1
|
Yan L, Yang Z, Li Y, Li X, Xiao J, Jing H, Luo Y. Five-year Outcome Between Radiofrequency Ablation vs Surgery for Unilateral Multifocal Papillary Thyroid Microcarcinoma. J Clin Endocrinol Metab 2023; 108:3230-3238. [PMID: 37318878 DOI: 10.1210/clinem/dgad360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
CONTEXT Ultrasound (US)-guided radiofrequency ablation (RFA) has been considered as an alternative to surgery or active surveillance for papillary thyroid microcarcinoma (PTMC). However, little is known about the long-term outcomes of RFA in comparison with surgery for unilateral multifocal PTMC. OBJECTIVE This work aims to report the comparison between RFA vs surgery for unilateral multifocal PTMC over a more than 5-year follow-up period. METHODS This was a retrospective study at a primary care center with a median follow-up period of 72.9 months. A total of 97 patients with unilateral multifocal PTMC were treated with RFA (RFA group, n = 44) or surgery (surgery group, n = 53). In the RFA group, patients were treated by a bipolar RFA generator and an 18-gauge bipolar RF electrode with a 0.9-cm active tip. In the surgery group, patients underwent thyroid lobectomy with prophylactic central neck dissection. RESULTS During the follow-up, no statistically significant differences were found in disease progression (4.5% vs 3.8%; P = ≥.999), lymph node metastasis (2.3% vs 3.8%; P = ≥.999), persistent lesion (2.3% vs 0%; P = .272), and RFS rates (97.7% vs 96.2%; P = .673) in the RFA and surgery groups. Patients undergoing RFA had a shorter hospitalization (0 vs 8.0 [3.0] d; P < .001), shorter procedure time (3.5 [2.4] vs 80.0 [35.0] min; P < .001), lower estimated blood loss (0 vs 20.0 [15.0] mL; P < .001), and lower costs ($1768.3 [0.1] vs $2084.4 [1173.8]; P = .001) than those in the surgery group. The complication rate in the surgery group was 7.5%, whereas none of the RFA-treated patients experienced any complications (P = .111). CONCLUSION This study revealed 6-year comparable outcomes between RFA and surgery for unilateral multifocal PTMC. RFA may be a safe and effective alternative to surgery in selected patients with unilateral multifocal PTMC.
Collapse
Affiliation(s)
- Lin Yan
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhen Yang
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yingying Li
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Xinyang Li
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Jing Xiao
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - HaoYu Jing
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yukun Luo
- Department of Ultrasound, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| |
Collapse
|
2
|
Chen DW, Lang BHH, McLeod DSA, Newbold K, Haymart MR. Thyroid cancer. Lancet 2023; 401:1531-1544. [PMID: 37023783 DOI: 10.1016/s0140-6736(23)00020-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/20/2022] [Accepted: 01/03/2023] [Indexed: 04/08/2023]
Abstract
The past 5-10 years have brought in a new era in the care of patients with thyroid cancer, with the introduction of transformative diagnostic and management options. Several international ultrasound-based thyroid nodule risk stratification systems have been developed with the goal of reducing unnecessary biopsies. Less invasive alternatives to surgery for low-risk thyroid cancer, such as active surveillance and minimally invasive interventions, are being explored. New systemic therapies are now available for patients with advanced thyroid cancer. However, in the setting of these advances, disparities exist in the diagnosis and management of thyroid cancer. As new management options are becoming available for thyroid cancer, it is essential to support population-based studies and randomised clinical trials that will inform evidence-based clinical practice guidelines on the management of thyroid cancer, and to include diverse patient populations in research to better understand and subsequently address existing barriers to equitable thyroid cancer care.
Collapse
Affiliation(s)
- Debbie W Chen
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian H H Lang
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Donald S A McLeod
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kate Newbold
- Thyroid Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
3
|
Yan L, Liu Y, Li W, Zhu Y, Wang J, Zhang M, Tang J, Che Y, Wang H, Wang S, Luo Y. Long-term Outcomes of Ultrasound-guided Thermal Ablation for the Treatment of Solitary Low-risk Papillary Thyroid Microcarcinoma: A Multicenter Retrospective Study. Ann Surg 2023; 277:846-853. [PMID: 36727947 DOI: 10.1097/sla.0000000000005800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To report more than 5-year outcomes of ultrasound-guided thermal ablation (TA) for patients with solitary low-risk papillary thyroid microcarcinoma (PTMC) in a large multicenter cohort. BACKGROUND TA, including radiofrequency ablation (RFA) and microwave ablation (MWA) have been used in patients with low-risk PTMC who refuse surgery or active surveillance. However, its clinical value remains controversial. MATERIALS AND METHODS This retrospective multicenter study included 474 patients with solitary low-risk PTMC treated with TA (357 for RFA; 117 for MWA) from 4 centers and followed up for at least 5 years. Disease progression including lymph node metastasis and recurrent tumors, volume reduction rate (VRR), tumor disappearance rate, complications, and delayed surgery were assessed. RFA and MWA outcomes were compared using propensity score matching. RESULTS During the median follow-up period of 77.2 months, disease progression incidence, lymph node metastasis, and recurrent tumors rates were 3.6%, 1.1%, and 2.5%, respectively. Age below 40 years old, male sex, Hashimoto thyroiditis, and tumor size were not independent factors associated with disease progression by Cox analysis. The median VRR was 100% and 471 tumors disappeared radiographically. Eight patients experienced transient voice change (1.7%) which recovered within 3 months. None of the patients underwent delayed surgery because of anxiety. After 1:1 matching, no significant differences were found in the disease progression, VRR, tumor disappearance rate, or complications between RFA and MWA subgroups. CONCLUSION This multicenter study revealed that TA was an effective and safe treatment for patients with solitary low-risk PTMC, which could be offered as a treatment option for the management for low-risk PTMC.
Collapse
Affiliation(s)
- Lin Yan
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ying Liu
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - WenHui Li
- Depart of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - YaLin Zhu
- Department of Ultrasound, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jinling Wang
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - Mingbo Zhang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Tang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ying Che
- Department of Ultrasound, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hui Wang
- Depart of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shurong Wang
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - Yukun Luo
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
4
|
Kim J, Roth EG, Carlisle K, Munir KM, Fletke KJ, Slejko JF, Mullins CD, Hu Y. Eliciting Low-Risk Thyroid Cancer Treatment Preferences using Clinical Vignettes: A Pilot Study. Endocr Pract 2023:S1530-891X(23)00397-X. [PMID: 37121401 DOI: 10.1016/j.eprac.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE While surgical resection has been the traditional standard treatment for small (≤1 cm), differentiated thyroid cancers, active surveillance and radiofrequency ablation are increasingly considered. The aim of this study was to explore patient preferences in thyroid cancer treatment using a series of clinical vignettes. METHODS Thyroid cancer survivors and general population volunteers were recruited to rank experience-driven clinical vignettes in order of preference. Rankings were compared using Wilcoxon signed rank. Formative qualitative methods were used to develop and refine clinical vignettes that captured four treatments-thyroid lobectomy (TL), total thyroidectomy (TT), active surveillance (AS), and radiofrequency ablation (RFA)-along with six treatment complications. Content was validated via interviews with five academic subspecialists. RESULTS Nineteen volunteers participated (10 survivors, 9 general population). Treatment complications were ranked lower than uncomplicated counterparts in 99.0% of cases, indicating excellent comprehension. Counter to our hypothesis, among uncomplicated vignettes, median rankings were 1 for AS, 2 for RFA, 3.5 for TL, and 5 for TT. Trends were consistent between thyroid cancer survivors and the general population. Active surveillance was significantly preferred over RFA (p = 0.02) and TT (p <0.01). Among surgical options, TL was significantly preferred over TT (p <0.01). CONCLUSION When treatments for low-risk thyroid cancer are described clearly and accurately through clinical vignettes, patients may be more likely to choose less invasive treatment options over traditional surgical resection.
Collapse
Affiliation(s)
- Justin Kim
- Department of Surgery, University of Maryland Baltimore
| | - Erin G Roth
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy
| | | | - Kashif M Munir
- Department of Medicine, University of Maryland School of Medicine
| | - Kyle J Fletke
- Department of Family Medicine, University of Maryland Baltimore
| | - Julia F Slejko
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy
| | - C Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy
| | - Yinin Hu
- Department of Surgery, University of Maryland Baltimore.
| |
Collapse
|
5
|
Yan L, Li Y, Li XY, Xiao J, Tang J, Luo Y. Clinical outcomes of ultrasound-guided radiofrequency ablation for solitary T1N0M0 papillary thyroid carcinoma: A retrospective study with more than 5 years of follow-up. Cancer 2023. [PMID: 37060239 DOI: 10.1002/cncr.34802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/13/2023] [Accepted: 03/29/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Ultrasound-guided radiofrequency ablation (RFA) has been used in patients with papillary thyroid carcinoma (PTC) who refuse surgery or active surveillance. However, the long-term outcomes are still limited. This study aimed to evaluate the clinical outcomes of RFA for solitary T1N0M0 PTC in a large cohort over a more than 5-year follow-up period. METHODS This retrospective study included 358 patients with solitary T1N0M0 PTC who were treated with RFA and followed for at least 5 years. The bipolar RFA procedure was performed using hydrodissection technique, transisthmic approach, and moving-shot technique. The primary outcomes were disease progression, including lymph node metastasis (LNM), recurrent tumor, persistent tumor, and distant metastasis. The secondary outcomes were volume reduction rate, complete disappearance rate, complications, and delayed surgery. RESULTS During a mean follow-up period of 75.5 ± 9.7 months, the overall disease progression was 5.0%. The incidence of LNM, recurrent tumor, and persistent tumor was 1.4%, 3.1%, and 0.6%, respectively. There were no significant differences in the disease progression (5.0% vs. 5.5%, p = 1.000), LNM (1.3% vs. 1.8%, p = .568), recurrent tumor (3.3% vs. 1.8%, p = .872), persistent tumors (0.3% vs. 1.8%, p = .284), and 5-year recurrence-free survival rates (95.4% vs. 96.4%, p = .785) in the T1a and T1b groups. Volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. No complications occurred. No patients underwent delayed surgery because of anxiety. CONCLUSIONS RFA is an effective and safe alternative for patients with T1N0M0 PTC and can offer a minimally invasive curative option for patients who refuse surgery or active surveillance. PLAIN LANGUAGE SUMMARY During a mean follow-up period of 75.5 ± 9.7 months, the overall papillary thyroid carcinoma disease progression was 5.0%. The volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. The T1a and T1b groups had similar incidence of disease progression and 5-year recurrence-free survival rates. No patients experienced complications or underwent delayed surgery because of anxiety.
Collapse
Affiliation(s)
- Lin Yan
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yingying Li
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin Yang Li
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing Xiao
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Tang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yukun Luo
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
6
|
Chiu AS, Saucke MC, Bushaw K, Voils CI, Sydnor J, Haymart M, Pitt SC. The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer. Surgery 2023; 173:183-188. [PMID: 36182602 DOI: 10.1016/j.surg.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations. METHODS A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test. RESULTS Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy. CONCLUSION Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.
Collapse
Affiliation(s)
- Alexander S Chiu
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kyle Bushaw
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Corrine I Voils
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin Sydnor
- University of Wisconsin School of Business, Madison, WI
| | - Megan Haymart
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Susan C Pitt
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI
| |
Collapse
|
7
|
Silva IMD, Nogueira TQDS, Couto DN, Lima PCTM, Bonfim NSC, Sousa IGVD, Telles ACT, Hecht F, Alkmim NR, Penna GCE, Ferraz C, Tomimori E, Ramos HE. Feasibility of a snowball sampling survey to study active surveillance for thyroid microcarcinoma treatment among endocrinologists and surgeons of Brazil. Braz J Otorhinolaryngol 2022; 88 Suppl 4:S163-S169. [PMID: 35177356 DOI: 10.1016/j.bjorl.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/15/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES This study aims to investigate if a sampling method using virtual networks is feasible to survey AS adoption among this "hard-to-reach" population of Brazilian doctors. METHODS An online piloted 11-point structured survey questionnaire (designed using Googleforms®) probed the actual treatment patterns for adult patients with PTMCs, including treatment decision-making nonoperative options, was undertaken between 10 November and 30 November 2020. Participants were reached by the mobile phone Application (APP) and a snowball sampling strategy was used to recruit a total of 4783 members (maximum number of potential reach), which is the total of doctors of the all 21 social media WhatsApp® groups. RESULTS From a total of 4783 members (maximum number of potential reach), there were 657 (13.7%) doctors (actual reach) who clicked the web link of the questionnaire, out of whom 512 (10.7%) fully completed the online survey. Among the survey respondents, 361 were endocrinologists (70.5%) and 151 were surgeons (29.5%). Overall, for low-risk PTMCs in an elderly patient, 118 responders (23%) recommend AS, while 390 (76%) recommend immediate surgery as the management, including lobectomy (18.5%) and Total Thyroidectomy (58.2%). The present responders tended to recommend surgery for PTMCs that were located adjacent to the dorsal surface of the thyroid, were multiple, or raised the size during the follow-up. CONCLUSION Using snowball sampling strategy as an innovative route to conduct surveys was feasible and applicable but the rate of response was still very low. Our data also suggests the need to investigate if AS is embraced by Brazilian doctors.
Collapse
Affiliation(s)
- Isabela Matos da Silva
- Centro Estadual de Referência em Atenção ao Diabetes e Endocrinologia, Salvador, BA, Brazil
| | | | - Deborah Nogueira Couto
- Universidade Federal da Bahia, Faculdade de Ciências Médicas, Serviço de Endocrinologia, Salvador, BA, Brazil
| | | | | | | | - Ana Clara Tosta Telles
- Universidade Federal da Bahia, Instituto de Ciências da Saúde, Programa de Pós-Graduação em Processos Interativos de Órgãos Sistemas, Salvador, BA, Brazil
| | - Fábio Hecht
- Universidade Federal do Rio de Janeiro, Instituto de Biofísica Carlos Chagas Filho, Rio de Janeiro, RJ, Brazil
| | - Nina Ramalho Alkmim
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Carolina Ferraz
- Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas da Santa Casa, Unidade de Doenças da Tireóide ‒ Divisão de Endocrinologia, Departamento de Medicina, São Paulo, SP, Brazil
| | | | - Helton Estrela Ramos
- Universidade Federal da Bahia, Instituto de Ciências da Saúde, Programa de Pós-Graduação em Processos Interativos de Órgãos Sistemas, Salvador, BA, Brazil; Universidade Federal da Bahia, Instituto de Ciências da Saúde, Departamento de Biorregulação, Salvador, BA, Brazil; Universidade Federal da Bahia, Faculdade de Ciências Médicas, Programa de Pós-Graduação em Medicina e Saúde, Salvador, BA, Brazil.
| |
Collapse
|
8
|
Ho AS, Bastien AJ, Sacks WL. Thyroid Cancer Active Surveillance: The Devil You Know or The Devil You Don't. Thyroid 2022; 32:1279-1280. [PMID: 36205589 DOI: 10.1089/thy.2022.0541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Allen S Ho
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amanda J Bastien
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Wendy L Sacks
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
9
|
Ho AS, Kim S, Zalt C, Melany ML, Chen IE, Vasquez J, Mallen-St. Clair J, Chen MM, Vasquez M, Fan X, van Deen WK, Haile RW, Daskivich TJ, Zumsteg ZS, Braunstein GD, Sacks WL. Expanded Parameters in Active Surveillance for Low-risk Papillary Thyroid Carcinoma: A Nonrandomized Controlled Trial. JAMA Oncol 2022; 8:2796440. [PMID: 36107411 PMCID: PMC9478884 DOI: 10.1001/jamaoncol.2022.3875] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/08/2022] [Indexed: 08/28/2023]
Abstract
Importance Unlike for prostate cancer, active surveillance for thyroid cancer has not achieved wide adoption. The parameters by which this approach is feasible are also not well defined, nor is the effect of patient anxiety. Objective To determine if expanded size/growth parameters for patients with low-risk thyroid cancer are viable, as well as to assess for cohort differences in anxiety. Design, Setting, and Participants This prospective nonrandomized controlled trial was conducted at a US academic medical center from 2014 to 2021, with mean [SD] 37.1 [23.3]-month follow-up. Of 257 patients with 20-mm or smaller Bethesda 5 to 6 thyroid nodules, 222 (86.3%) enrolled and selected treatment with either active surveillance or immediate surgery. Delayed surgery was recommended for size growth larger than 5 mm or more than 100% volume growth. Patients completed the 18-item Thyroid Cancer Modified Anxiety Scale over time. Interventions Active surveillance. Main Outcomes and Measures Cumulative incidence and rate of size/volume growth. Results Of the 222 patients enrolled, the median (IQR) age for the study population was 46.8 (36.6-58) years, and 76.1% were female. Overall, 112 patients (50.5%) underwent treatment with active surveillance. Median tumor size was 11.0 mm (IQR, 9-15), and larger tumors (10.1-20.0 mm) comprised 67 cases (59.8%). One hundred one (90.1%) continued to receive treatment with active surveillance, 46 (41.0%) had their tumors shrink, and 0 developed regional/distant metastases. Size growth of more than 5 mm was observed in 3.6% of cases, with cumulative incidence of 1.2% at 2 years and 10.8% at 5 years. Volumetric growth of more than 100% was observed in 7.1% of cases, with cumulative incidence of 2.2% at 2 years and 13.7% at 5 years. Of 110 patients who elected to undergo immediate surgery, 21 (19.1%) had equivocal-risk features discovered on final pathology. Disease severity for all such patients remained classified as stage I. Disease-specific and overall survival rates in both cohorts were 100%. On multivariable analysis, immediate surgery patients exhibited significantly higher baseline anxiety levels compared with active surveillance patients (estimated difference in anxiety scores between groups at baseline, 0.39; 95% CI, 0.22-0.55; P < .001). This difference endured over time, even after intervention (estimated difference at 4-year follow-up, 0.50; 95% CI, 0.21-0.79; P = .001). Conclusions and Relevance The results of this nonrandomized controlled trial suggest that a more permissive active surveillance strategy encompassing most diagnosed thyroid cancers appears viable. Equivocal-risk pathologic features exist in a subset of cases that can be safely treated, but suggest the need for more granular risk stratification. Surgery and surveillance cohorts possess oppositional levels of worry, elevating the importance of shared decision-making when patients face treatment equivalence. Trial Registration ClinicalTrials.gov Identifier: NCT02609685.
Collapse
Affiliation(s)
- Allen S. Ho
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sungjin Kim
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia Zalt
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle L. Melany
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Irene E. Chen
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joan Vasquez
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon Mallen-St. Clair
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M. Chen
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Missael Vasquez
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xuemo Fan
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Welmoed K. van Deen
- Center for Outcomes Research and Education, Division of Health Sciences Research, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert W. Haile
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Timothy J. Daskivich
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zachary S. Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Glenn D. Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wendy L. Sacks
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
10
|
Dedhia PH, Saucke MC, Long KL, Doherty GM, Pitt SC. Physician Perspectives of Overdiagnosis and Overtreatment of Low-Risk Papillary Thyroid Cancer in the US. JAMA Netw Open 2022; 5:e228722. [PMID: 35467735 PMCID: PMC9039765 DOI: 10.1001/jamanetworkopen.2022.8722] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This survey study assesses physicians’ recommendations regarding overdiagnosis and overtreatment of thyroid nodules and low-risk papillary thyroid cancer.
Collapse
Affiliation(s)
- Priya H. Dedhia
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus
| | - Megan C. Saucke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Kristin L. Long
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Gerard M. Doherty
- Brigham and Women’s Hospital, Brigham Health, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan C. Pitt
- Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
11
|
Pacini F, Fuhrer D, Elisei R, Handkiewicz-Junak D, Leboulleux S, Luster M, Schlumberger M, Smit JW. 2022 ETA Consensus Statement: What are the indications for post-surgical radioiodine therapy in differentiated thyroid cancer? Eur Thyroid J 2022; 11:e210046. [PMID: 34981741 PMCID: PMC9142814 DOI: 10.1530/etj-21-0046] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/04/2021] [Indexed: 11/08/2022] Open
Abstract
Modern use of post-operative radioactive iodine (RAI) treatment for differentiated thyroid cancer (DTC) should be implemented in line with patients' risk stratification. Although beneficial effects of radioiodine are undisputed in high-risk patients, controversy remains in intermediate-risk and some low-risk patients. Since the last consensus on post-surgical use of RAI in DTC patients, new retrospective data and results of prospective randomized trials have been published, which have allowed the development of a new European Thyroid Association (ETA) statement for the indications of post-surgical RAI therapy in DTC. Questions about which patients are candidates for RAI therapy, which activities of RAI can be used, and which modalities of pre-treatment patient preparation should be used are addressed in the present guidelines.
Collapse
Affiliation(s)
- Furio Pacini
- Section of Endocrinology, University of Siena, Siena, Italy
- Correspondence should be addressed to F Pacini:
| | - Dagmar Fuhrer
- Department of Endocrinology, Diabetes and Metabolism, West German Cancer Centre (WTZ), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rossella Elisei
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daria Handkiewicz-Junak
- Department of Nuclear Medicine and Endocrine Oncology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Sophie Leboulleux
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | - Markus Luster
- Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany
| | - Martin Schlumberger
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | | |
Collapse
|
12
|
Zhang H, Zheng X, Liu J, Gao M, Qian B. Development of an Active Surveillance or Surgery Model to Predict Lymph Node Metastasis in cN0 Papillary Thyroid Microcarcinoma. Front Endocrinol (Lausanne) 2022; 13:896121. [PMID: 35937812 PMCID: PMC9353015 DOI: 10.3389/fendo.2022.896121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Involvement of multiple lymph node (LN) metastasis in papillary thyroid microcarcinoma (PTMC) may indicate a progressive disease. To assist treatment decision, we conducted a clinical study to develop and validate a prediction model for the preoperative evaluation of LN metastasis involving more than five lymph nodes in patients with clinical N0 (cN0) PTMC. MATERIAL AND METHODS Using data from 6,337 patients with cN0 PTMCs at Tianjin Medical University Cancer Institute and Hospital from 2013 to 2017, we identified and integrated risk factors for the prediction of multiple LN metastasis to build a nomogram. The predictive accuracy and discriminative ability of the nomogram were evaluated by the concordance index (C-index) and calibration curve. The model was validated using bootstrap resampling of the training cohort and an independent temporal validation cohort at the same institution. RESULTS In the training cohort (n = 3,209 patients), six independent risk factors were identified and included the prediction model (PTMC Active Surveillance or Surgery (ASOS) Model), including age, gender, multifocality, tumor size, calcification, and aspect ratio. The PTMC ASOS model was validated both internally and through the temporal validation cohort (n = 3,128 patients) from the same institute. The C-indexes of the prediction model in the training cohort were 0.768 (95% CI, 0.698-0.838), 0.768 and 0.771 in the internal validation and external validation cohorts, respectively. The area under the receiver operating characteristic curve (AUC) was 0.7068 and 0.6799. The calibration curve for probability of large-LN metastasis showed good agreement between prediction by nomogram and actual observation. DCA curves were used for comparison with another model, and IDI and NRI were also calculated. The cutoff value of our model was obtained by the ROC curve. Based on this model and cut point, a web-based dynamic nomogram was developed (https://tjmuch-thyroid.shinyapps.io/PTMCASOSM/). CONCLUSION We established a novel nomogram that can help to distinguish preoperatively cN0 PTMC patients with or without metastasis of multiple lymph nodes. This clinical prediction model may be used in decision making for both active surveillance and surgery.
Collapse
Affiliation(s)
- Huan Zhang
- Cancer Prevention Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Xiangqian Zheng
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Juntian Liu
- Cancer Prevention Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Ming Gao
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Department of Thyroid and Breast Surgery, Tianjin Union Medical Center, Tianjin, China
- *Correspondence: Biyun Qian, ; Ming Gao,
| | - Biyun Qian
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and Faculty of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Clinical Research Promotion and Development Center, Shanghai Shenkang Hospital Development Center, Shanghai, China
- *Correspondence: Biyun Qian, ; Ming Gao,
| |
Collapse
|