.19; 71 females; 77 T1a) and 91 were in the SR (age 47.36 ± 11.05; 68 females; 69 T1a). The average treatment time, length of hospital stays, blood loss volume, and scar length are substantially less in the RFA than in the SR. Major complications as well as postoperative permanent recurrent laryngeal nerve injury and postoperative transient parathyroid dysfunction occurred only in the SR, with a substantial distinction between the two groups (p < 0.05). There is no substantial distinction in the disease progression between RFA and SR treatment of T1N0M0 PTC.

CONCLUSION

RFA is as effective as surgery for PTC in the danger triangle area in the short term, with faster recovery and fewer complications.

CLINICAL RELEVANCE STATEMENT

Radiofrequency ablation has a clinical efficacy comparable to surgery in the treatment of papillary thyroid carcinoma in the danger triangle area in the short term with the advantages of faster recovery and fewer complications when compared with surgery.

KEY POINTS

Use of radiofrequency ablation (RFA) in the thyroid danger triangle is still controversial. RFA and surgery groups showed no difference in disease progressions, and no major complications occurred with RFA. Radiofrequency ablation offers a new option for papillary thyroid carcinoma patients in the danger triangle.

Papillary thyroid microcarcinoma: Does management differ based on facility variables?

PURPOSE

Papillary thyroid carcinoma detection has increased dramatically in the United States. However, the indolent nature of papillary thyroid microcarcinoma (mPTC) has led the American Thyroid Association (ATA) to advocate for more conservative management. The 2015 ATA recommendations advocated for observation or lobectomy for mPTC. However, the majority of mPTCs continue to be treated with more aggressive surgical management. In this study, we aim to understand the management of mPTC based on facility variables.

MATERIALS AND METHODS

A retrospective observational study of patients diagnosed with mPTC between 2004 and 2018 was performed using the National Cancer Database incidence data. We collected data on patient sex, age, tumor size, race, ethnicity, geographic location, thyroid surgical volume at the facility, and treatment modality for mPTC were collected. Conservative and non-conservative treatment modalities based on patient and facility characteristics were compared both longitudinally and cross-sectionally between pre- and post-2015 ATA recommendations.

RESULTS

Total thyroidectomy with or without radioactive iodine ablation (RAI) remains the treatment of choice regardless of patient and facility characteristics. Patients treated at low-volume facilities were actually more likely to be treated conservatively.

CONCLUSIONS

Despite 2015 ATA recommendations advocating for observation or lobectomy for mPTC, patients with mPTC are still more likely to be treated with total thyroidectomy with or without RAI, especially at high-volume facilities.

Differentiated thyroid cancer and adverse pregnancy outcomes: a propensity score-matched retrospective cohort study

Background

Differentiated thyroid cancer (DTC) has been increasingly common in women of reproductive age. However, the evidence remains mixed regarding the association of DTC with adverse pregnancy outcomes in pregnant women previously diagnosed with DTC.

Methods

We conducted a retrospective cohort study in the Peking University Third Hospital in Beijing, China between January 2012 and December 2022. We included singleton-pregnancy women with a pre-pregnancy DTC managed by surgical treatment (after-surgery DTC) or active surveillance (under-surveillance DTC). To reduce the confounding effects, we adopted a propensity score to match the after-surgery and under-surveillance DTC groups with the non-DTC group, respectively, on age, parity, gravidity, pre-pregnancy weight, height, and Hashimoto's thyroiditis. We used conditional logistics regressions, separately for the after-surgery and under-surveillance DTC groups, to estimate the adjusted associations of DTC with both the composite of adverse pregnancy outcomes and the specific mother-, neonate-, and placenta-related pregnancy outcomes.

Results

After the propensity-score matching, the DTC and non-DTC groups were comparable in the measured confounders. In the after-surgery DTC group (n = 204), the risk of the composite or specific adverse pregnancy outcomes was not significantly different from that of the matched, non-DTC groups (n = 816; P > 0.05), and the results showed no evidence of difference across different maternal thyroid dysfunctions, gestational thyrotropin levels, and other pre-specified subgroup variables. We observed broadly similar results in the under-surveillance DTC group (n = 37), except that the risk of preterm birth, preeclampsia, and delivering the low-birth-weight births was higher than that of the matched, non-DTC group [n = 148; OR (95% CI): 4.79 (1.31, 17.59); 4.00 (1.16, 13.82); 6.67 (1.59, 27.90)].

Conclusions

DTC was not associated with adverse pregnancy outcomes in pregnant women previously treated for DTC. However, more evidence is urgently needed for pregnant women with under-surveillance DTC, which finding will be clinically significant in individualizing prenatal care.

Tumor Growth Kinetics Based on Initial Tumor Volume Doubling Time in Active Surveillance of Low-Risk Papillary Thyroid Carcinoma

Background: During active surveillance (AS) of low-risk papillary thyroid carcinomas (PTCs), the majority remain stable, while some exhibit either an increase or a decrease in tumor diameter or tumor volume (TV). We aimed to evaluate the clinical outcomes and relevant parameters influencing tumor growth kinetics of low-risk PTCs. Methods: This retrospective cohort study evaluated clinical parameters of 402 patients with low-risk PTC sized <2 cm, with a follow-up duration over 3 years. Changes in maximum tumor diameter, TV, and initial TV doubling time (i-TVDT) calculated within 3 years were assessed. A significant change in TV was defined as a change of 75% or more. Results: Of the 402 patients with low-risk PTC, 93.3% (375/402) were diagnosed with papillary thyroid microcarcinoma. During a median follow-up of 5 years, 3.4% (14/402) of patients developed new cervical lymph node (LN) metastasis, and 8.2% (33/402) experienced a maximal diameter increase of ≥3 mm. The i-TVDT of <5 years emerged as an independent risk factor for both maximal diameter growth and new LN metastasis (p < 0.001 and p = 0.04, respectively). Based on TV changes and i-TVDT during AS, we identified four statistically significant tumor kinetic patterns (p < 0.001): Stable (±75% change in TV), Rapid growth (TV increase >75% and i-TVDT <5 years), Slow growth (TV increase >75% and i-TVDT ≥5 years), and Shrinkage (TV decrease >75%). Most of the PTCs remained stable (67.7%), but 17.2% were rapidly growing, with a median onset of growth of 2.0 years. Slowly growing PTCs, comprising 10.9%, grew at a median of 4.3 years. A minority, 4.2%, exhibited shrinkage. In total, 115 (28.6%) patients underwent delayed surgery >12 months after initiating AS. The reasons for delayed surgery included patient preference (51/115, 44.3%), disease progression (31/115, 27.0%), and suspected disease progression, which was referred to as tumor growth not meeting the criteria of an increase of ≥3 mm in maximal tumor diameter (17/115, 14.8%). Conclusion: An i-TVDT of <5 years serves as an important prognostic indicator for disease progression, including tumor growth and new LN metastasis. The four tumor kinetic patterns based on TV changes and i-TVDT assist in guiding personalized decisions early in AS.

Single-cell and bulk RNA sequencing reveal heterogeneity and diagnostic markers in papillary thyroid carcinoma lymph-node metastasis

PURPOSE

Papillary thyroid carcinoma (PTC) is characterized by lymph-node metastasis (LNM), which affects recurrence and prognosis. This study analyzed PTC LNM by single-cell RNA sequencing (scRNA-seq) data and bulk RNA sequencing (RNA-seq) to find diagnostic markers and therapeutic targets.

METHODS

ScRNA-seq data were clustered and malignant cells were identified. Differentially expressed genes (DEGs) were identified in malignant cells of scRNA-seq and bulk RNA-seq, respectively. PTC LNM diagnostic model was constructed based on intersecting DEGs using glmnet package. Next, PTC samples from 66 patients were used to validate the two most significant genes in the diagnostic model, S100A2 and type 2 deiodinase (DIO2) by quantitative reverse transcription-polymerase chain reaction (RT-qPCR) and immunohistochemical (IHC). Further, the inhibitory effect of DIO2 on PTC cells was verified by cell biology behavior, western blot, cell cycle analysis, 5-ethynyl-2'-deoxyuridine (EdU) assay, and xenograft tumors.

RESULTS

Heterogeneity of PTC LNM was demonstrated by Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) analysis. A total of 19 differential genes were used to construct the diagnostic model. S100A2 and DIO2 differ significantly at the RNA (p < 0.01) and protein level in LNM patient tissues (p < 0.001). And differed in PTC tissues with different pathologic typing (p < 0.001). Further, EdU (p < 0.001) and cell biology behavior revealed that PTC cells overexpressed DIO2 had reduced proliferative capacity. Cell cycle proteins were reduced and cells are more likely to be stuck in G2/M phase (p < 0.001).

CONCLUSIONS

This study explored the heterogeneity of PTC LNM using scRNA-seq. By combining with bulk RNA-seq data, diagnostic markers were explored and the model was established. Clinical diagnostic efficacy of S100A2 and DIO2 was validated and the treatment potential of DIO2 was discovered.

Decision Regret Following the Choice of Surgery or Active Surveillance for Small, Low-Risk Papillary Thyroid Cancer: A Prospective Cohort Study

Background: It is important to understand cancer survivors' perceptions about their treatment decisions and quality of life. Methods: We performed a prospective observational cohort study of Canadian patients with small (<2 cm) low-risk papillary thyroid cancer (PTC) who were offered the choice of active surveillance (AS) or surgery (Clinicaltrials.gov NCT03271892). Participants completed a questionnaire one year after their treatment decision. The primary intention-to-treat analysis compared the mean decision regret scale total score between patients who chose AS or surgery. A secondary analysis examined one-year decision regret score according to treatment status. Secondary outcomes included quality of life, mood, fear of disease progression, and body image perception. We adjusted for age, sex, and follow-up duration in linear regression analyses. Results: The overall questionnaire response rate was 95.5% (191/200). The initial treatment choices of respondents were AS 79.1% (151/191) and surgery 20.9% (40/191). The mean age was 53 years (standard deviation [SD] 15 years) and 77% (147/191) were females. In the AS group, 7.3% (11/151) of patients crossed over to definitive treatment (two for disease progression) before the time of questionnaire completion. The mean level of decision regret did not differ significantly between patients who chose AS (mean 22.4, SD 13.9) or surgery (mean 20.9, SD 12.2) in crude (p = 0.730) or adjusted (p = 0.29) analyses. However, the adjusted level of decision regret was significantly higher in patients who initially chose AS and crossed over to surgery (beta coefficient 10.1 [confidence interval; CI 1.3-18.9], p = 0.02), compared with those remaining under AS. In secondary adjusted analyses, respondents who chose surgery reported that symptoms related to their cancer or its treatment interfered with life to a greater extent than those who chose AS (p = 0.02), but there were no significant group differences in the levels of depression, anxiety, fear of disease progression, or overall body image perception. Conclusions: In this study of patients with small, low-risk PTC, the mean level of decision regret pertaining to the initial disease management choice was relatively low after one year and it did not differ significantly for respondents who chose AS or surgery.

Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis

BACKGROUND

The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC.

METHODS

The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657.

RESULTS

The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four.

CONCLUSION

Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Active Surveillance for Low-Risk Papillary Thyroid Carcinoma as an Acceptable Management Option with Additional Benefits: A Comprehensive Systematic Review

BACKGRUOUND

Active surveillance (AS) has been introduced as a management strategy for low-risk papillary thyroid carcinoma (PTC) due to its typically indolent nature. Despite this, the widespread adoption of AS has encountered several challenges. The aim of this systematic review was to evaluate the safety of AS related to disease progression and its benefits compared with immediate surgery (IS).

METHODS

Studies related to AS in patients with low-risk PTC were searched through the Ovid MEDLINE, Embase, Cochrane Library, and KoreaMed databases. Studies on disease progression, surgical complication, quality of life (QoL), and cost-effectiveness were separately analyzed and narratively synthesized.

RESULTS

In the evaluation of disease progression, the proportions of cases with tumor growth ≥3 mm and a volume increase >50% were 2.2%-10.8% and 16.0%-25.5%, respectively. Newly detected lymph node metastasis was identified in 0.0%-1.4% of patients. No significant difference was found between IS and delayed surgery in surgical complications, including vocal cord paralysis and postoperative hypoparathyroidism. AS was associated with better QoL than IS. Studies on the cost-effectiveness of AS reported inconsistent data, but AS was more cost-effective when quality-adjusted life years were considered.

CONCLUSION

AS is an acceptable management option for patients with low-risk PTC based on the low rate of disease progression and the absence of an increased mortality risk. AS has additional benefits, including improved QoL and greater QoL-based cost-effectiveness.

Active Surveillance for Low-Risk Thyroid Cancers: A Review of Current Practice Guidelines

The indolent nature and favorable outcomes associated with papillary thyroid microcarcinoma have prompted numerous prospective studies on active surveillance (AS) and its adoption as an alternative to immediate surgery in managing low-risk thyroid cancer. This article reviews the current status of AS, as outlined in various international practice guidelines. AS is typically recommended for tumors that measure 1 cm or less in diameter and do not exhibit aggressive subtypes on cytology, extrathyroidal extension, lymph node metastasis, or distant metastasis. To determine the most appropriate candidates for AS, factors such as tumor size, location, multiplicity, and ultrasound findings are considered, along with patient characteristics like medical condition, age, and family history. Moreover, shared decision-making, which includes patient-reported outcomes such as quality of life and cost-effectiveness, is essential. During AS, patients undergo regular ultrasound examinations to monitor for signs of disease progression, including tumor growth, extrathyroidal extension, or lymph node metastasis. In conclusion, while AS is a feasible and reliable approach for managing lowrisk thyroid cancer, it requires careful patient selection, effective communication for shared decision-making, standardized follow-up protocols, and a clear definition of disease progression.

Choice of management strategy for papillary thyroid microcarcinoma: active surveillance or immediate surgery?

Overdiagnosis of papillary thyroid microcarcinoma (PTMC) is prevalent, and effective management of PTMC is an important matter. The high incidence and low mortality rate of papillary thyroid carcinoma (PTC) justify the preference for active surveillance (AS) over immediate surgery (IS), particularly in cases of low-risk PTMC. Japan began AS in the 1990s as an alternative surgical option for PTMC and it has shown promising results. The safety and efficacy of AS management in PTMC have been verified. However, AS may not be suitable for all PTMC cases. How to find the balance between the decision-making of AS and IS requires careful consideration. Therefore, we collected and analyzed the relevant evidence on the clinical strategies for PTC and discussed AS and IS from the perspectives of health, economic, and psychological aspects, to help clinicians in choosing a more appropriate clinical strategy for PTC.

A dynamic study of the postoperative management of thyroid cancer from 2003 to 2022: a bibliometric analysis

Background

Over the past 20 years, the global incidence of thyroid cancer has continued to increase. The volume of literature on the postoperative management of thyroid cancer comprises 1,040 articles, from 64 countries, with 1,400 journals publishing the relevant literature, and several guidelines on the treatment of thyroid cancer. This study used bibliometric methods to identify research hotspots and explore future directions in this field.

Methods

We comprehensively searched the Science Citation Index Expanded (SCI-E) database of the Web of Science Core Collection (WOSCC) for articles published from 2003 to 2022 on the postoperative management of thyroid cancer. Using CiteSpace 6.1.R6 and Microsoft Office Excel 2010, we evaluated and visualized the search results. Using R Studio, we generated a network of spatial geographic distribution maps and cooperative network.

Results

A total of 1,040 publications were included in the study. The results revealed an overall upward trend in the number of publications and citations over the past 20 years. The United States of America (USA) had the largest number of publications and the highest centrality (n=282, centrality =0.28). Johns Hopkins University had highest centrality (centrality =0.15) and was the academic center of the field. Thyroid was the journal with the highest number of citations (n=826), and the American Journal of Surgical Pathology was the journal with the highest centrality (centrality =0.08). The top 10 citations in the literature were mainly guidelines and consensus statements on the management of thyroid cancer. A keyword-based clustering analysis revealed the prominence of clusters of keywords, such as follow-up, recurrent laryngeal nerve, and medullary thyroid carcinoma (MTC). A keyword burst detection analysis showed that the term papillary had the highest burst intensity (strength =8.02), while management guidelines, association guidelines, active surveillance (AS), microcarcinoma, and differentiated thyroid cancer were the current burst words.

Conclusions

Over the past two decades, the number of relevant publications in the postoperative management of thyroid cancer field has continued to grow. Among the many research directions, follow-up, recurrent laryngeal nerve, and MTC are research hotspots. Future research is likely to revolve around guidelines and consensus statements on the management of thyroid cancer, AS, and microcarcinoma in differentiated thyroid cancer.

Radiofrequency Ablation of Unifocal Papillary Thyroid Microcarcinoma With BRAF V600E Mutation

CONTEXT

To date there is no study on the feasibility of radiofrequency ablation (RFA) for papillary thyroid microcarcinomas (PTMCs) with BRAF V600E mutation.

OBJECTIVE

This study was designed to evaluate the efficiency, safety, and prognosis of ultrasound (US)-guided percutaneous RFA for unifocal PTMCs with BRAF V600E mutation.

MATERIALS AND METHODS

Sixty patients with 60 unifocal BRAF V600E mutation-positive PTMCs who received US-guided RFA between January 2020 and December 2021 were retrospectively analyzed. The mean maximum PTMC tumor diameter was 5.8 ± 1.7 mm (range, 2.5-10.0 mm). All PTMCs were pathologically confirmed by fine needle aspiration or core needle biopsy, and BRAF V600E mutation was confirmed to be positive by real-time fluorescent quantitative polymerase chain reaction. Contrast-enhanced ultrasound (CEUS) was performed immediately after RFA to evaluate whether PTMCs were extendedly ablated. Ultrasound was performed 1, 3, 6, and 12 months after RFA and every 6 months thereafter to evaluate the changes in the ablation zone, local recurrence, and cervical lymph node metastasis (LNM). The complications were recorded and evaluated.

RESULTS

Extended ablation was achieved in all enrolled patients. The ablation zone sizes increased immediately after RFA compared with those of tumors before treatment. One month later, the ablation zone sizes were smaller than immediately after RFA. At the last follow-up assessment, 42 nodules (70.0%) completely disappeared and the ablation zones of 18 nodules (30.0%) showed fissure-like changes. No local recurrence or cervical LNM was detected. Voice change (1.7%) was the only major complication.

CONCLUSION

RFA is effective and safe in treating unifocal PTMCs with BRAF V600E mutation, especially when surgery is not feasible or refused by patients who are unwilling to continue active surveillance.

Benefits of basil tea for patients with differentiated thyroid cancer during radioiodine therapy: A randomized controlled trial

Background

Acute sialadenitis is one of the major physical complications of radioactive iodine therapy (RAIT) for differentiated thyroid cancer (DTC). It is considered necessary to pay attention to the psychological impact on the patient as well as the physical influence during RAIT.

Objective

To find evidence of the benefits of Basil tea on the psychological and physical side effects of RAIT.

Methods

Forty-four DTC patients after total thyroidectomy were randomly divided into Group A (Basil tea group, n = 22) and Group B (Control group, n = 22). Subjects in Group A drank 180 mL of Basil tea prepared from 2.0 g of Holy basil (Ocimum tenuiflorum Linn.) leaves after each meal for four days, starting on the day RAIT was performed. Those in Group B drank the same amount of distilled water after each meal for the same period as those in Group A. The State-Trait Anxiety Inventory (STAI) was used to assess anxiety, while the saliva component test, and salivary gland scintigraphy were used to assess the oral cavity.

Results

The rate of change of the STAI score (both State Anxiety and Trait Anxiety) was significantly lower in Group A than in Group B (P < 0.05). The rates of change of cariogenic bacteria, ammonia, protein, and occult blood were significantly lower in Group A than in Group B (P < 0.05). The rate of change of the washout ratio for salivary gland scintigraphy was significantly lower in Group B than in Group A (P < 0.05).

Conclusions

Basil tea consumption not only protected against oral mucosal conditions and salivary gland disorders but also significantly relieved the patient's RAIT-related anxiety. Therefore, it was suggested that this tea could be useful for the maintenance of patients' QOL during RAIT.

Active surveillance versus immediate surgery: A comparison of clinical and quality of life outcomes among patients with highly suspicious thyroid nodules 1 cm or smaller in China

INTRODUCTION

Active surveillance (AS) is considered an alternative to immediate surgery (IS) for low-risk papillary thyroid microcarcinoma (PTMC) patients. However, it is difficult to decide between AS and IS due to limited evidence regarding risks and benefits for patients in China.

METHODS

This study prospectively enrolled 485 patients with highly suspicious thyroid nodules

RESULTS

The oncological outcomes of the IS and AS groups were similarly excellent. The IS group had significantly higher rates of temporary vocal cord paralysis (VCP) and temporary hypoparathyroidism than the AS group (2.7% vs. 0.2%, p = 0.002; 13.6% vs.1.9%, p < 0.001, respectively). The IS group had significantly more patients on hormone replacement therapy (98.4% vs. 10.9%, p < 0.001) and a significantly higher incidence of neck scarring (94.3% vs. 9.1%, p < 0.001) compared to the AS group. In the early stages, the quality of life questionnaire showed significant differences with respect to three items: voice, throat/mouth, and surgical scarring, with more complaints in the IS group. However, one year or more after surgery, the main complaint was surgical scarring.

CONCLUSION

In China, AS can achieve similar short-term therapeutic effects as IS. As this approach can reduce the occurrence of unfavorable events, achieve better quality of life, it is a feasible option for patients with highly suspicious thyroid nodules.

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Key Words

• Active surveillance
• Adverse events
• Highly suspicious thyroid nodules
• Immediate surgery
• Quality of life

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MESH Headings

• Humans
• Thyroid Nodule/surgery
• Quality of Life
• Watchful Waiting
• Cicatrix/pathology
• Cicatrix/surgery
• Thyroidectomy/methods
• Thyroid Neoplasms/pathology
• China/epidemiology

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Affiliation(s)

Chunhao Liu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Hao Zhao Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Yu Xia Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Yue Cao Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Liyang Zhang Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Ya Zhao Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Luying Gao Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Ruifeng Liu Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Yuewu Liu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Hongfeng Liu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Zhilan Meng Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Shuzhou Liu Department of Otolaryngology Head and Neck Surgery, Hainan General Hospital, Hainan, 570311, China.
Ying Lu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
Xiaoyi Li Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.

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Cost-effectiveness of active surveillance versus early surgery for thyroid micropapillary carcinoma based on diagnostic and treatment norms in China

Objectives

In this study, we compared the cost-effectiveness comparison of the active surveillance (AS) and early surgery (ES) approaches for papillary thyroid microcarcinoma (PTMC) from the perspective of the Chinese healthcare system.

Methods

We performed a cost-effectiveness analysis using a Markov model of PTMC we developed to evaluate the incremental cost-effectiveness ratio of AS and ES. Our reference case was of a 40-year-old woman diagnosed with unifocal (<10 mm) PTMC. Relevant data were extracted after an extensive literature review, and the cost incurred in each state was determined using China Medicare data on payments for ES and AS. The willingness-to-pay threshold was set at ¥242,928/quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to account for any uncertainty in the model's variables. Additional subgroup analyses were performed to determine whether AS was cost-effective when different initial monitoring ages were used.

Results

ES exhibited an effectiveness of 5.2 QALYs, whereas AS showed an effectiveness of 25.8 QALYs. Furthermore, the incremental cost-effectiveness ratio for ES versus AS was ¥1,009/QALY. The findings of all sensitivity analyses were robust. Compared with ES, AS was found to be the cost-effective strategy at initial monitoring ages of 20 and 60 years, with an incremental cost-effectiveness ratio of ¥3,431/QALY and -¥1,316/QALY at 20 and 60 years, respectively. AS was a more cost-effective strategy in patients with PTMC aged more than 60.

Conclusions

With respect to the norms of the Chinese healthcare system, AS was more cost-effective for PTMC over lifetime surveillance than ES. Furthermore, it was cost-effective even when the initial monitoring ages were different. In addition, if AS is incorporated into the management plan for PTMC in China at the earliest possible stage, a predicted savings of ¥10 × 108/year could be enabled for every 50,000 cases of PTMC, which indicates a good economic return for future management programs. The identification of such nuances can help physicians and patients determine the best and most individualized long-term management strategy for low-risk PTMC.

Patient-Reported Outcomes in Patients with Low-Risk Papillary Thyroid Carcinoma: Cross-Sectional Study to Compare Active Surveillance and Immediate Surgery

BACKGROUND

This cross-sectional study compared patient-reported outcomes of low-risk papillary thyroid carcinoma (PTC, T1N0M0) between patients who underwent active surveillance (AS) and those who received immediate surgery, METHODS: Using the State-Trait Anxiety Inventory, Short-Form 36 version 2, and a visual analog scale for neck symptoms, 249 patients under AS and 32 patients underwent immediate surgery were compared. To match the difference in time from the onset of treatment to the survey, we conducted propensity score matching. We also investigated factors affecting anxiety in patients under AS in multiple linear regression analysis.

RESULTS

In the entire group, patients under AS had significantly longer time from the onset to the survey than patients underwent immediate surgery (7.9 vs. 4.0 years). After matching, AS group showed significantly better trait anxiety and mental component summary (MCS) compared to surgery group, while surgery group showed better role-social component summary. AS group also had significantly better MCS than the Japanese norm-based score. Surgery group displayed worse neck symptoms than AS group. Among AS group, trait anxiety and time from the onset were significant predictors of state anxiety. Compared with the group with < 5 years since starting AS, the group with ≥ 5 years of follow-up showed a significantly better state anxiety only in patients with better trait anxiety.

CONCLUSIONS

Low-risk PTC patients under AS showed better trait anxiety and mental health than surgery group. After a certain period, the anxiety of patients under AS seems to be improved, especially in patients with better trait anxiety.

Microwave Ablation for Papillary Thyroid Microcarcinoma with and without US-detected Capsule Invasion: A Multicenter Prospective Cohort Study

Background Microwave ablation (MWA) has achieved favorable results in the treatment of papillary thyroid microcarcinoma (PTMC) confined in glandular parenchyma. However, studies on the outcome of MWA for PTMC with US-detected capsular invasion remain unclarified in the literature. Purpose To compare the feasibility, effectiveness, and safety of MWA in the treatment of PTMC with and without US-detected capsular invasion. Materials and Methods Participants from 12 hospitals with a PTMC maximal diameter of 1 cm or less without US- or CT-detected lymph node metastasis (LNM) who planned to undergo MWA were enrolled in this prospective study between December 2019 and April 2021. All tumors were evaluated with preoperative US and were divided into those with and those without capsular invasion. The participants were observed until July 1, 2022. The primary end points, including technical success and disease progression, and the secondary end points, including treatment parameters, complications, and tumor shrinkage during follow-up, were compared between the two groups, and multivariable regression was performed. Results After exclusion, 461 participants (mean age, 43 years ± 11 [SD]; 337 women) were included: 83 with and 378 without capsular invasion. After one participant with capsular invasion aborted MWA because of technical failure, 82 participants with and 378 participants without capsular invasion (mean tumor volume, 0.1 mL ± 0.1 vs 0.1 mL ± 0.1; P = .07) were analyzed with a mean follow-up period of 20 months ± 4 (range, 12-25 months) and 21 months ± 4 (range, 11-26 months), respectively. In those with and those without capsular invasion, comparable technical success rates were achieved (99% [82 of 83] vs 100% [378 of 378], P = .18), with one and 11 complications, respectively (1% [one of 82] vs 3% [11 of 378], P = .38). There was no evidence of differences in disease progression (2% [one of 82] vs 1% [four of 378]; P = .82) or tumor shrinkage (mean, 97% ± 8 [SD] vs 96% ± 13; P = .58). Conclusion Microwave ablation was feasible in the treatment of papillary thyroid microcarcinoma with US-detected capsular invasion and showed comparable short-term efficacy with or without the presence of capsular invasion. © RSNA, 2023 Clinical trial registration no. NCT04197960 Supplemental material is available for this article.

Analysis of Therapeutic Effect and Influencing Factors of Ultrasound-Guided Radiofrequency Ablation in the Treatment of Papillary Thyroid Microcarcinoma

OBJECTIVES

The current study sought to explore the effects of ultrasound (US)-guided radiofrequency ablation (RFA) on papillary thyroid microcarcinoma (PTMC) and influencing factors.

METHODS

PTMC patients were assigned to observation (US-guided RFA) and control (surgical operation) groups. A series of operation-related indexes (operation time, intraoperative bleeding, wound closure time, hospital stay, and expenses), visual analogue scale score, lesion size, and thyroid function-related indexes (thyroid-stimulating hormone [TSH], free triiodothyronine*** [FT3], free thyroxine [FT4]), inflammatory factors, and thyroglobulin antibody (TgAb) were assessed and compared. After a 6-month follow-up period, the complications and recurrence were recorded, in addition to analyses of postoperative recurrence cumulative incidence and evaluation of recurrence risk factors.

RESULTS

Operation-related indexes of the observation group were relatively decreased compared with the control group. In addition, the lesion volume in the observation group was lower compared to that in the control group at the 6th month after operation, whereas the volume reduction rate was higher. There were no significant differences in regard to thyroid function-related indexes in the observation group before/after operation. After operation, serum TSH levels and inflammatory factors, and TgAb levels were all diminished, while the FT3 and FT4 levels were both elevated in the observation group relative to the control group, and postoperative recurrence cumulative incidence was lower in the observation group. TSH and TgAb were established as the independent risk factors for recurrence after RFA in PTMC patients.

CONCLUSIONS

Our findings highlighted that US-guided RFA exhibits better efficacy, safety, and postoperative recovery and lower recurrence risk for PTMC.

Ultrasound-guided thermal ablation for papillary thyroid microcarcinoma: A systematic review

OBJECTIVE

Thyroidectomy is the first-line treatment for papillary thyroid microcarcinoma (PTMC), but often involves aggressive overtreatment. Thermal ablation (TA) has been gradually used for the treatment of recurrent PTMC. However, it is not recommended for the treatment of primary PTMC according to the Korean and Italian guidelines. Therefore, this systematic review aimed to analyse the indications, efficacy, and safety of TA in the treatment of PTMC.

DESIGN

Systematic review.

PATIENTS AND MEASUREMENTS

A search strategy was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A total of 27 articles were included in this study until January 2022.

RESULTS

According to current guidelines and studies, we divided the indications of TA for PTMC into six primary and three secondary indications. Laser ablation (LA) has the advantages of a small needle, accurate output energy and precision ablation, and it is safe to important organs around the lesion. The patients recover quickly after radiofrequency ablation (RFA), with no major complications, recurrence, or lymph node metastasis. The volume reduction rate after RFA was the highest, followed by microwave ablation and LA, and the improvement in patient quality of life after TA was significantly better than after thyroidectomy.

CONCLUSIONS

TA is an effective alternative method for surgery in the treatment of low-risk PTMC and has the advantages of being minimally invasive, economical, having less bleeding and having a high postoperative quality of life.

Psychological adjustment to initial treatment for low-risk thyroid cancer: Preliminary study

BACKGROUND

Low-risk papillary thyroid carcinoma (LR-PTC) can be managed by immediate surgery (IS) or active surveillance (AS). We compare the psychological impact of these treatments on patients with LR-PTC.

METHODS

Psychological data were collected over 1 year, with assessments at the time of treatment decision (T1), at 6 months (T2) and 12 months (T3) follow-up. Assessments included 13 validated psychological tools.

RESULTS

Of 27 enrolled patients, 20 chose AS and 7 chose IS. The average times to T2 and T3 were 5.7 and 11.3 months, respectively. For both groups, Impact of Events Scale scores significantly decreased (p = 0.001) at T2, and depressive/anxiety symptoms remained low.

CONCLUSIONS

This study demonstrates the feasibility of assessing psychological outcomes among patients treated for LR-PTC. Further studies are needed to evaluate the impact of AS versus IS on quality of life and changes that patients experience over longer time periods following their treatment decision.

Active surveillance of low-risk papillary thyroid microcarcinoma

Recently, the incidence of thyroid carcinoma has been increasing rapidly worldwide. This is interpreted as an increase in the incidental detection of small papillary thyroid carcinomas by the widespread use of high-resolution imaging techniques such as ultrasonography. However, the mortality rates of thyroid carcinoma have not changed, suggesting that small papillary thyroid carcinomas may be overdiagnosed and overtreated. Active surveillance management has been introduced from Japan since the 1990s, as one of the measures to prevent overtreatment of low-risk papillary thyroid microcarcinoma. Based on the favorable outcomes, active surveillance has been gradually adopted worldwide as an alternative to immediate surgery. The management should be carried out with strict eligibility criteria and close monitoring for cancer progression, under a multidisciplinary team. In addition, an adequate shared decision-making is mandatory for individual patients. Papillary thyroid microcarcinomas with clinically apparent lymph node metastasis, distant metastasis, or invasion to adjacent organs should have surgery.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules : Follow-up: How and how long?

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians, surgeons, and other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the follow-up of thyroid nodules, low-grade tumors and microcarcinomas.

Radiofrequency Ablation of Indeterminate Thyroid Nodules: The First North American Comparative Analysis

Thyroid nodules can be classified as benign, malignant, or indeterminate, the latter of which make up 10-30% of nodules. Radiofrequency ablation (RFA) has become an attractive and promising therapy for the treatment of benign thyroid nodules. However, few studies have investigated the safety and efficacy of RFA for the management of indeterminate thyroid nodules. In this study, 178 patients with thyroid nodules diagnosed as benign (Bethesda II) or indeterminate (Bethesda III/IV) by preoperative cytopathological analysis were included. Patients in the benign and indeterminate cohorts had similar thyroid nodule volume reduction rates at 65.60% and 64.20%, respectively (p = 0.68). The two groups had similar nodular regrowth rates, at 11.2% for benign nodules and 9.40% for indeterminate nodules (p = 0.72). A total of three cases of transient dysphonia were reported. RFA of indeterminate thyroid nodules was comparable to that of benign thyroid nodules in all parameters of interest, including volume reduction rate. To our best knowledge, our work is the first North American analysis comparing benign and indeterminate thyroid nodules and suggests RFA to be a promising modality for the management of indeterminate thyroid nodules.

Efficacy and Safety of Different Thermal Ablation Modalities for Papillary Thyroid Microcarcinoma: A Network Meta-Analysis

Background

Small thyroid-like carcinoma (PTMC) is one of the most common subtypes of thyroid cancer. The main treatment options include surgery and radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA). Thermal ablation has the advantage of being less invasive and has fewer complications than traditional surgical treatment.

Objective

The objective is to explore the efficacy and safety of PTMC by different thermal ablation modalities through a network meta-analysis.

Methods

From the database establishment to October 2021, a computerized search of the Chinese Knowledge Infrastructure (CKNI), VIP Chinese Science and Technology Journal Full-Text Database (VP-CSJFD), WanFang Data journal article resource (WangFang), PubMed, the Cochrane Library, and Embase were performed to include the different methods of thermal ablation for small thyroid carcinoma. A retrospective study of different methods of thermal ablation of small thyroid carcinoma was included.

Results

A total of 12 retrospective studies involving 1,926 patients with PTMC were included, all of which were of high quality. This study mainly involved RFA, MWA, LA, and ethanol combined with radiofrequency ablation (EA + RFA). Network meta-analysis showed no significant difference between interventions (p > 0.05) in terms of recurrence rate.

Conclusions

Surgical resection may be the measure with the lowest recurrence rate after treatment of PTMC, LA may be the measure with the lowest incidence of complications after treatment, and RFA may be the measure with the least length of hospital stay, operation time, and postoperative lymph node metastasis rate. However, due to the limitations of network meta-analysis, this result still needs to be treated with caution, and more high-quality, large-sample clinical studies are recommended for further verification.

A novel tool for predicting the risk of central lymph node metastasis in patients with papillary thyroid microcarcinoma: a retrospective cohort study

Introduction

Central lymph node status in papillary thyroid microcarcinoma (PTMC) plays an important role in treatment decision-making clinically, however, it is not easy to predict central lymph node metastasis (CLNM). The present work focused on finding the more rational alternative for evaluating central lymph node status while identifying influencing factors to construct a model to predict CLNM incidence.

Methods

In this study, we retrospectively analyzed the typical sonographic and clinicopathologic features of 546 PTMC patients who underwent surgery, among which, the data of 382 patients were recruited in the training cohort and that of 164 patients in the validation cohort. Based on the outcome of the training cohort, significant influencing factors were further identified through univariate analysis and were considered as independent variables in multivariable logistic regression analysis and incorporated in and presented with a nomogram.

Results

In total, six independent predictors, including the age, sex, tumor size, multifocality, capsular invasion, Hashimotos thyroiditis were entered into the nomogram. Both internal validation and external validation revealed the favorable discrimination of our as-constructed nomogram. Calibration curves exhibited high consistency. As suggested by decision-curve analyses, the as-constructed nomogram might be applied in clinic. Besides, the model also distinguished patients according to risk stratification.

Conclusions

The novel nomogram containing remarkable influencing factors for CLNM cases was established in the present work. The nomogram can assist clinicians in clinical decision-making.

Active Surveillance Versus Immediate Surgery for Low-Risk Papillary Thyroid Microcarcinoma Patients in South Korea: A Cost-Minimization Analysis from the MAeSTro Study

Background: Active surveillance (AS) has been established as an alternative to immediate surgery for low-risk papillary thyroid microcarcinoma (PTMC). Nonetheless, it remains difficult to decide between AS and immediate surgery, since limited objective evidence exists regarding risks and benefits. The aim of study is to compare the cumulative costs of AS and immediate surgery. Methods: To estimate cumulative costs, a hypothetical model is simulated based on the Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Micro-Carcinoma (MAeSTro) study, a multicenter prospective cohort study of AS for PTMC. Direct and indirect costs are estimated from diagnosis to the treatment decision and follow-up for 10 years and a longer period. In the case of the scenarios, AS, AS to surgery due to changing their mind, and lobectomy (analyzed regardless of levothyroxine [LT4] treatment, as well as subdivided into lobectomy/LT4[-] and lobectomy/LT4[+]) are considered. A sensitivity analysis is performed using different discount rates to address uncertainties in future time costs. To compare the cumulative costs, we referred to previous research conducted in Hong Kong, the United States, and Japan. Results: The initial cost of AS is estimated to be 5.6 times lower than that of lobectomy (regardless of LT4 use), while the 10-year cumulative costs of AS ($2545) and lobectomy regardless of LT4 ($3045) are similar under a discount rate of 3%. However, in the long-term follow-up period, immediate surgery is going to be estimated more economical than AS. The costs of the two management approaches are similar in Hong Kong, but substantially different in the United States and Japan, implying that it could be affected by each country's national health insurance coverage and the thyroid ultrasound interval during follow-up. Conclusion: Considering both direct and indirect costs, the cumulative costs of AS and immediate surgery in low-risk PTMC patients are similar during 10 years, and surgery could be more economical for patients with a life expectancy in long-term follow-up. However, careful interpretation is needed for long-term follow-up and the country's health care system and environment. Nevertheless, considering the representative protocols and objective costs in South Korea, it is expected to be a key to suggest the appropriate treatment for PTMC patients.

Anxiety and quality of life among papillary thyroid cancer patients awaiting final pathology results after surgery

PURPOSE

There is a lack of research on short-term mental health and health-related quality of life (HRQoL) in thyroid cancer patients. This study aimed to assess the short-term anxiety level and HRQoL of patients during the early postoperative period while awaiting pathology results, and to explore the important factors associated with state anxiety.

METHODS

In this single-center cross-sectional study, 349 patients with papillary thyroid cancer were included. Anxiety and HRQoL were measured using the State-Trait Anxiety Inventory (STAI) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30), respectively.

RESULTS

In general, papillary thyroid cancer patients reported good quality of life with a mean global quality of life score of 75.69 ± 20.66 (on a scale of 0-100, where 100 means the best). There was no significant difference in HRQoL between the two groups, except regarding social functioning (p = 0.027). The anxiety levels of the two groups were similar; however, the state anxiety score (42.17 ± 12.52) was significantly higher than the trait anxiety score (40.69 ± 11.18) among patients in the non-FNA group (p = 0.023). Dyspnea, insomnia, QL, and trait anxiety were independent factors that affected state anxiety.

CONCLUSION

Patients with papillary thyroid cancer had good postoperative HRQoL and a significantly higher than usual level of state anxiety while awaiting pathology results. Symptoms of dyspnea and insomnia, global quality of life, and trait anxiety are important factors associated with state anxiety. Preoperative FNA results may moderate the change in anxiety level. These findings may help clinicians provide psychological support.

Papillary Thyroid Microcarcinoma: Active Surveillance Against Surgery. Considerations of an Italian Working Group From a Systematic Review

Introduction

Active surveillance is considered a viable option for papillary thyroid microcarcinoma. Since the last decade of the 20th century, this method has spread from Japan to other countries, but has not yet been fully accepted and validated by the major Western Scientific Societies. In 2016, a systematic review on the results of active surveillance was published, based on two articles that showed encouraging results. Other reviews published subsequently, were mainly based on articles from the Far East. The aim of this review is to assess the most recent results published from 2017 to 2020 on this subject.

Materials and Methods

A systematic literature search was performed on MEDLINE via PUBMED, Web of Science, and Scopus according to PRISMA criteria. The MESH terms “papillary thyroid microcarcinoma” and “active surveillance” were adopted. Tumor progression, secondary localizations, and quality of life were the main benchmarks.

Results

Nine studies met the inclusion criteria. The increase in volume ranged from 2.7% and 23.2%; the occurrence of lymph node metastases from 1.3% to 29%; QoL was improved in both articles that addressed this topic. The level of evidence is considered low due to the retrospective and uncontrolled nature of most of the studies included in the review.

Conclusion

The evidence from the literature currently available on AS falls into two strands: a robust data set from the Japanese experience, and an initial experience from Western countries, whose data are still limited but which show a lack of substantial alerts against this practice. Further data is useful to validate the spread of Active Surveillance.

Fine-needle aspiration cytology of an intrathyroidal nodule diagnosed as squamous cell carcinoma: A case report

BACKGROUND

Both squamous cell carcinoma (SCC) and papillary thyroid carcinoma (PTC) are common malignant tumors in the neck. However, seldom has SCC of the thyroid been diagnosed. Further, cytological features of SCC and PTC have rarely been reported. The significance of fine-needle aspiration cytology (FNAC) in the diagnosis of neck masses has been established. Herein, we present an exceedingly rare case of an intrathyroidal SCC diagnosed using FNAC, along with its cytological features.

CASE SUMMARY

A 66-year-old man presented with a left-sided neck mass. Ultrasound examination showed an ill-defined nodule. The appearance was hypoechoic with a few hyperechoic spots. FNAC of the left thyroid nodule was performed. A cellular smear was obtained, and it showed a large number of neoplastic cells with rich cytoplasm and poor cell adhesion. Tumor cell nuclei showed coarse nuclear chromatin and a few enlarged prominent nucleoli. An increased nuclear/cytoplasm ratio was observed. Thus, malignancy was diagnosed without a confirmed tumor type. Percutaneous tumor biopsy was performed to make a definite diagnosis. The tumor cells showed typical squamous cell characteristics.

CONCLUSION

Head and neck SCC and PTC have different cytologies. Measures are needed to ensure accurate diagnosis using FNAC.

One year follow-up of US-Guided radiofrequency ablation for low-risk papillary thyroid microcarcinoma: The first experience in Taiwan

BACKGROUND

The incidence of papillary thyroid microcarcinoma (PTMC) has increased rapidly in recent decades, with a favorable overall prognosis. We aimed to evaluate the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) for treating low-risk PTMC in Taiwan.

METHODS

This prospective study included patients with PTMC who were ineligible or refused surgery and underwent US-guided RFA between October 2018 and June 2020. US and computed tomography (CT) were performed before RFA to assess tumor lesions and exclude cervical lymph node metastasis. Sequential US follow-up following RFA was performed after 1, 3, 6, and 12 months, and yearly thereafter. Volume reduction ratio (VRR) and complete disappearance rate of tumor at one year were evaluated.

RESULTS

13 PTMCs in 12 patients were enrolled with a mean follow-up of 16.2 ± 8.1 months (range, 1-24 months). The median largest tumor diameter and tumor volume before RFA were 0.76 cm and 0.15 ml (range, 0.02-0.37 ml). The median (interquartile range, IQR) volume and VRR at 12 months post-RFA were 0 (0, 0.03) ml (p = 0.033) and 100% (84.26%, 100%) (p = 0.008). Eight tumors (61.54%) were completely disappeared at 12 months post-RFA and no tumor recurrence, lymph nodes, or distant metastasis were noted. All tumors were successfully treated without complications.

CONCLUSION

Minimally invasive US-guided RFA is an effective and safe alternative for low-risk PTMC, resulting a satisfied VRR.

Position paper from the Japan Thyroid Association task force on the management of low-risk papillary thyroid microcarcinoma (T1aN0M0) in adults

The incidence of thyroid carcinoma has been increasing worldwide. This is interpreted as an increase in the incidental detection of papillary thyroid microcarcinomas (PTMCs). However, mortality has not changed, suggesting overdiagnosis and overtreatment. Prospective clinical trials of active surveillance for low-risk PTMC (T1aN0M0) have been conducted in two Japanese institutions since the 1990s. Based on the favorable outcomes of these trials, active surveillance has been gradually adopted worldwide. A task force on the management of PTMC in adults organized by the Japan Thyroid Association therefore conducted a systematic review and has produced the present position paper based on the scientific evidence concerning active surveillance. This paper indicates evidence for the increased incidence of PTMC, favorable surgical outcomes for low-risk PTMC, recommended criteria for diagnosis using fine needle aspiration cytology, and evaluation of lymph node metastasis (LNM), extrathyroidal extension (ETE) and distant metastasis. Active surveillance has also been reported with a low incidence of disease progression and no subsequent recurrence or adverse events on survival if conversion surgery was performed at a slightly advanced stage. Active surveillance is a safe and valid strategy for PTMC, because it might preserve physical quality of life and reduce 10-year medical costs. However, some points should be noted when performing active surveillance. Immediate surgery is needed for PTMC showing high-risk features, such as clinical LNM, ETE or distant metastasis. Active surveillance should be performed under an appropriate medical team and should be continued for life.

Effect of Initial Treatment Choice on 2-year Quality of Life in Patients with Low-risk Papillary Thyroid Microcarcinoma

CONTEXT

The long-term quality of life (QoL) in patients with low-risk papillary thyroid microcarcinoma (PTMC) underwent active surveillance (AS) and immediate surgery is unclear.

OBJECTIVE

The aim of this study was to investigate the effect of initial treatment choice on 2-year QoL in patients with low-risk PTMC.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 2652 QoL surveys from 1055 subjects enrolled in ongoing multicenter prospective cohort study on active surveillance of PTMC, in which the median follow-up duration was 24.4 months.

MAJOR OUTCOME MEASURE

We evaluated QoL of patients with low-risk PTMC according to their treatment modality using generalized estimating equation.

RESULTS

Six hundred and seventy-four subjects (male = 161; mean age = 48.8 ± 11.9 years) with low-risk PTMC chose AS while 381 subjects (male = 75; mean age = 45.7 ± 10.4 years) chose immediate surgery, including lobectomy/isthmusectomy (L/I) and total thyroidectomy (TT). Among the 817 subjects who completed baseline QoL surveys, 2-year QoL was good in order of AS (n = 500), L/I (n = 238), and TT (n = 79) groups after adjustment for age, sex, baseline tumor size, and baseline QoL scores. Among the 101 subjects who changed their treatment from AS to surgery during the follow-up period, 35 subjects who changed treatment due to disease progression had better QoL than 66 subjects who had no disease progression.

CONCLUSIONS

This study identified QoL as a major issue in choosing an initial treatment of low-risk PTMC and highlighted the possibility of using AS as the primary treatment.

Thyroid cancer patients satisfaction at the management outcome: an analysis of the results of a nationwide survey in 485 subjects

BACKGROUND

We aimed to measure satisfaction of patients with thyroid cancer concerning different aspects of healthcare.

METHODS

We developed a web-based survey. Questions focused on patient satisfaction with specialists, the health centers and departments, and the information received about their disease. Level of satisfaction was quantified using a scale of 1 to 5. Values ≥4 were considered a high degree of satisfaction.

RESULTS

Four hundred eighty-five patients (aged 43.4 ± 9.9 yrs., 88% females) completed the survey. A high overall satisfaction with the specialists was reported by 52.5% of patients. The most highly valued specialists were surgeons, oncologists, and endocrinologists. 56.5% of respondents reported a high overall satisfaction with the health centers and departments. Lastly, the proportion of patients who were highly satisfied with the information received was only 42.5%. The presence of complications was indirectly related with satisfaction with specialists and information. Satisfaction with health centers and services was directly related with the level of education and inversely related to the time of evolution of the disease.

CONCLUSION

Our results show a high degree of overall satisfaction of thyroid cancer patients. However, satisfaction can be improved in some areas, such with regards to the information provided to patients.

Indications and Strategy for Active Surveillance of Adult Low-Risk Papillary Thyroid Microcarcinoma: Consensus Statements from the Japan Association of Endocrine Surgery Task Force on Management for Papillary Thyroid Microcarcinoma

Background: The question of how to manage patients with low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0) has recently become an important clinical issue. Two Japanese centers have conducted prospective clinical trials of active surveillance (AS) for low-risk PTMC since the 1990s, reporting favorable outcomes. This policy has thus seen gradual adoption worldwide to avoid overtreatment. Not all PTMCs are suitable for AS, however, and many physicians still hesitate to apply the management policy in daily clinical practice. A task force on management for PTMC created by the Japan Association of Endocrine Surgery collected and analyzed bibliographic evidence and has produced the present consensus statements regarding indications and concrete strategies for AS to facilitate the management of adult patients diagnosed with low-risk PTMC. Summary: These statements provide indications for AS in adult patients with T1aN0M0 low-risk PTMC. PTMCs with clinical lymph node metastasis, distant metastasis, recurrent laryngeal nerve (RLN) paralysis due to carcinoma invasion, or protrusion into the tracheal lumen warrant immediate surgery. Tumors suspected of aggressive subtypes on cytology are recommended for immediate surgery. Immediate surgery is also recommended for tumors adherent to the trachea or located along the course of the RLN. Practical strategies include diagnosis, decision-making, follow-up, and monitoring related to the implementation of AS. The rate of low-risk PTMC progression is lower in older patients. However, we recommend continuing AS as long as circumstances permit. Future tasks in optimizing management for low-risk PTMC are also described, including molecular markers and patient-reported outcomes. Conclusions: An appropriate multidisciplinary team is necessary to accurately evaluate primary tumors and lymph nodes at the beginning of and during AS, and to adequately reach a shared-decision with individual patients. If appropriately applied, AS of low-risk PTMC is a safe management strategy offering favorable outcomes and preserves quality of life at low cost.

Quality of Life in Patients with Low-Risk Papillary Thyroid Microcarcinoma: Active Surveillance Versus Immediate Surgery

OBJECTIVE

This study aimed to compare the quality of life (QoL) and psychological issues of patients with papillary thyroid microcarcinoma (PMC) who were under active surveillance (AS) and those who underwent immediate surgery (OP).

METHODS

This was a cross-sectional study conducted on 347 patients with low-risk PMC who were under AS (n = 298) or who underwent OP (n = 49). They were asked to complete two questionnaires (thyroid cancer-specific health-related QoL [THYCA-QoL] and the Hospital Anxiety and Depression Scale [HADS]). The results between the AS and OP groups were compared.

RESULTS

The mean ages of patients in the AS and OP groups were 58.6±12.5 and 58.4±13.1 years (P =.94), respectively, and the male ratios were 34/298 (11%) and 2/49 (4.1%) (P =.14), respectively. The median follow-up periods from diagnosis in the AS and OP groups were 56.5 months (interquartile range [IQR], 32 to 88 months) and 84 months (IQR, 64 to 130 months) (P<.001), respectively. In the THYCA-QoL questionnaire, the OP group had more complaints about "voice" (P<.001), "psychological" (P =.025), "problems with scar" (P<.001), and "gained weight" (P =.047) than the AS group. Other scales of the THYCA-QoL were comparable in the two groups. In the HADS questionnaire, the AS group had significantly better anxiety (P =.020), depression (P =.027), and total scores (P =.014) than the OP group.

CONCLUSION

PMC patients in the OP group had more complaints and were more anxious and depressed than the AS group. These findings suggest that AS is a reasonable alternative to surgery for patients with low-risk PMC from the point of view of QoL and psychology.

ABBREVIATIONS

AS = active surveillance; CI = confidence interval; HADS = Hospital Anxiety and Depression Scale; LT4 = levothyroxine; OP = immediate surgery; PMC = papillary microcarcinoma; PTC = papillary thyroid carcinoma; QoL = quality of life; STAI = State-Trait Anxiety Inventory; THYCA-QoL = thyroid cancer-specific health-related quality of life; TSH = thyrotropin.

NATIONAL SURVEY OF ENDOCRINOLOGISTS AND SURGEONS REGARDING ACTIVE SURVEILLANCE FOR LOW-RISK PAPILLARY THYROID CANCER

OBJECTIVE

Active surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known.

METHODS

A national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change.

RESULTS

Among 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance.

CONCLUSION

Although there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.

Thermal Ablation for Papillary Thyroid Microcarcinoma: How Far We Have Come?

Purpose

Thermal ablation (TA), as one of the most currently remarkable technologies, has achieved great success in many malignant diseases including but not limited to hepatic and renal carcinoma. In recent years, this technology was gradually introduced to the treatment of papillary thyroid microcarcinoma (PTMC) and even papillary thyroid carcinoma (PTC). Thereby, we summarized the current progress of TA development in the treatment of PTMC.

Methods

The latest relevant literature from the PubMed database with keywords "thermal ablation", "papillary thyroid microcarcinoma", "microwave ablation", "radio-frequency ablation", and "laser ablation", among others, were comprehensively reviewed in this article. The follow-up outcomes of patients in these articles were analyzed.

Results

The efficacy and safety of TA including microwave ablation (MWA), laser ablation (LA), and radiofrequency ablation (RFA) in the treatment of PTC and PTC have been intensively studied. Based on existing clinical trials, the relatively long-term follow-up (range, from 6 to 64.2 months) results in MWA, LA, and RFA were satisfactory that tumor volume reduction rate (VRR) reached and even surpass 99%. Compared with routine surgery methods (total thyroidectomy and lobectomy), the incidence rate of complications was relatively lower and the recurrence rate of TA techniques was not statistically significant, whereas the operative time, blood loss, length of hospital stay, and hospital cost were significantly decreased.

Conclusion

TA presents the same satisfactory therapeutic effects but minimal postoperative trauma can significantly improve the patients' quality of life. However, future larger sample, multicenter, and prospective randomized controlled trials are urgently needed to validate the feasibility of TA in dealing with PTMC.

Active surveillance in low risk papillary thyroid carcinoma

In recent decades, while the incidence of thyroid cancer has increased exponentially around the world, mortality has remained stable. The vast majority of this increase is attributable to the identification of intrathyroidal papillary microcarcinomas, which exhibit slow growth rates with indolent courses. A diagnosis of thyroid cancer based upon the presence of these small tumors could be considered as an overdiagnosis, as the majority of these tumors would not likely result in death if left untreated. Although surgical resection was the classical standard therapy for papillary microcarcinomas, active surveillance (AS) has emerged over the last three decades as an alternative approach that is aimed to recognize a minority group of patients who will clinically progress and would likely benefit from rescue surgery. Despite the encouraging results of AS, its implementation in clinical practice is strongly influenced by psychosocial factors. The aim of this review is to describe the epidemiology, clinical evolution, prognostic factors, and mortality of papillary thyroid microcarcinomas. We also summarize the AS strategy according to published evidence, characterize the criteria for selecting patients for AS according to risk factors and environmental characteristics, as well as analyze the current limitations for AS implementation.