Long-Term Outcome of Lobectomy for Thyroid Cancer

Controversies in the management of intermediate-risk differentiated thyroid cancer

This comprehensive review examines the current controversies regarding diagnosis and management of intermediate risk differentiated thyroid cancer (DTC). The evolution of risk stratification systems is discussed, highlighting limitations such as heterogeneity in patient cohorts, variability in outcome definitions, and the need for more precise risk estimation tools incorporating genetic profiles and individual risk modifiers. The role of radioactive iodine (RAI) therapy in intermediate-risk DTC is examined, considering evolving evidence, conflicting study results, and the necessity for personalized treatment decisions based on risk modifiers, potential morbidity, and patient preferences. Furthermore, the shift from total thyroidectomy to lobectomy in certain intermediate-risk cases is explored, emphasizing the need for tailored surgical approaches and the impact on long-term outcomes, recurrence rates, and quality of life. This review underscores the importance of ongoing research, prospective trials, and interdisciplinary collaboration to address these complexities and advance personalized management strategies for patients with intermediate-risk DTC.

Summary and update on the management of differentiated thyroid cancer in 2023

The 6-fold increase in the incidence of differentiated thyroid cancer over the past 30 years in industrialized countries can be mainly attributed to improved detection. At the same time, in addition to the excellent prognosis for low-risk cancers, improved survival in metastatic forms has been also reported, likely due to the progress made recently in the treatment of aggressive forms, for which there is now an extensive therapeutic arsenal. Today, clinical management of differentiated thyroid cancer represents a paradigm of precision oncology, with personalized, risk-adapted therapeutic strategies. This has led to therapeutic de-escalation in those forms with a good prognosis, while targeted treatments play an increasingly important role in the management of radioiodine-refractory or advanced cancers. While endocrinologists will not always have the opportunity to prescribe these treatments, they will be called on to support and monitor patients during treatment. The aim of this article is to provide an overview of treatment options for differentiated thyroid cancer in 2023.

Improvement in neck ultrasound report quality following the implementation of European Thyroid Association guidelines for postoperative cervical ultrasound for thyroid cancer follow-up, a prospective population study

Objective

The aim of this study was to prospectively evaluate the quality of postoperative neck ultrasound (POU) for thyroid cancer patients after implementing European Thyroid Association (ETA) guideline-based POU assessment.

Methods

Our analysis involved 672 differentiated thyroid cancer patients. POU report quality was compared between the implementation radiology group (IRG), which implemented ETA guideline-based assessment in 2018, and all non-implementation radiology groups (NIRG). Differences in POU quality were evaluated before and after the implementation of guideline-based assessment. Additionally, we evaluated the ability of serum thyroglobulin (Tg) level <0.2 ng/mL or between 0.21 and 0.99 ng/mL and normal POU lesion status at 1-year follow-up to predict the absence of persistent disease or relapse at 3-year follow-up.

Results

IRG had significantly higher mean utility scores for POU reports of abnormal thyroid bed nodules compared to NIRG (P < 0.001). IRG's POU reports for suspicious nodules and lymph nodes were considered sufficient in 94% and 85% of cases, respectively, compared to 45% and 68% for NIRG. For patients with normal US lesion status and Tg <0.2 ng/mL or Tg 0.21-0.99 ng/mL at 1-year follow-up, the negative predictive values were 96% for both.

Conclusions

Implementation of 2013 ETA POU-reporting guidelines allowed for the provision of high-quality POU reports, which may lead to increased accuracy in assessing the response to treatment and in estimating the risk of recurrence of thyroid cancer and likely reduce unnecessary repeat POU or FNA.

Implications of isthmic location as a risk factor in papillary thyroid carcinoma

Background

Papillary thyroid carcinoma (PTC) located in the isthmus generally has been known to have more extrathyroidal extension (ETE), lymph node involvement, and multifocality. The purpose of this study was to determine the clinical significance of an isthmic location of PTC.

Methods

The records of 160 patients who underwent a total thyroidectomy due to a single, dominant isthmic PTC were retrospectively reviewed. The characteristics of isthmic cancer were compared with those of unilateral-lobar cancer in a PTC cohort at Seoul St. Mary's hospital. After propensity score matching for age, sex, and tumor size, 160 isthmic PTCs and 800 unilateral-lobar PTCs were compared. The clinicopathologic characteristics were analyzed to evaluate the prognostic significance of an isthmic tumor location.

Results

The isthmic group was significantly older (49.6 vs. 46.8 years, P=0.007) and had a smaller mean tumor size (0.8±0.4 vs. 1.0±0.7 cm, P<0.001) than the unilateral-lobar group. After propensity score matching, tumor size categories, ETE, multifocality, nodal metastasis and proportion of patients with more than five metastatic lymph nodes were similar in both groups. However, N1b cases were more frequent in the unilateral-lobar group both before and after propensity score matching. In multivariate analysis, isthmic location was not correlated with gross ETE, multifocality, and higher-risk N1 disease. Younger age and more than five metastatic nodes increased the risk of PTC recurrence. However, isthmic tumor location was not significantly correlated with recurrence-free survival.

Conclusions

Isthmic location is not an independent risk factor for aggressive clinicopathologic features and is not related to PTC recurrence.

Insurance-Based Disparities in Guideline-Concordant Thyroid Cancer Care in the Era of De-Escalation

INTRODUCTION

Prior studies have demonstrated insurance-based disparities in the treatment of well-differentiated thyroid cancer. However, it remains unclear whether these disparities have persisted in the era of the 2015 American Thyroid Association (ATA) management guidelines. The goal of this study was to assess whether insurance type is associated with the receipt of guideline-concordant and timely thyroid cancer treatment in a modern cohort.

METHODS

Patients diagnosed with well-differentiated thyroid cancer between 2016 and 2019 were identified from the National Cancer Database. Appropriateness of surgical and radioactive iodine treatment (RAI) was determined based on the 2015 ATA guidelines. Multivariable logistic regression and Cox proportional hazard regression analyses, stratified at age 65, were used to evaluate the associations between insurance type and appropriateness and timeliness of the treatment.

RESULTS

125,827 patients were included (private = 71%, Medicare = 19%, Medicaid = 10%). Compared to privately insured patients, patients with Medicaid more frequently presented with tumors >4 cm in size (11% versus 8%, P < 0.001) and regional metastases (29% versus 27%, P < 0.001). However, patients with Medicaid were also less likely to undergo appropriate surgical treatment (odds ratio 0.69, P < 0.001), less likely to undergo surgery within 90 d of diagnosis (hazard ratio 0.80, P < 0.001), and more likely to be undertreated with RAI (odds ratio 1.29, P < 0.001). There were no differences in the likelihood of guideline-concordant surgical or medical treatment by insurance type in patients ≥65 y old.

CONCLUSIONS

In the era of the 2015 ATA guidelines, patients with Medicaid remain less likely to receive guideline-concordant, timely surgery and more likely to be undertreated with RAI compared to privately insured patients.

Lobectomy or Total Thyroidectomy-Where Is the Pendulum now for Differentiated Thyroid Cancer?

Thyroid surgery remains an essential treatment of thyroid cancer. The historical one-size-fits-all approach to differentiated (papillary and follicular) thyroid carcinoma of total thyroidectomy with central lymph node dissection has been shown to be overtreatment with associated risk of perioperative complications including nerve palsy and hypoparathyroidism. Furthermore, thyroid lobectomy may obviate life-long thyroid hormone replacement. Low-risk thyroid cancers have a low risk of recurrence and those that do recur can be salvaged with reoperation without compromising prognosis. Perioperative risk stratification for recurrence and death greatly influence the need for total thyroidectomy.

Lobo-isthmectomy in the management of differentiated thyroid cancer

We have recently witnessed a rapid increase in the incidence of differentiated thyroid carcinoma (DTC), particularly low and very low-risk papillary thyroid carcinoma. Simultaneously, the number of cancer-related deaths has remained stable for more than 30 years. Such an indolent nature and long-term survival prompted researchers and experts to an ongoing discussion on the adequacy of DTC management to avoid, on the one hand, the overtreatment of low-risk cases and, on the other hand, the undertreatment of highly aggressive ones.The most recent guidelines of the American Thyroid Association (ATA GL) moved primary thyroid surgery in DTC towards a less aggressive approach by making lobectomy an option for patients with intrathyroidal low-risk DTC tumors up to 4 cm in diameter without evidence of extrathyroidal extension or lymph node metastases. It was one of the key changes in DTC management proposed by the ATA in 2015.Following the introduction of the 2015 ATA GL, the role of thyroid lobectomy in DTC management has slowly become increasingly important. The data coming from analyses of the large databases and retrospective studies prove that a less extensive surgical approach, even if in some reports it was related to a slight increase of the risk of recurrence, did not show a negative impact on disease-specific and overall survival in T1T2N0M0 low-risk DTC. There is no doubt that making thyroid lobectomy an option for low-risk papillary and follicular carcinomas was an essential step toward the de-escalation of treatment in thyroid carcinoma.This review summarizes the current recommendations and evidence-based data supporting the necessity of de-escalation of primary thyroid surgery in low-risk DTC. It also discusses the controversies raised by introducing new ATA guidelines and tries to resolve some open questions.

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.