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Biondi B. TSH Suppression in Differentiated Thyroid Cancer Patients. Still More Questions than Answers after 30 Years. Thyroid 2024. [PMID: 38742990 DOI: 10.1089/thy.2024.0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Bernadette Biondi
- Division of Internal Medicine and Cardiovascular Endocrinology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Gubbi S, Al-Jundi M, Foerster P, Cardenas S, Butera G, Auh S, Wright EC, Klubo-Gwiezdzinska J. The Effect of Thyrotropin Suppression on Survival Outcomes in Patients with Differentiated Thyroid Cancer: A Systematic Review and Meta-Analysis. Thyroid 2024. [PMID: 38717947 DOI: 10.1089/thy.2023.0711] [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] [Indexed: 05/15/2024]
Abstract
Background: Long-term management of intermediate- and high-risk differentiated thyroid cancer (DTC) involves thyrotropin (TSH) suppression with thyroid hormone to prevent potential stimulation of TSH receptors on DTC cells, leading to tumor growth. However, the current guidelines recommending TSH suppression are based on low- to moderate-quality evidence. Methods: We performed a systematic review and meta-analysis of studies evaluating the role of TSH suppression in intermediate- and high-risk DTC patients (≥18 years) treated as per regional guideline-based therapy with a follow-up duration of 5 years (PROSPERO #252396). TSH suppression was defined as "below normal reference range" or, when known, <0.5 mIU/L. Primary outcome measures included (i) composite of progression-free survival (PFS), disease-free survival (DFS), and relapse-free survival (RLFS), and (ii) composite of disease-specific survival (DSS), and overall survival (OS). Secondary outcome included a composite of cardiac or skeletal adverse events. All outcomes and comparisons were represented as TSH suppression versus TSH nonsuppression. Randomized controlled trials, cohort studies, and case-control studies were included for analysis. Pooled hazard ratio (HR) and 95% confidence interval (CI) were calculated using random-effects model. Results: Abstract screening was performed on 6,369 studies. After the exclusion of irrelevant studies and full-text screening, nine studies were selected for the final meta-analysis. Based on seven studies (3,591 patients), the composite outcome of PFS, DFS, and RLFS was not significantly different between TSH suppression and nonsuppression groups (HR: 0.75; 95% CI: 0.48-1.17; I2 = 76%). Similarly, a DSS and OS composite outcome assessment based on four studies (3,616 patients) did not favor TSH suppression (HR: 0.69; 95% CI: 0.31-1.52; I2 = 88%). Even after excluding studies of lower quality, the primary outcomes were not significantly different between the TSH suppression and nonsuppression cohorts. The secondary outcome, obtained from two studies (1,294 patients), was significantly higher in the TSH-suppressed groups (HR: 1.82; 95% CI: 1.30-2.55; I2 = 0%). Significant study heterogeneity was noted for primary outcomes. Conclusion: TSH suppression in intermediate- and high-risk DTC may not improve survival outcomes but may increase the risk of secondary complications. However, the limited evidence and study heterogeneity warrant cautious interpretation of our findings. Registration: PROSPERO #252396.
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Affiliation(s)
- Sriram Gubbi
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mohammad Al-Jundi
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter Foerster
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Stephanie Cardenas
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gisela Butera
- Division of Library Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Chalmers Wright
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Abelleira E, Jerkovich F. Dynamic risk assessment in patients with differentiated thyroid cancer. Rev Endocr Metab Disord 2024; 25:79-93. [PMID: 38015344 DOI: 10.1007/s11154-023-09857-7] [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] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
The current approach for patients with differentiated thyroid carcinoma should be individualized according to the risk of recurrence, and this stratification could be used to identify the risk of persistent/recurrent disease in three scenarios: preoperatively, immediately postoperatively, and during long-term follow-up. The initial risk of recurrence will tailor the management of the patient in the preoperative and immediate postoperative settings, while the dynamic risk, which considers the responses to treatment, could guide the decision-making process for remnant ablation and long-term management.This review provides a summary of the existing information regarding the dynamic risk of recurrence and recommended management for patients with differentiated thyroid cancer. The application of this approach is essential to avoid unnecessary treatments for most patients who will have a favorable prognosis. On the other hand, it allows specific therapeutic interventions for those patients at high risk of recurrence. In the future, analysis of tumor biology and prospective studies will surely improve the accuracy of recurrence risk prediction.
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Affiliation(s)
- Erika Abelleira
- Division of Endocrinology, Hospital de Clínicas José de San Martín (UBA), University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, C 1120, Argentina.
| | - Fernando Jerkovich
- Division of Endocrinology, Hospital de Clínicas José de San Martín (UBA), University of Buenos Aires, Córdoba 2351, 5th floor, Buenos Aires, C 1120, Argentina
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Horiuchi K, Fujimoto M, Hidenori K, Yoshida Y, Noguchi E, Omi Y, Okamoto T. Outcomes of Patients with an Intermediate-Risk Group According to the Japanese Risk Classification of Papillary Thyroid Carcinoma. World J Surg 2023; 47:2464-2473. [PMID: 37266697 PMCID: PMC10474173 DOI: 10.1007/s00268-023-07073-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND The management of intermediate-risk group of papillary thyroid cancer (PTC) is still vague, particularly regarding whether or not total thyroidectomy, postoperative radioactive iodine ablation (RAI-a), and postoperative TSH suppression are mandatory. METHODS This retrospective study evaluated 680 PTC patients from 2010 to 2017, who were classified into the three risk groups as low, intermediate, and high-risk groups according to the criteria of the Japanese Association of Endocrine Surgeons (JAES) 2010 and underwent surgery according to the JAES guidelines. We retrospectively collected patient data for analyses of disease-free survivals in the intermediate-risk group patients. RESULTS We performed surgery on 680 PTC patients from 2010 to 2017. Of them, 297 were classified as the intermediate-risk group. DFS was not statistically significantly different in patients with/without total thyroidectomy and postoperative TSH suppression therapy. For RAI-a, DFS (95% confidence interval) at 3, 5, and 8 years were 93.2% (84.6 ~ 97.2), 81.6% (68,3 ~ 90.2), and 70.7% (51.4 ~ 84.6) in patients with postoperative RAI-a and 100%, 100%, and 100% in patients without postoperative RAI-a after total thyroidectomy, respectively. DFS of patients without RAI-a was superior to those with RAI-a (P < 0.0004). Multivariable analysis by stepwise selection method revealed that postoperative RAI-a was a risk factor with a hazard ratio of 5.69. (95% CI 1.998-16.21) (P = 0.001131). CONCLUSIONS Our study did not show the efficacy of RAI-a in patients with intermediate-risk PTC. This study implies that judging the efficacy of adjuvant therapy such as RAI or TSh suppression in intermediate-risk patients is difficult.
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Affiliation(s)
- Kiyomi Horiuchi
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan.
| | - Mikiko Fujimoto
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
| | - Kamio Hidenori
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
| | - Yusaku Yoshida
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
| | - Eiichiro Noguchi
- Department of Breast Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
| | - Yoko Omi
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
| | - Takahiro Okamoto
- Department of Endocrine Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 1628666, Japan
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Drugda J, Čáp J, Kosák M, Gabalec F. Levothyroxine suppressive therapy in differentiated thyroid cancer treatment. VNITŘNÍ LÉKAŘSTVÍ 2023; 69:128-131. [PMID: 37072271 DOI: 10.36290/vnl.2023.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Levothyroxine therapy in management of diferentiated thyroid carcinoma (DTC) has been common practice for decades. Levothyroxine is being administered to patiens with DTC after total thyreoidectomy (with or without postopreative radioiodine treatment) not only to restore euthyroidism but to suppress the production of thyroid-stimulating hormone (TSH) as well because TSH is considered as a growth factor for thyroid follicular cells. However there has been a downside to this threatment recently. The main concerns are the known risks related to iatrogenic subclinical or even mild but clinicaly overt iatrogenic hyperthyroidism. Therefore individualized treatment approach aiming to balance between the risk of tumor recurence and the risks related to hypertyhroidism in view of pateints age, risk factors and comorbidities is essential. Close folow-up is therefore necessary with frequent dose adjustments according to target TSH values published in American Thyroid Association guidelines.
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Ullmann TM, Papaleontiou M, Sosa JA. Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis. J Clin Endocrinol Metab 2023; 108:271-280. [PMID: 36327392 PMCID: PMC10091361 DOI: 10.1210/clinem/dgac646] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Low-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy. EVIDENCE ACQUISITION This mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed. EVIDENCE SYNTHESIS Recommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad. CONCLUSION Clinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.
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Affiliation(s)
- Timothy M Ullmann
- Division of General Surgery, Department of Surgery, Albany Medical College, 50 New Scotland Ave., MC-193, Albany, NY 12208, USA
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Bldg. 16, Rm 453S, Ann Arbor, MI 48109, USA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave. Ste. S320, Box 0104, San Francisco, CA 94143, USA
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Díaz-Soto G, Fernández-Velasco P, Torres Torres B, López Gómez JJ, García Calvo S, de Luis Román D. Evolution of suppressing TSH therapy at diagnosis and in the long-term follow-up in a cohort of differentiated thyroid cancer. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2022; 69:844-851. [PMID: 36470820 DOI: 10.1016/j.endien.2022.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/09/2021] [Indexed: 12/05/2022]
Abstract
INTRODUCTION To evaluate the adequacy of TSH suppression therapy (TSHst) at the first disease assessment and the last follow-up visit. METHODS Retrospective observational study of those patients under follow-up of DTC in a reference hospital. RESULTS 216 patients (79.2% women) were evaluated, with a mean age 59.0 ± 13.1 years-old and a mean follow-up of 6.9 ± 4.3 years. 88.4% were papillary carcinomas. At diagnosis, 69.2% had a low risk of recurrence (RR) compared to 13.6% with a high RR. Dynamic risk stratification (DRS) classified patients at first disease assessment and the last visit as excellent response (ER) in 60.0% and 70.7%, respectively. Those patients with ER in the first and last follow-up control maintained TSHst in 30.7% and 16.3% of the cases, respectively (p < 0.001). The factors associated with maintaining TSHst at the last control were younger age, higher RR at diagnosis, DRE at follow-up, presence of multifocality and histological vascular invasion (p < 0.05). In a logistic regression analysis adopting tsTSH at follow-up as the dependent variable, exclusively age (β = -0.062; p < 0.001), RR at diagnosis (β = 1.074; p < 0.05) and EDR during follow-up (β = 1.237; p < 0.05) maintained statistical significance. CONCLUSIONS Despite the current recommendations, 30.7% of patients with low RR and initial ER are under TSHst. This percentage reduced to 16.3% in those patients with ER after a mean follow-up of 6.9 years. Age, baseline RR, and DRE during follow-up were associated to maintaining tsTSH.
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Affiliation(s)
- Gonzalo Díaz-Soto
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain.
| | - Pablo Fernández-Velasco
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - Beatriz Torres Torres
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - Juan José López Gómez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - Susana García Calvo
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - Daniel de Luis Román
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Valladolid, Valladolid, Spain; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
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Yavuz DG, Yazan CD, Hekimsoy Z, Aydin K, Gokkaya N, Ersoy C, Akalın A, Topaloglu O, Aydogan BI, Dilekci ENA, Alphan Uc Z, Cansu GB, Ozsari L, Iyidir OT, Olgun ME, Keskin L, Mert M, Can B, Gungor K, Galip T, Cantürk Z, Elbuken G, Pekkolay Z, Kutbay NO, Yorulmaz G, Kalkan AT, Unsal YA, Yay A, Karagun B, Bozkur E. Assesment of attainment of recommended TSH levels and levothyroxine compliance in differentiated thyroid cancer patients. Clin Endocrinol (Oxf) 2022; 97:833-840. [PMID: 35639050 DOI: 10.1111/cen.14787] [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: 01/10/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Thyroid-stimulating hormone (TSH) suppression treatment can induce signs and symptoms of hyperthyroidism and hypothyroidism due to inappropriate treatment or poor compliance to the treatment. The current study aimed to investigate TSH levels, frequency of being on target TSH, adherence to levothyroxine (LT4) suppression treatment in differentiated thyroid cancer (DTC) patients after surgery in a multicentric setting. DESIGN AND PATIENTS This multicentric cross-sectional study was conducted at 21 medical centres from 12 cities in Turkey. DTC patients followed at least one year in the same center included in the study. Clinical data, serum TSH, free thyroxine (FT4), thyroglobulin (Tg) and anti-Tg levels were recorded during the most recent visit. Body mass index, systolic and diastolic blood pressures, pulse rate were measured. LT4 doses were recorded and doses per kilogram of bodyweight were calculated. Pill ingestion habits recorded and adherence to the therapy were evaluated using the Morisky Medication Adherence Scale and categorized as good, moderate or poor compliant based on their scores. Risk stratification forpredicting the disease persistance and/or reccurence was assessed using the American Joint Committee on Cancer-7th edition thyroid cancer staging calculator. TSH serum concentrations were classified as severe suppression (TSH < 0.01 mU/L), moderate suppression (TSH: 0.01-0.1 mU/L), mild suppression (TSHL 0.1-0.5 mU/L), euthyroid (TSH: 0.5-4 mU/L) and hypothyroid (TSH > 4 mU/L). TSH levels can also be classified as on being on target, under the target, or beyond over the target, according to the American Thyroid Association recommendations. RESULTS A group of 1125 patients (F/M: 941/184, 50.7 ± 11.7 years) were included in the study. The mean LT4 daily dosage was 132.4 ± 39.6 mcg/day. TSH levels showed severe suppression in 99 (%8.8) patients, moderate suppression in 277 (%24.6) patients and mild suppression in 315 (%28) patients and euthyroid range in 332 (%29.5) patients and hypothyroid range in 97 (8.6%). TSH levels were in target in 29.2% of the patients 20.4% of the patients were undertreated, 50.4% overtreated. The daily LT4 dose and LT4 dose/kg were significantly higher in the severe suppression group (p < .001, p < .001). According to the Morisky scale, 564 patients (50.1%) were good compliant, 368 patients (32.7%) were moderate compliant, and 193 patients (17.1%) were noncompliant. Patients with poor compliance need a higher dose of LT4 compared to the good compliance group (p < .001). TSH levels of patients with good compliance were 0.67 ± 1.96 mU/L and TSH with poor compliance was 2.74 ± 7.47 mU/L (p < .001). TSH levels were similar in patients on fixed and alternating dosages. CONCLUSION In 29.2% of the DTC patients, serum TSH levels were at target levels. Remaining of the study group have TSH levels under or over treatment range, exposing the patient to medication side effects. Majorty of the study group 82.8% have good or moderate adherence to LT4 therapy. Reaching TSH targets requires simplified and applicable guidelines and following the guideline recommendations.
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Affiliation(s)
- Dilek Gogas Yavuz
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey
| | - Ceyda D Yazan
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey
| | - Zeliha Hekimsoy
- Department of Endocrinology and Metabolism, Celal Bayar University, Manisa, Turkey
| | - Kadriye Aydin
- Department of Endocrinology and Metabolism, Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Naile Gokkaya
- Department of Endocrinology and Metabolism, Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Canan Ersoy
- Department of Endocrinology and Metabolism, Uludag University School of Medicine, Bursa, Turkey
| | - Aysen Akalın
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Omercan Topaloglu
- Department of Endocrinology and Metabolism, Kocaeli Derince Research and Training Hospital, Kocaeli, Turkey
| | - Berna I Aydogan
- Department of Endocrinology and Metabolism, Batman Research and Training Hospital, Batman, Turkey
| | - Esra N A Dilekci
- Department of Endocrinology and Metabolism, Bolu Abant Izzet Baysal University School of Medicine, Bolu, Turkey
| | - Ziynet Alphan Uc
- Department of Endocrinology and Metabolism, Usak Research and Training Hospital, Usak, Turkey
| | - Guven B Cansu
- Department of Endocrinology and Metabolism, Kutahya Health Sciences University, Kütahya, Turkey
| | - Levent Ozsari
- Department of Endocrinology and Metabolism, Sultan Abdulhamid Han Research and Training Hospital, Istanbul, Turkey
| | - Ozlem T Iyidir
- Department of Endocrinology and Metabolism, Baskent University School of Medicine, Ankara, Turkey
| | - Mehtap E Olgun
- Department of Endocrinology and Metabolism, Cukurova University School of Medicine, Adana, Turkey
| | - Lezzan Keskin
- Department of Endocrinology and Metabolism, Malatya Research and Training Hospital, Malatya, Turkey
| | - Meral Mert
- Department of Endocrinology and Metabolism, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Bulent Can
- Department of Endocrinology and Metabolism, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Kaan Gungor
- Department of Endocrinology and Metabolism, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Tayfun Galip
- Department of Endocrinology and Metabolism, Medical Park Pendik Hospital, Istanbul, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Gulsah Elbuken
- Department of Endocrinology and Metabolism, School of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Zafer Pekkolay
- Department of Endocrinology and Metabolism, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Nilufer O Kutbay
- Department of Endocrinology and Metabolism, Celal Bayar University, Manisa, Turkey
| | - Goknur Yorulmaz
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Ahmet T Kalkan
- Department of Endocrinology and Metabolism, Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Yasemin A Unsal
- Department of Endocrinology and Metabolism, Uludag University School of Medicine, Bursa, Turkey
| | - Adnan Yay
- Department of Endocrinology and Metabolism, Sultan Abdulhamid Han Research and Training Hospital, Istanbul, Turkey
| | - Baris Karagun
- Department of Endocrinology and Metabolism, Cukurova University School of Medicine, Adana, Turkey
| | - Evin Bozkur
- Department of Endocrinology and Metabolism, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
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Stramazzo I, Capriello S, Antonelli A, Fallahi P, Centanni M, Virili C. Seeking optimization of LT4 treatment in patients with differentiated thyroid cancer. Hormones (Athens) 2022; 21:537-543. [PMID: 35655116 PMCID: PMC9712340 DOI: 10.1007/s42000-022-00376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 12/25/2022]
Abstract
Levothyroxine sodium (LT4) is the mainstay treatment to replace thyroid hormonal production in thyroidectomized patients, but, depending on the aggressiveness of the cancer and on the risk of recurrence, patients with differentiated thyroid cancer may also be treated in a TSH-suppressive or semi-suppressive mode. The pathophysiological rationale for this LT4 treatment stems from the role of TSH, considered to be a growth factor for follicular cells, potentially inducing initiation or progression of follicular cell-derived thyroid cancer. Therefore, accurate tailoring of treatment, taking into account both patient characteristics (age and comorbidities) and risk of persistent/recurrent disease, is highly recommended. Furthermore, adjustments to traditional LT4 treatment should be made in thyroidectomized patients due to the lack of thyroidal contribution to whole body triiodothyronine (T3) concentration. Since LT4 exhibits a narrow therapeutic index and the side effects of over- and under-treatment could be deleterious, particularly in this category of patients, caution is required in dose individualization, in the mode of ingestion, and in potential pharmacological and other types of interference as well. Our aim was to analyze the current knowledge concerning LT4 dose requirements in patients with thyroid cancer according to different therapeutic approaches, taking into account a number of factors causing interference with LT4 efficacy. Specific mention is also made about the use of the novel LT4 formulations.
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Affiliation(s)
- Ilaria Stramazzo
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy
- Endocrine Unit, AUSL Latina, Latina, Italy
| | | | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy.
- Endocrine Unit, AUSL Latina, Latina, Italy.
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, ''Sapienza'' University of Rome, Latina, Italy
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Effect of Suppressive Levothyroxine Therapy on Bone Mineral Density in Young Patients with Differentiated Thyroid Carcinoma. Metabolites 2022; 12:metabo12090842. [PMID: 36144246 PMCID: PMC9500704 DOI: 10.3390/metabo12090842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
Suppressive levothyroxine therapy (sT4) is a cornerstone in the management of differentiated thyroid cancer (DTC). Long-term sT4 may affect bone mineral density (BMD). We evaluated the effect of sT4 on the bone mass of young DTC patients. In this cross-sectional study, BMD was evaluated via dual-energy X-ray absorptiometry in DTC patients younger than 25 years at diagnosis and undergoing sT4 for ≥1 year. The two control groups comprised patients matched for sex, age, and body-mass-index who were thyroidectomized for indications other than DTC and undergoing L-T4-replacement therapy, and healthy individuals with no prior known thyroid disease. Ninety-three participants were included (thirty-one in each group). There were no differences in the mean age, female sex (77.4% in all groups), or BMI between the sT4 group and each control group. The median TSH level was lower (0.4 [0.04–6.5] vs. 2.7 [0.8–8.5] mIU/mL, p = 0.01) and the mean L-T4 mcg/Kg levels were higher (2.4 ± 0.6 vs. 1.6 ± 0.3, p = 0.01) in the sT4 group compared to the L-T4-replacement therapy group. Lumbar spine, femoral neck, and total femur BMD were all similar among the groups. sT4 does not impact BMD in young DTC patients after a median time of suppression of 8 years. These findings may help in the decision-making and risk/benefit evaluation of sT4 for this population.
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Sánchez G, Díaz M, Ángel I, Ariza A. Carcinoma de tiroides: Descripción de 634 pacientes atendidos en el Hospital Universitario San Ignacio, Bogotá, D.C., Colombia. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La incidencia del carcinoma de tiroides ha aumentado a nivel mundial, probablemente relacionado con el sobre diagnóstico de nódulos tiroideos asintomáticos. La alta sobrevida del carcinoma diferenciado de tiroides ha permitido posibilidades de manejo quirúrgico menos radicales, o inclusive, la vigilancia activa de tumores seleccionados. Existen reportes de características clínico-patológicas del carcinoma de tiroides de nuestro país distintas a las reportadas en la literatura internacional.
Métodos. Estudio observacional descriptivo de una cohorte retrospectiva de pacientes con carcinoma de tiroides atendidos en un hospital universitario entre 2015 y 2020.
Resultados. Se identificaron 634 pacientes, el 83,4 % de sexo femenino. La tiroidectomía total con vaciamiento central fue el procedimiento más realizado (86,7 %). De 613 carcinomas diferenciados de tiroides, el 94,2 % corresponden al tipo papilar, seguido por el carcinoma de células de Hürtle (1,6 %); el 26,2 % presentaron subtipos histológicos agresivos y el 28,4 % compromiso tumoral bilateral. En los vaciamientos centrales se encontró 58,7 % de enfermedad metastásica; que fue de 49 % en los pacientes con microcarcinomas papilares (19 %). De las 68 lesiones del nervio laríngeo recurrente, 47 % fueron por secciones oncológicas.
Discusión. En nuestra serie, la proporción de pacientes con carcinoma papilar de tiroides y de sus variantes histológicas agresivas, así como el compromiso tumoral bilateral es mayor a lo reportado en la literatura científica.
Conclusión. El comportamiento biológico del carcinoma de tiroides es variable y puede tener características diferentes entre regiones; el manejo en nuestro medio debería considerar las características propias de nuestra población.
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Silaghi H, Lozovanu V, Georgescu CE, Pop C, Nasui BA, Cătoi AF, Silaghi CA. State of the Art in the Current Management and Future Directions of Targeted Therapy for Differentiated Thyroid Cancer. Int J Mol Sci 2022; 23:ijms23073470. [PMID: 35408830 PMCID: PMC8998761 DOI: 10.3390/ijms23073470] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 02/06/2023] Open
Abstract
Two-thirds of differentiated thyroid cancer (DTC) patients with distant metastases would be classified as radioactive iodine-refractory (RAIR-DTC), evolving into a poor outcome. Recent advances underlying DTC molecular mechanisms have shifted the therapy focus from the standard approach to targeting specific genetic dysregulations. Lenvatinib and sorafenib are first-line, multitargeted tyrosine kinase inhibitors (TKIs) approved to treat advanced, progressive RAIR-DTC. However, other anti-angiogenic drugs, including single targeted TKIs, are currently being evaluated as alternative or salvage therapy after the failure of first-line TKIs. Combinatorial therapy of mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K) signalling cascade inhibitors has become a highly advocated strategy to improve the low efficiency of the single agent treatment. Recent studies pointed out targetable alternative pathways to overcome the resistance to MAPK and PI3K pathways’ inhibitors. Because radioiodine resistance originates in DTC loss of differentiation, redifferentiation therapies are currently being explored for efficacy. The present review will summarize the conventional management of DTC, the first-line and alternative TKIs in RAIR-DTC, and the approaches that seek to overcome the resistance to MAPK and PI3K pathways’ inhibitors. We also aim to emphasize the latest achievements in the research of redifferentiation therapy, immunotherapy, and agents targeting gene rearrangements in advanced DTC.
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Affiliation(s)
- Horatiu Silaghi
- Department of Surgery V, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania;
| | - Vera Lozovanu
- County Clinical Emergency Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania;
| | - Carmen Emanuela Georgescu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (C.E.G.); (C.A.S.)
| | - Cristina Pop
- Department of Pharmacology, Physiology, and Pathophysiology, Faculty of Pharmacy, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 6A Louis Pasteur Street, 400349 Cluj-Napoca, Romania
- Correspondence:
| | - Bogdana Adriana Nasui
- Department of Community Health, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 6 Louis Pasteur Street, 400349 Cluj-Napoca, Romania;
| | - Adriana Florinela Cătoi
- Department of Pathophysiology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania;
| | - Cristina Alina Silaghi
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (C.E.G.); (C.A.S.)
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Won HR, Jeon E, Chang JW, Kang YE, Song K, Kim SW, Lim DM, Ha TK, Chung KW, Kim HJ, Park YJ, Koo BS. Is Maintaining Thyroid-Stimulating Hormone Effective in Patients Undergoing Thyroid Lobectomy for Low-Risk Differentiated Thyroid Cancer? A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14061470. [PMID: 35326621 PMCID: PMC8946503 DOI: 10.3390/cancers14061470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary In order to reduce the recurrence rate after surgical treatment of differentiated thyroid cancer (DTC), suppression of thyroid-stimulating hormone (TSH) or maintenance of a certain level after surgery are important. However, the effectiveness of TSH maintenance in the mid to lower reference range (0.5–2 mU/L) in patients undergoing thyroid lobectomy for low-risk DTC is uncertain. In this systematic review and meta-analysis, we compared and analyzed the recurrence rate according to whether TSH maintenance was performed in patients who underwent thyroid lobectomy for low-risk DTC. There was no difference in the recurrence rate with or without TSH control. Therefore, the recommendation to maintain TSH to reduce the recurrence rate after thyroid lobectomy is still controversial. Abstract There is no clear evidence that post-operative maintenance of thyroid-stimulating hormone (TSH) in the mid to lower reference range (0.5–2 mU/L) improves prognosis in patients undergoing thyroid lobectomy for low-risk differentiated thyroid cancer (DTC). The purpose of this systematic review and meta-analysis was to compare and analyze the recurrence rate according to whether the serum TSH level was maintained below 2 mU/L in patients who underwent thyroid lobectomy for low-risk DTC. Clinical data and outcomes were collected from MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. The inclusion criteria were related studies on TSH maintenance or serum TSH concentration after surgery for DTC. Seven observational studies with a total of 3974 patients were included in this study. In the patients who received TSH maintenance less than 2 mU/L, the recurrence rate during the follow-up period was 2.3%. A subgroup analysis of five studies showed that the odds ratio for recurrence in patients who received TSH maintenance was 1.45 (p-value = 0.45) compared to patients who did not receive TSH maintenance. In conclusion, the evidence for the effectiveness of post-operative TSH maintenance less than 2 mU/L in patients undergoing thyroid lobectomy for low-risk DTC is insufficient.
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Affiliation(s)
- Ho-Ryun Won
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Sejong Hospital, Sejong 30099, Korea
| | - Eonju Jeon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu 42472, Korea;
| | - Jae Won Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Yea Eun Kang
- Division of Endocrinology and Metabolism, Departments of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Kunho Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Sungkyunkwan University School of Medicine, Seoul 16419, Korea;
| | - Dong Mee Lim
- Department of Internal Medicine, Konyang University Hospital, Daejeon 35365, Korea;
| | - Tae Kwun Ha
- Department of Surgery, Inje University Busan Paik Hospital, Busan 47392, Korea;
| | - Ki-Wook Chung
- Department of Surgery, Ulsan University College of Medicine, Seoul 05505, Korea;
| | - Hyo-Jeong Kim
- Department of Internal Medicine, Eulji University College of Medicine, Daejeon 34824, Korea;
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: (Y.J.P.); (B.S.K.)
| | - Bon Seok Koo
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
- Correspondence: (Y.J.P.); (B.S.K.)
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Evolución del tratamiento supresor de la TSH al diagnóstico y en el seguimiento en una cohorte de carcinoma diferenciado de tiroides. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Newman SK, Harries V, Wang L, McGill M, Ganly I, Girshman J, Tuttle RM. Invasion of a Recurrent Laryngeal Nerve from Small Well-Differentiated Papillary Thyroid Cancers: Patient Selection Implications for Active Surveillance. Thyroid 2022; 32:164-169. [PMID: 34714169 PMCID: PMC8861915 DOI: 10.1089/thy.2021.0310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: The success of an active surveillance management approach to low-risk papillary thyroid cancer (PTC) is heavily dependent on proper patient selection. For example, primary tumors located in a subcapsular position immediately adjacent to the trachea or a recurrent laryngeal nerve (RLN) are considered to be inappropriate for active surveillance. Since preoperative imaging cannot reliably rule out extrathyroidal extension or reveal the full course of the RLN relative to the thyroid gland, it is important for clinicians to understand subcapsular tumor locations and minimum tumor sizes that are most likely to be associated with gross invasion of the RLNs. Methods: We assessed the medical records of 123 patients treated at Memorial Sloan Kettering Cancer Center (MSK) between 1986 and 2015 who had a primary PTC tumor demonstrating gross extrathyroidal extension to either the right or left RLN. Thirty patients with a primary tumor ≤2 cm in diameter demonstrating extrathyroidal extension into an RLN were included in the analysis. Results: Gross invasion of an RLN by tumors ≤2 cm is a rare event that was seen in only 0.8% (35/4334) of patients with PTC who underwent initial thyroid surgery at MSK between 1986 and 2015. Gross RLN invasion was associated with subcapsular PTC tumors located in either the right paratracheal area (60%), left paratracheal area (36.7%), or right lateral posterior lobe area not adjacent to the trachea (3.3%). Only a quarter of the patients had imaging findings suggestive of extrathyroidal extension and only 30% had clinically apparent vocal paresis/paralysis on preoperative examination. Invasion of the RLN was not observed for primary tumors <0.9 cm in diameter, regardless of tumor location. Conclusions: Well-differentiated PTC tumors ≥0.9 cm in maximal diameter that are located in the right paratracheal, left paratracheal, and right lateral posterior lobe subcapsular positions are usually not appropriate for active surveillance even in the absence of definitive evidence for nerve invasion on preoperative imaging or vocal cord examination. Patient selection for active surveillance management should take into account not only the size and growth rate of a tumor but also its location in relation to the expected course of RLNs.
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Affiliation(s)
- Samantha K. Newman
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Victoria Harries
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Wang
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marlena McGill
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey Girshman
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R. Michael Tuttle
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Address correspondence to: R. Michael Tuttle, MD, Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, USA
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Hsu CJ, Lai KY, Lu YL, Wu MH, Liu FH, Lin SF. Outcomes of Patients With Metastatic Differentiated Thyroid Cancer After Excellent Response to Treatment. Front Endocrinol (Lausanne) 2022; 13:923182. [PMID: 35837311 PMCID: PMC9273717 DOI: 10.3389/fendo.2022.923182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To evaluate the outcomes in differentiated thyroid cancer (DTC) patients who achieved excellent response to initial treatment and developed distant metastasis during follow-up. METHODS Thyroid cancer patients registered in Chang Gung Memorial Hospital thyroid cancer database between January 1979 and December 2019 were assessed. RESULTS Among 1053 DTC patients with excellent response to initial therapy, 14 (1.3%) patients developed metastatic disease during follow-up, including 6 males and 8 females with median age of 50.2 years [interquartile range (IQR), 39.9-53.7]. Nine (64.3%) patients had papillary cancer, four (28.6%) had follicular cancer, and one (7.1%) had Hürthle cell cancer. Most patients (92.9%) had stage I disease at diagnosis. The sites of metastasis were lung (71.4%), bone (7.1%), mediastinum (7.1%) and multiple sites (14.3%). With a median follow-up of 18.3 years (IQR, 14.8-23.8), 2 patients had disease-specific mortality. The 5- and 10-year disease-specific survival after the diagnosis of distant metastasis was 92% and 74%, respectively. Multiple sites of metastasis was associated with increased risk of mortality (P = 0.022). CONCLUSIONS A small proportion of DTC patients with an excellence response to initial therapy developed distant metastasis during follow-up. Multiple organ distant metastases conferred a worse disease-specific survival.
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Affiliation(s)
- Chia-Jung Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Kun-Yu Lai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Ling Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (built and operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Ming-Hsien Wu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (built and operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Feng-Hsuan Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- *Correspondence: Shu-Fu Lin, ; Feng-Hsuan Liu,
| | - Shu-Fu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (built and operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- *Correspondence: Shu-Fu Lin, ; Feng-Hsuan Liu,
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De Marchi AF, de Macedo ABT, Soares CSP, Bolfi F, Iessi MRG, de Oliveira CC, Koga KH, Moriguchi SM, Tagliarini JV, da Silva Mazeto GMF. Thyroglobulin/thyrotropin ratio for predicting long-term response in differentiated thyroid carcinoma: a retrospective study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:428-435. [PMID: 34283903 PMCID: PMC10522177 DOI: 10.20945/2359-3997000000387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Thyrotropin-stimulated thyroglobulin (STg) after total thyroidectomy is a prognosis marker for differentiated thyroid carcinoma (DTC). As Tg level is influenced by thyrotropin (TSH), perhaps the STg/TSH ratio is also a prognosis marker for these tumours. We aimed to compare STg/TSH ratio and first STg level in differentiated thyroid carcinoma patients for their ability to predict the long-term response to initial treatment. METHODS This retrospective study evaluated data from 181 DTC patients for first (1st) STg and STg/TSH ratio, at 1-3 months post-total thyroidectomy and before iodine-131 therapy, according to response to initial therapy [Excellent/Indeterminate or Incomplete (Biochemical/Structural)] observed at final evaluation, and with the survival time with excellent/indeterminate response. RESULTS Cases with incomplete response presented higher STg level [225.13 ± 585.26 ng/mL versus (vs) 20.4 ± 192.9 ng/mL; p < 0.001] and STg/TSH ratio (3.01 ± 7.8 vs 0.27 ± 2.58; p < 0.001). Cutoffs of 5 ng/mL for STg and 0.085 for STg/TSH displayed sensitivities of 76.7% and 76.9%, and specificities of 79.2% and 82.6%, respectively, in predicting response to therapy. Values below these cutoffs were associated with longer survival time in excellent/indeterminate response (140.4 vs 15.9 and 144.6 vs 15.9 months, respectively). CONCLUSION STg/TSH ratio has a similar performance to the 1st STg in predicting long-term response to initial therapy.
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Affiliation(s)
- Adriano Francisco De Marchi
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Ana Bárbara Trizzotti de Macedo
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Carlos Segundo Paiva Soares
- Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Fernanda Bolfi
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Mariana Riello Gomes Iessi
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Cristiano Claudino de Oliveira
- Departamento de Patologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Katia Hiromoto Koga
- Departamento de Medicina Nuclear, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Sonia Marta Moriguchi
- Departamento de Medicina Nuclear, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - José Vicente Tagliarini
- Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
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Papaleontiou M, Chen DW, Banerjee M, Reyes-Gastelum D, Hamilton AS, Ward KC, Haymart MR. Thyrotropin Suppression for Papillary Thyroid Cancer: A Physician Survey Study. Thyroid 2021; 31:1383-1390. [PMID: 33779292 PMCID: PMC8558057 DOI: 10.1089/thy.2021.0033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Current guidelines recommend against thyrotropin (TSH) suppression in low-risk differentiated thyroid cancer patients; however, physician practices remain underexplored. Our objective was to understand treating physicians' approach to TSH suppression in patients with papillary thyroid cancer. Methods: Endocrinologists and surgeons identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles were surveyed in 2018-2019. Physicians were asked to report how likely they were to recommend TSH suppression (i.e., TSH <0.5 mIU/L) in three clinical scenarios: patients with intermediate-risk, low-risk, and very low-risk papillary thyroid cancer. Responses were measured on a 4-point Likert scale (extremely unlikely to extremely likely). Multivariable logistic regressions were performed to determine physician characteristics associated with recommending TSH suppression in each of the aforementioned scenarios. Results: Response rate was 69% (448/654). Overall, 80.4% of physicians were likely/extremely likely to recommend TSH suppression for a patient with an intermediate-risk papillary thyroid cancer, 48.8% for a patient with low-risk papillary thyroid cancer, and 29.7% for a patient with very low-risk papillary thyroid cancer. Surgeons were less likely to recommend TSH suppression for an intermediate-risk papillary thyroid cancer patient (odds ratio [OR] = 0.36 [95% confidence interval, CI, 0.19-0.69]) compared with endocrinologists. Physicians with higher thyroid cancer patient volume were less likely to suppress TSH in low-risk and very low-risk papillary thyroid cancer patients (i.e., >40 patients per year, OR = 0.53 [CI 0.30-0.96]; OR = 0.49 [CI 0.24-0.99], respectively, compared with 0-20 patients per year). Physicians who estimated higher likelihood of recurrence were more likely to suppress TSH in a patient with very low-risk papillary thyroid cancer (OR = 2.34 [CI 1.91-4.59]). Conclusions: Many patients with low-risk thyroid cancer continue to be treated with suppressive doses of thyroid hormone, emphasizing the need for more high-quality research to guide thyroid cancer management, as well as better understanding of barriers that hinder guideline adoption.
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Affiliation(s)
- Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie W. Chen
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Address correspondence to: Megan R. Haymart, MD, Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16, Room 408E, Ann Arbor, MI 48109, USA.
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Nabhan F, Dedhia PH, Ringel MD. Thyroid cancer, recent advances in diagnosis and therapy. Int J Cancer 2021; 149:984-992. [PMID: 34013533 DOI: 10.1002/ijc.33690] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 12/23/2022]
Abstract
Over the past several decades, the approach to the diagnosis and management of patients with follicular cell-derived thyroid cancer has evolved based on improved classification of patients better matching clinical outcomes, as well as advances in imaging, laboratory, molecular technologies and knowledge. While thyroid surgery, radioactive iodine therapy and TSH suppression remain the mainstays of treatment, this expansion of knowledge has enabled de-escalation of therapy for individuals diagnosed with low-risk well-differentiated thyroid cancer; better definition of treatment choices for patients with more aggressive disease; and improved ability to optimize treatments for patients with persistent and/or progressive disease. Most recently, the advancement of knowledge regarding the molecular aspects of thyroid cancer has improved thyroid cancer diagnosis and has enabled individualized therapeutic options for selected patients with the most aggressive forms of the disease. Guidelines from multiple societies across the world reflect these changes, which focus on taking a more individualized approach to clinical management. In this review, we discuss the current more personalized approach to patients with follicular cell-derived thyroid cancer and point toward areas of future research still needed in the field.
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Affiliation(s)
- Fadi Nabhan
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Cancer Biology Program, Arthur G. James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Priya H Dedhia
- Cancer Biology Program, Arthur G. James Comprehensive Cancer Center, Columbus, Ohio, USA.,Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Cancer Biology Program, Arthur G. James Comprehensive Cancer Center, Columbus, Ohio, USA
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20
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Schlumberger M, Leboulleux S. Current practice in patients with differentiated thyroid cancer. Nat Rev Endocrinol 2021; 17:176-188. [PMID: 33339988 DOI: 10.1038/s41574-020-00448-z] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 01/30/2023]
Abstract
Considerable changes have occurred in the management of differentiated thyroid cancer (DTC) during the past four decades, based on improved knowledge of the biology of DTC and on advances in therapy, including surgery, the use of radioactive iodine (radioiodine), thyroid hormone treatment and availability of recombinant human TSH. Improved diagnostic tools are available, including determining serum levels of thyroglobulin, neck ultrasonography, imaging (CT, MRI, SPECT-CT and PET-CT), and prognostic classifications have been improved. Patients with low-risk DTC, in whom the risk of thyroid cancer death is <1% and most recurrences can be cured, currently represent the majority of patients. By contrast, patients with high-risk DTC represent 5-10% of all patients. Most thyroid cancer-related deaths occur in this group of patients and recurrences are frequent. Patients with high-risk DTC require more aggressive treatment and follow-up than patients with low-risk DTC. Finally, the strategy for treating patients with intermediate-risk DTC is frequently defined on a case-by-case basis. Prospective trials are needed in well-selected patients with DTC to demonstrate the extent to which treatment and follow-up can be limited without increasing the risk of recurrence and thyroid cancer-related death.
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Affiliation(s)
- Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Institut Gustave Roussy and Université Paris Saclay, Villejuif, France.
| | - Sophie Leboulleux
- Department of Nuclear Medicine and Endocrine Oncology, Institut Gustave Roussy and Université Paris Saclay, Villejuif, France
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21
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Schumm MA, Lechner MG, Shu ML, Ochoa JE, Kim J, Tseng CH, Leung AM, Yeh MW. Frequency of Thyroid Hormone Replacement After Lobectomy for Differentiated Thyroid Cancer. Endocr Pract 2021; 27:691-697. [PMID: 33642257 DOI: 10.1016/j.eprac.2021.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the frequency of levothyroxine (LT4) supplementation after therapeutic lobectomy for low-risk differentiated thyroid cancer (DTC). METHODS This retrospective cohort study enrolled adult patients with low-risk DTC confirmed using surgical pathology who underwent therapeutic lobectomy at a single institution from January 2016 through May 2020. The outcome measures were postoperative serum thyroid-stimulating hormone (TSH) levels and the initiation of LT4. The predictors of a postoperative TSH level of >2 mU/L and initiation of LT4 were evaluated using Cox proportional hazards models. RESULTS Postoperative TSH levels were available for 115 patients (91%), of whom 97 (84%) had TSH levels >2 mU/L after thyroid lobectomy. Over a median follow-up of 2.6 years, a postoperative TSH level of >2 mU/L was associated with older age (median 52 vs 37 years; P = .01), higher preoperative TSH level (1.7 vs 0.85 mU/L; P < .001), and primary tumor size of <1 cm (38% vs 11%, P = .03). Multivariate analysis revealed that only preoperative TSH level was an independent predictor of a postoperative TSH level of >2 mU/L (hazard ratio [HR] 1.53, P = .003). Among patients with a postoperative TSH level of >2 mU/L, 66 (68%) were started on LT4 at a median of 74 days (interquartile range 41-126) after lobectomy, with 51 (77%) undergoing at least 1 subsequent dose adjustment to maintain compliance with current guidelines. CONCLUSION More than 80% of the patients who underwent therapeutic lobectomy for DTC developed TSH levels that were elevated beyond the recommended range, and most of these patients were prescribed LT4 soon after the surgery.
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Affiliation(s)
- Max A Schumm
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California.
| | - Melissa G Lechner
- Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michelle L Shu
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Joana E Ochoa
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jiyoon Kim
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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22
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Tourani SS, Fleming B, Gundara J. Value of thyroglobulin post hemithyroidectomy for cancer: a literature review. ANZ J Surg 2020; 91:724-729. [PMID: 33244886 DOI: 10.1111/ans.16459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND An increasing number of patients with low and moderate risk differentiated thyroid cancer (DTC) are now managed with lobectomy alone. The value of serum thyroglobulin (Tg) in the follow up of these patients remains poorly defined. METHODS A review of the MEDLINE and EMBASE databases was performed to assess the utility of Tg in the follow up of patients undergoing thyroid lobectomy for DTC. RESULTS A total of five retrospective reviews were identified including 1136 patients undergoing hemithyroidectomy with or without prophylactic central neck dissection. The overall locoregional recurrence rate was 3.7%. Changes in serum Tg following hemithyroidectomy for cancer were found to be clinically useful in one study only. The proposed cut-off value of 30 ng/mL following hemithyroidectomy as a predictor of recurrent disease was not validated by any study. CONCLUSION Serum Tg values are not useful in the follow up of DTC patients managed with lobectomy alone. Good quality neck ultrasound appears to be an effective modality in the detection of locoregional recurrence in these patients while research efforts continue to identify and validate novel biomarkers.
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Affiliation(s)
- Saam S Tourani
- Department of Surgery, Division of Breast and Endocrine Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Bill Fleming
- Endocrine Surgery Unit, Western Health, Melbourne, Victoria, Australia
| | - Justin Gundara
- School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Metro South QLD Health and Griffith University, Brisbane, Queensland, Australia
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Marotta V, Botti G, Ionna F, Pezzullo L. TSH modulation in advanced differentiated thyroid cancer: a continuous walk on the tightrope between prognostic stratification, adverse events, and levothyroxine bioavailability. Minerva Endocrinol (Torino) 2020; 47:99-102. [PMID: 33213117 DOI: 10.23736/s2724-6507.20.03334-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Vincenzo Marotta
- Service of Oncologic Thyroid Surgery, Istituto Nazionale Tumori - IRCCS G. Pascale Foundation, Naples, Italy -
| | - Gerardo Botti
- Service of Anatomic Pathology and Cytopathology, Istituto Nazionale Tumori - IRCCS G. Pascale Foundation, Naples, Italy
| | - Franco Ionna
- Service of Maxillofacial and ENT Oncologic Surgery, Istituto Nazionale Tumori - IRCCS G. Pascale Foundation, Naples, Italy
| | - Luciano Pezzullo
- Service of Oncologic Thyroid Surgery, Istituto Nazionale Tumori - IRCCS G. Pascale Foundation, Naples, Italy
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24
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Colombo C, Giancola N, Fugazzola L. Personalized treatment for differentiated thyroid cancer: current data and new perspectives. Minerva Endocrinol (Torino) 2020; 46:62-89. [PMID: 33213119 DOI: 10.23736/s2724-6507.20.03342-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
More conservative and personalized treatment options have been developed in recent years to face the rising diagnosis of low-risk differentiated thyroid carcinoma (DTC). The present review describes the change towards a more risk-adapted management either in the treatment or in the follow-up of DTC. Particular attention is given to the innovations introduced by the latest guidelines for low-risk tumors, starting from the most appropriate extension of surgery up to the postoperative management. The emerging role of active surveillance for low-risk microcarcinoma is discussed, as well as the development of percutaneous strategies in the setting of malignant thyroid disease. The recent use of approved new systemic target therapies for advanced radioiodine refractory thyroid cancer is reported, together with the description of new compounds in trial. Finally, we provide some considerations to improve the risk evaluation in a presurgical setting, especially related to the rising role of genetics, to enable better risk-based cancer management and personalized treatment choices.
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Affiliation(s)
- Carla Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy - .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy -
| | - Noemi Giancola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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25
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Ito Y, Onoda N, Okamoto T. The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer. Endocr J 2020; 67:669-717. [PMID: 32269182 DOI: 10.1507/endocrj.ej20-0025] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.
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Affiliation(s)
- Yasuhiro Ito
- Department of Clinical Trial, Kuma Hospital, Kobe 650-0011, Japan
| | - Naoyoshi Onoda
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Takahiro Okamoto
- Department of Breast and Endocrine Surgery, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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26
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Gambale C, Elisei R, Matrone A. Management and follow-up of differentiated thyroid cancer not submitted to radioiodine treatment: a systematic review. MINERVA ENDOCRINOL 2020; 45:306-317. [PMID: 32623845 DOI: 10.23736/s0391-1977.20.03240-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The treatment of differentiated thyroid cancer (DTC) has been changing. In low (LR) and intermediate (IR) risk DTC, surgery is becoming more conservative and the usefulness of radioiodine (131I) has been questioned. An increasing number of patients are treated with lobectomy or total thyroidectomy (TTx), but without 131I. Consequently, the management and the follow-up of these patients need to be revised. EVIDENCE ACQUISITION We reviewed the available data about the management of these growing categories of patients. We focused on the emerging roles of the conventional tools in the follow-up [thyroglobulin (Tg), thyroglobulin antibodies (TgAb) and neck ultrasound (US)]. Moreover, we evaluated the changes in the use of levothyroxine (L-T4) therapy, and the role of the ongoing risk re-stratification. EVIDENCE SYNTHESIS Tg, TgAb and neck US continue to represent the cornerstone of the follow-up, however, a change in their interpretation is needed. In particular, the absolute value of Tg and TgAb lost their clinical meaning, while their trend over time acquired a greater value. At variance, the diagnostic role of neck US is becoming very relevant for the early identification of the local recurrences. In addition, L-T4 therapy should be personalized according with the type of surgery, the age of patients and their comorbidities. CONCLUSIONS Management of DTC treated with lobectomy or TTx but without 131I is worldwide changing. The evidences suggest that in this setting of patients with LR or IR of recurrences, a relaxed surveillance could represent the most reasonable choice.
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Affiliation(s)
- Carla Gambale
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Rossella Elisei
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Antonio Matrone
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy -
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27
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Abstract
Thyroid hormones stimulate bone turnover in adults by increasing osteoclastic bone resorption. TSH suppressive therapy is usually applied in patients with differentiated thyroid cancer (DTC) to improve the disease outcome. Over the last decades several authors have closely monitored the potential harm suffered by the skeletal system. Several studies and meta-analyses have shown that chronic TSH suppressive therapy is safe in premenopausal women and men. Conversely, in postmenopausal women TSH suppressive therapy is associated with a decrease of bone mineral density, deterioration of bone architecture (quantitative CT, QCT; trabecular bone score, TBS), and, possibly, an increased risk of fractures. The TSH receptor is expressed in bone cells and the results of experimental studies in TSH receptor knockout mice and humans on whether low TSH levels, as opposed to solely high thyroid hormone levels, might contribute to bone loss in endogenous or exogenous thyrotoxicosis remain controversial. Recent guidelines on the use of TSH suppressive therapy in patients with DTC give value not only to its benefit on the outcome of the disease, but also to the risks associated with exogenous thyrotoxicosis, namely menopause, osteopenia or osteoporosis, age >60 years, and history of atrial fibrillation. Bone health (BMD and/or preferably TBS) should be evaluated in postmenopausal women under chronic TSH suppressive therapy or in those patients planning to be treated for several years. Antiresorptive therapy could also be considered in selected cases (increased risk of fracture or significant decline of BMD/TBS during therapy) to prevent bone loss.
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Affiliation(s)
- Alessandro Brancatella
- Endocrine Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Endocrine Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Correspondence should be addressed to C Marcocci:
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28
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Hawkins Carranza F, Guadalix Iglesias S, Luisa De Mingo Domínguez M, Martín-Arriscado Arroba C, López Álvarez B, Allo Miguel G, Martínez Díaz-Guerra G. Trabecular bone deterioration in differentiated thyroid cancer: Impact of long-term TSH suppressive therapy. Cancer Med 2020; 9:5746-5755. [PMID: 32583973 PMCID: PMC7433843 DOI: 10.1002/cam4.3200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 01/16/2023] Open
Abstract
Background Conflicting results has been reported regard osteoporosis and fractures in patients with Differentiated Thyroid Cancer (DTC). Our objective was to evaluate the long‐term effects of TSH suppression therapy with Levothyroxine (LT4) on trabecular bone score (TBS) and bone mineral density (BMD) in females with DTC after thyroidectomy. Methods About 145 women with resected DTC and receiving long‐term TSH therapy, were stratified according to the degree of TSH suppression. Mean duration of follow‐up was 12.3 ± 6.1 years. BMD and TBS, were assessed using dual‐energy X‐ray absorptiometry (DXA) and TBS iNsight (Med‐Imaps), at baseline (1‐3 months after surgery) and at the final study visit. Results In patients stratified by duration of TSH suppression therapy (Group I, 5‐10 years; Group II, >10 years), slight increases from baseline TSH levels were observed. Significant decreases in LS‐BMD and FN‐BMD were seen in patients after >10 years. TBS values were lower in Groups I (1.289 ± 0.122) and II (1.259 ± 0.129) compared with baseline values (P = .0001, both groups). Regarding the degree of TSH suppression, TBS was significantly reduced in those with TSH < 0.1 µU/mL (P = .0086), and not in patients with TSH suppression of 0.1.‐0.5 or >0.5 µU/mL. Conclusions We found deterioration of trabecular structure in patients with DTC and TSH suppression therapy below 0.1 µU/mL and after 5‐10 years of follow‐up. Significant changes in BMD according to TSH levels were not observed. Trabecular Bone Score is a useful technique for identifying thyroid cancer patients with risk of bone deterioration.
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29
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Ahn D, Lee GJ, Sohn JH, Jeon JH. Oncological impact of hypothyroidism and levothyroxine supplementation following hemithyroidectomy in patients with papillary thyroid carcinoma. Head Neck 2020; 42:1004-1013. [PMID: 31930773 DOI: 10.1002/hed.26075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/06/2019] [Accepted: 12/31/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND We aimed to evaluate the oncological impact of hypothyroidism and levothyroxine (LT) supplementation after hemithyroidectomy in patients with papillary thyroid carcinoma (PTC). METHODS We retrospectively examined 401 patients who underwent hemithyroidectomy for classic PTC and who were postoperatively followed-up with ≥3 thyroid function measurements for ≥24 months. RESULTS During 77.4 months of follow-up, 268/401 patients (66.8%) developed hypothyroidism and 19/401 patients (4.7%) showed recurrence. Recurrence rates did not differ between the euthyroidism and hypothyroidism development groups. Recurrence rates were significantly lower in the LT group than in the no-LT group, although mean postoperative thyroid-stimulating hormone (TSH) levels were not different between the two groups. Univariate and multivariate analysis showed that tumors sized >1 cm and lack of LT supplementation were significantly associated with recurrence. CONCLUSIONS Postoperative hypothyroidism development was not a risk factor for PTC recurrence after hemithyroidectomy. Nevertheless, LT supplementation reduced recurrence risk without suppressing TSH.
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Affiliation(s)
- Dongbin Ahn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Gil J Lee
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jin H Sohn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae H Jeon
- Department of Endocrinology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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30
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Kim SY, Kim HJ, Kim SM, Chang H, Lee YS, Chang HS, Park CS. Thyroid Hormone Supplementation Therapy for Differentiated Thyroid Cancer After Lobectomy: 5 Years of Follow-Up. Front Endocrinol (Lausanne) 2020; 11:520. [PMID: 32849303 PMCID: PMC7412630 DOI: 10.3389/fendo.2020.00520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Lobectomy with preservation of the contralateral lobe has already become the most preferred surgical method for patients with low-risk thyroid cancer. The incidence of and risk factors for the development of hypothyroidism after lobectomy for thyroid cancer remains unclear. The previous practice of levothyroxine supplementation post-thyroidectomy, to bring about thyroid stimulating hormone (TSH) suppression, had some serious side effects. This study aimed to evaluate the incidence of hypothyroidism and to identify the factors associated with hypothyroidism requiring thyroid hormone replacement. Methods: We retrospectively reviewed the charts of 256 consecutive patients with differentiated thyroid cancer treated with lobectomy at the Gangnam Severance Hospital between April and December 2014 who were followed-up for more than 5 years. Patients were evaluated using a thyroid function test at the time of outpatient visit every 6 months for the 1st year, with an annual follow-up thereafter. Results: After 5 years, 66.0% (169) of the patients needed levothyroxine supplementation to maintain euthyroid status. The incidence of hypothyroidism requiring levothyroxine supplementation increased until 3 years but showed no significant change in the 4 and 5th year. Recurrence showed no difference between the group with and without levothyroxine supplementation. The presence of thyroiditis and preoperative TSH levels were correlated with postoperative levothyroxine supplementation to maintain euthyroid status, in univariate and multivariate analyses. Conclusion: High preoperative TSH levels and/or thyroiditis indicate a significantly increased likelihood of developing hypothyroidism requiring thyroid hormone supplementation after a thyroid lobectomy. Patients with an increased risk of postoperative hypothyroidism must be aware of their risk factors and should undergo more intensive follow-ups.
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Affiliation(s)
- Soo Young Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Hee Jun Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Seok-Mo Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Hojin Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Sang Lee
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Yong Sang Lee
| | - Hang-Seok Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheong Soo Park
- Department of Surgery, CHA Ilsan Medical Center, Goyang-si, South Korea
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31
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Filetti S, Durante C, Hartl D, Leboulleux S, Locati LD, Newbold K, Papotti MG, Berruti A. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol 2019; 30:1856-1883. [PMID: 31549998 DOI: 10.1093/annonc/mdz400] [Citation(s) in RCA: 491] [Impact Index Per Article: 98.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
MESH Headings
- Humans
- Adenocarcinoma, Follicular/diagnosis
- Adenocarcinoma, Follicular/epidemiology
- Adenocarcinoma, Follicular/pathology
- Adenocarcinoma, Follicular/therapy
- Carcinoma, Neuroendocrine/diagnosis
- Carcinoma, Neuroendocrine/epidemiology
- Carcinoma, Neuroendocrine/pathology
- Carcinoma, Neuroendocrine/therapy
- Follow-Up Studies
- Thyroid Cancer, Papillary/diagnosis
- Thyroid Cancer, Papillary/epidemiology
- Thyroid Cancer, Papillary/pathology
- Thyroid Cancer, Papillary/therapy
- Thyroid Carcinoma, Anaplastic/diagnosis
- Thyroid Carcinoma, Anaplastic/epidemiology
- Thyroid Carcinoma, Anaplastic/pathology
- Thyroid Carcinoma, Anaplastic/therapy
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/epidemiology
- Thyroid Neoplasms/pathology
- Thyroid Neoplasms/therapy
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Affiliation(s)
- S Filetti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - C Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - D Hartl
- Department of Head and Neck Oncology, Gustave Roussy, Villejuif; Université Paris Saclay, Villejuif
| | - S Leboulleux
- Université Paris Saclay, Villejuif; Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy, Villejuif, France
| | - L D Locati
- Head and Neck Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - K Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - M G Papotti
- Department of Pathology, University of Turin, Turin
| | - A Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Medical Oncology Unit, University of Brescia, ASST Spedali Civili, Brescia, Italy
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32
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McLeod DSA, Zhang L, Durante C, Cooper DS. Contemporary Debates in Adult Papillary Thyroid Cancer Management. Endocr Rev 2019; 40:1481-1499. [PMID: 31322698 DOI: 10.1210/er.2019-00085] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/05/2019] [Indexed: 02/06/2023]
Abstract
An ever-increasing population of patients with papillary thyroid cancer is engaging with health care systems around the world. Numerous questions about optimal management have arisen that challenge conventional paradigms. This is particularly the case for patients with low-risk disease, who comprise most new patients. At the same time, new therapies for patients with advanced disease are also being introduced, which may have the potential to prolong life. This review discusses selected controversial issues in adult papillary thyroid cancer management at both ends of the disease spectrum. These topics include: (i) the role of active surveillance for small papillary cancers; (ii) the extent of surgery in low-risk disease (lobectomy vs total thyroidectomy); (iii) the role of postoperative remnant ablation with radioiodine; (iv) optimal follow-up strategies in patients, especially those who have only undergone lobectomy; and (v) new therapies for advanced disease. Although our current management is hampered by the lack of large randomized controlled trials, we are fortunate that data from ongoing trials will be available within the next few years. This information should provide additional evidence that will decrease morbidity in low-risk patients and improve outcomes in those with distant metastatic disease.
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Affiliation(s)
- Donald S A McLeod
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Ling Zhang
- Department of Head and Neck Surgery, Fudan University Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Cosimo Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Grani G, Ramundo V, Verrienti A, Sponziello M, Durante C. Thyroid hormone therapy in differentiated thyroid cancer. Endocrine 2019; 66:43-50. [PMID: 31617165 DOI: 10.1007/s12020-019-02051-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Abstract
Surgery-with or without postoperative radioiodine-is the standard of care for most patients with differentiated thyroid carcinoma (DTC). Thyroid hormone replacement therapy is the mainstay of long-term medical management. Patients treated with total thyroidectomy and some who undergo lobectomy alone require thyroid hormone therapy to restore euthyroidism with normal serum thyroid-stimulating hormone (TSH) levels. Because TSH acts as a growth factor for thyroid follicular cells (including those that are neoplastic), it can potentially affect the onset and/or progression of follicular-cell derived thyroid cancer. For this reason, some patients are placed on thyroid hormone therapy at doses that suppress secretion of TSH (suppression therapy). This mini-review looks at the potential benefits and risks of this practice in patients diagnosed with DTC. Aggressive TSH-suppressive therapy is of little or no benefit to the vast majority of patients with DTC. Practice guidelines, therefore, recommend a graded algorithm in which the potential benefits of suppression are weighed against the associated cardiovascular and skeletal risks. Large randomized controlled studies are needed to confirm the presumed oncological benefits of TSH-suppression and its causal role in adverse cardiac, skeletal, and quality of life effects and to assess the efficacy of TSH normalization in reversing or reducing these effects.
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Affiliation(s)
- Giorgio Grani
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Ramundo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Antonella Verrienti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marialuisa Sponziello
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cosimo Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
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Saito Y, Matsuzu K, Sugino K, Takami H, Kitagawa W, Nagahama M, Ito K. The impact of completion thyroidectomy followed by radioactive iodine ablation for patients with lymph node recurrence of papillary thyroid carcinoma. Surgery 2019; 166:342-348. [DOI: 10.1016/j.surg.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/29/2019] [Accepted: 04/16/2019] [Indexed: 11/28/2022]
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Optimal Thyrotropin Suppression Therapy in Low-Risk Thyroid Cancer Patients after Lobectomy. J Clin Med 2019; 8:jcm8091279. [PMID: 31443521 PMCID: PMC6780946 DOI: 10.3390/jcm8091279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 12/16/2022] Open
Abstract
Background: This study aimed to identify the clinical results after thyrotropin suppression therapy (TST) cessation and evaluated clinical factors associated with successful TST cessation. Methods: Patients who underwent lobectomy due to low-risk papillary thyroid carcinoma (PTC) were included in this study. We compared clinical characteristics and outcomes between patients who succeeded to stop TST and failed to stop TST. Results: A total of 363 patients were included in the study. One hundred and ninety-three patients (53.2%, 193/363) succeeded to stop TST. The independent associated factors for successful TST cessation were the preoperative thyroid-stimulating hormone (TSH) level and the maintenance period of TST. Patients with low TSH level showed a higher success rate for levothyroxine (LT4) cessation than patients with high TSH level (1.79 ± 1.08 and 2.76 ± 1.82 mU/L, p < 0.001). Patients who failed to discontinue TST showed a longer maintenance period of TST than patients who succeeded to discontinue TST (54.09 ± 17.44 and 37.58 ± 17.68 months, p < 0.001). Conclusions: Preoperative TSH level and maintenance period of TST are important factors for successful cessation of TST. If TST cessation is planned for patients who are taking LT4 after lobectomy, a higher success rate of TST cessation is expected with low preoperative TSH level and early cessation of LT4.
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Izkhakov E, Vaisman N, Barnes S, Barchana M, Stern N, Keinan-Boker L. Body Composition, Resting Energy Expenditure, and Metabolic Changes in Women Diagnosed with Differentiated Thyroid Carcinoma. Thyroid 2019; 29:1044-1051. [PMID: 31088334 PMCID: PMC6707037 DOI: 10.1089/thy.2018.0483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Thyroid hormones heavily impact energy expenditure, body mass, and body composition. Their role in the state of exogenous subclinical hyperthyroidism in differentiated thyroid carcinoma (DTC) patients, however, is less well defined. The first aim of this study was to assess changes in body weight, body composition, resting energy expenditure (REE), respiratory quotient (RQ), and metabolic parameters in female DTC patients, starting from the phase of a euthyroid state before total thyroidectomy through the subsequent year after thyrotropin (TSH) suppression. The second aim was to assess the relationship between these variables and thyroid function parameters. Methods: This observational case series analyzed changes in body composition, calorimetric, and metabolic parameters of 15 DTC female patients at 5 time points: (1) at initial DTC diagnosis (euthyroid state), (2) at 2-3 weeks after thyroidectomy (hypothyroid state), (3) at 2-3 months of levothyroxine (LT4) treatment (exogenous euthyroid state), (4) after 6-9 months, and (5) after 1 year of TSH suppressive LT4 therapy (exogenous subclinical hyperthyroid state). A generalized estimating equation (GEE) analysis was performed to estimate the longitudinal correlations of the total triiodothyronine (TT3)/free thyroxine (fT4) ratio (as an independent variable) with body composition, metabolic, and calorimetric parameter changes (as dependent variables). Results: REE, REE per kilogram of lean body mass (REE/LBM), pulse, and systolic and diastolic blood pressure were significantly higher after TSH suppressive LT4 therapy. The GEE analysis revealed longitudinal negative correlations between the TT3/fT4 ratio and systolic blood pressure, fasting blood glucose, body mass index, android (abdominal wall and visceral mesentery) fat distribution, trunk, and arm fat distribution, REE, and REE/LBM. There was a positive correlation with RQ. Conclusions: REE, REE/LBM, pulse, and systolic and diastolic blood pressure were significantly higher after thyroidectomy, radioiodine and TSH suppressive therapy in female DTC patients, while no changes were observed in body weight or body composition. A lower TT3/fT4 ratio longitudinally correlated with increases in REE, REE/LBM, abdominal fat distribution, systolic blood pressure, and fasting blood glucose, as well as with decreased RQ. These findings highlight the importance of judicial balancing of the benefits and detriments of TSH suppression with subsequent decreased TT3/fT4 ratios for female DTC patients.
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Affiliation(s)
- Elena Izkhakov
- Institute of Endocrinology, Metabolism and Hypertension; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Address correspondence to: Elena Izkhakov, MD, PhD, Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv 64233, Israel
| | - Nachum Vaisman
- Unit of Clinical Nutrition, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sophie Barnes
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Ultrasound Division of Imaging, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Micha Barchana
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Naftali Stern
- Institute of Endocrinology, Metabolism and Hypertension; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lital Keinan-Boker
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- National Cancer Registry, Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
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Tian T, Huang R, Liu B. Is TSH suppression still necessary in intermediate- and high-risk papillary thyroid cancer patients with pre-ablation stimulated thyroglobulin <1 ng/mL before the first disease assessment? Endocrine 2019; 65:149-154. [PMID: 30924085 DOI: 10.1007/s12020-019-01914-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/19/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Since papillary thyroid cancer (PTC) patients with pre-ablation stimulated thyroglobulin (s-Tg) < 1 ng/mL generally have a favorable prognosis, is TSH suppression still necessary in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL after initial therapy? The aim of this study was to assess the rate of disease recurrence in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL according to TSH levels measured 1 year after initial therapy. METHODS A retrospective series of intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL was analyzed. Disease status was defined as the presence or absence of structural disease during late follow-up. Patients were grouped according to TSH level at 1 year: group 1, TSH < 0.1 mIU/L; group 2, TSH 0.1‒0.5 mIU/L; group 3, 0.5‒2 mIU/L; group 4, >2 mIU/L. RESULTS This study included 166 patients (78.3% females, median age 44 years) of whom the risk of recurrence was intermediate in 97 (58.4%) and high in 69 (41.6%). The response to initial therapy at 1 year was excellent in 163 patients (98.2%) and indeterminate in 3 (1.8%). Group 1 consisted of 63 patients (38%), group 2 of 47 (28%), group 3 of 28 (17%), and group 4 of 28 (17%). During a median follow-up duration of 5.8 years, disease recurrence was observed in only 4 patients (2.4%). The rate of disease recurrence was not significantly different between the TSH groups. CONCLUSION TSH suppression before the first response to treatment assessment does not seem to influence the rate of disease recurrence after initial therapy in intermediate- and high-risk PTC patients with pre-ablation s-Tg < 1 ng/mL.
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Affiliation(s)
- Tian Tian
- Department of Nuclear Medicine, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Rui Huang
- Department of Nuclear Medicine, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Bin Liu
- Department of Nuclear Medicine, West China Hospital, Sichuan University, 610041, Chengdu, China.
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Lee MC, Kim MJ, Choi HS, Cho SW, Lee GH, Park YJ, Park DJ. Postoperative Thyroid-Stimulating Hormone Levels Did Not Affect Recurrence after Thyroid Lobectomy in Patients with Papillary Thyroid Cancer. Endocrinol Metab (Seoul) 2019; 34:150-157. [PMID: 31099202 PMCID: PMC6599911 DOI: 10.3803/enm.2019.34.2.150] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Thyroid-stimulating hormone (TSH) suppression is recommended for patients who undergo thyroidectomy for differentiated thyroid cancer (DTC). However, the impact of TSH suppression on clinical outcomes in low-risk DTC remains uncertain. Therefore, we investigated the effects of postoperative TSH levels on recurrence in patients with low-risk DTC after thyroid lobectomy. METHODS Patients (n=1,528) who underwent thyroid lobectomy for papillary thyroid carcinoma between 2000 and 2012 were included in this study. According to the mean and dominant TSH values during the entire follow-up period or 5 years, patients were divided into four groups (<0.5, 0.5 to 1.9, 2.0 to 4.4, and ≥4.5 mIU/L). Recurrence-free survival was compared among the groups. RESULTS During the 5.6 years of follow-up, 21 patients (1.4%) experienced recurrence. Mean TSH levels were within the recommended low-normal range (0.5 to 1.9 mIU/L) during the total follow-up period or 5 years in 38.1% or 36.0% of patients. The mean and dominant TSH values did not affect recurrence-free survival. Adjustment for other risk factors did not alter the results. CONCLUSION Serum TSH levels did not affect short-term recurrence in patients with low-risk DTC after thyroid lobectomy. TSH suppression should be conducted more selectively.
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Affiliation(s)
- Myung Chul Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Min Joo Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Korea.
| | - Hoon Sung Choi
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea.
| | - Sun Wook Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Guk Haeng Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Do Joon Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Izkhakov E, Meyerovitch J, Barchana M, Shacham Y, Stern N, Keinan-Boker L. Long-term cardiovascular and cerebrovascular morbidity in Israeli thyroid cancer survivors. Endocr Connect 2019; 8:398-406. [PMID: 30865929 PMCID: PMC6454303 DOI: 10.1530/ec-19-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/13/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Thyroid cancer (TC) survivors may be at risk of subsequent cardiovascular and cerebrovascular (CaV&CeV) morbidity. The 2009 American Thyroid Association (ATA) guidelines recommended less aggressive treatment for low-risk TC patients. The aim of this study was to assess the atherosclerotic CaV&CeV outcome of Israeli TC survivors compared to individuals with no thyroid disease, and the atherosclerotic CaV&CeV outcome before (2000-2008) and after (2009-2011) implementation of the 2009 ATA guidelines. METHODS All members of the largest Israeli healthcare organization who were diagnosed with TC from 1/2000 to 12/2014 (study group) and age- and sex-matched members with no thyroid disease (controls) were included. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated using Cox proportional hazards models. RESULTS The mean follow-up was 7.6 ± 4.2 and 7.8 ± 4.1 years for the study (n = 5,677, 79% women) and control (n = 23,962) groups, respectively. The former had an increased risk of new atherosclerotic CaV&CeV events (adjusted HR 1.26, 95% CI 1.15-1.39). The 5-year incidence of CaV&CeV was lower (adjusted HR 0.49, 95% CI 0.38-0.62) from 2009 to 2011 compared to 2000 to 2008, but remained higher in the study group than in the control group (adjusted HR 1.5, 95% CI 1.14-1.69). CONCLUSIONS This large Israeli population-based cohort study showed greater atherosclerotic CaV&CeV morbidity in TC survivors compared to individuals with no thyroid diseases. There was a trend toward a decreased 5-year incidence of atherosclerotic CaV&CeV events among TC survivors following the implementation of the 2009 ATA guidelines, but it remained higher compared to the general population.
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Affiliation(s)
- Elena Izkhakov
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Correspondence should be addressed to E Izkhakov:
| | - Joseph Meyerovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Community Division, Clalit Health Services, Tel Aviv, Israel
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Micha Barchana
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Yacov Shacham
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Naftali Stern
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lital Keinan-Boker
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- National Cancer Registry, Israel Center for Disease Control, Ministry of Health, Israel, Ramat Gan, Israel
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Tuttle RM, Alzahrani AS. Risk Stratification in Differentiated Thyroid Cancer: From Detection to Final Follow-up. J Clin Endocrinol Metab 2019; 104:4087-4100. [PMID: 30874735 PMCID: PMC6684308 DOI: 10.1210/jc.2019-00177] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/04/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT Modern management of differentiated thyroid cancer requires individualized care plans which tailor the intensity of therapy and follow-up to the estimated risks of recurrence and disease-specific mortality. EVIDENCE ACQUISITION This summary is based on the authors' knowledge and extensive clinical experience supplemented by review of published review articles, thyroid cancer management guidelines, published staging systems, and original articles identified through a PubMed search which included terms such as risk stratification, staging, clinical outcomes, and differentiated thyroid cancer. EVIDENCE SYNTHESIS In the past, risk stratification in differentiated thyroid cancer usually referred to a static estimate of disease-specific mortality that was based on a small set of clinicopathological features available within a few weeks of completing initial therapy (thyroidectomy with or without radioactive iodine). Today, risk stratification is a dynamic, active process used to predict the appropriateness for minimalistic initial therapy, disease-specific mortality, risk of recurrence, and the most likely response to initial therapy. Rather than being a static prediction available only after initial therapy, modern risk stratification is a dynamic, iterative process that begins as soon as a suspicious nodule is detected and continues through final follow-up. CONCLUSIONS Dynamic risk assessment should be used to guide all aspects of thyroid cancer management, beginning before a definitive diagnosis is made and continuing through the final follow-up visit.
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Affiliation(s)
- R Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Correspondence and Reprint Requests: R. Michael Tuttle, MD, Endocrinology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065. E-mail:
| | - Ali S Alzahrani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Abstract
The worldwide incidence of thyroid cancer is increasing. A third of new thyroid cancer cases are papillary thyroid microcarcinoma (PTM), which are 1 cm or less. These tumors are mostly indolent with excellent prognosis. Although thyroid surgery is the most common management option for patients with PTM, new management options demand that treatment decisions must be individualized and based on patient's preference, context, and biology. This article describes management options for PTM patients and shared decision-making as a novel method for individualizing care.
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Affiliation(s)
- Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Ian D Hay
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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Abstract
Thyroid hormone suppression therapy is designed to lower serum thyrotropin (TSH) levels using doses of thyroid hormone in excess of what would normally be required to maintain a euthyroid state. The basis of this therapy is the knowledge that TSH is a growth factor for thyroid cancer, so that lower serum TSH levels might be associated with decreased disease activity. However, clinical studies have not documented improved outcomes with TSH suppression, except in patients with the most advanced disease. Furthermore, there are a number of negative outcomes related to aggressive thyroid hormone therapy, including osteoporosis, fracture, and cardiovascular disease. Therefore, a graded approach to TSH suppression is recommended by the American Thyroid Association, based on initial risk and ongoing risk assessment.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, Naples 80131, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA.
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Klubo-Gwiezdzinska J, Auh S, Gershengorn M, Daley B, Bikas A, Burman K, Wartofsky L, Urken M, Dewey E, Smallridge R, Chindris AM, Kebebew E. Association of Thyrotropin Suppression With Survival Outcomes in Patients With Intermediate- and High-Risk Differentiated Thyroid Cancer. JAMA Netw Open 2019; 2:e187754. [PMID: 30707227 PMCID: PMC6484595 DOI: 10.1001/jamanetworkopen.2018.7754] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Suppression of thyrotropin (often referred to as thyroid-stimulating hormone, or TSH) with levothyroxine used in management of intermediate- and high-risk differentiated thyroid cancer (DTC) to reduce the likelihood of progression and death is based on conflicting evidence. OBJECTIVE To examine a cohort of patients with intermediate- and high-risk DTC to assess the association of thyrotropin suppression with progression-free survival (PFS) and overall survival. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a multicenter database analysis including patients from tertiary referral centers and local clinics followed up for a mean (SD) of 7.2 (5.8) years. Patients with DTC treated uniformly with total thyroidectomy and radioactive iodine between January 1, 1979, and March 1, 2015, were included. Among the 1012 patients, 145 patients were excluded due to the lack of longitudinal thyrotropin measurements. EXPOSURES Levothyroxine therapy to target thyrotropin suppression with dose adjustments based on changing thyrotropin goal. MAIN OUTCOMES AND MEASURES The primary outcome measures were overall survival and PFS. A Cox proportional hazards model was used to assess the contribution of age, sex, tumor size, histology, and lymph node and distant metastases at landmarks 1.5, 3.0, and 5.0 years. The patients were divided into 3 groups based on mean thyrotropin score before each landmark: (1) suppressed thyrotropin, (2) moderately suppressed or low-normal thyrotropin, and (3) low-normal or elevated thyrotropin. RESULTS Among 867 patients (557 [64.2%] female; mean [SD] age, 48.5 [16.5] years) treated with a median (range) cumulative dose of 151 (30-1600) mCi radioactive iodine, disease progression was observed in 293 patients (33.8%), and 34 patients (3.9%) died; thus, the study was underpowered in death events. Thyrotropin suppression was not associated with improved PFS at landmarks 1.5 (P = .41), 3.0 (P = .51), and 5.0 (P = .64) years. At 1.5 and 3.0 years, older age (hazard ratio [HR], 1.06; 95% CI, 1.03-1.08 and HR, 1.05; 95% CI, 1.01-1.08, respectively), lateral neck lymph node metastases (HR, 4.64; 95% CI, 2.00-10.70 and HR, 4.02; 95% CI, 1.56-10.40, respectively), and distant metastases (HR, 7.54; 95% CI, 3.46-16.50 and HR, 7.10; 95% CI, 2.77-18.20, respectively) were independently associated with subsequent time to progression, while at 5.0 years, PFS was shorter for patients with lateral neck lymph node metastases (HR, 3.70; 95% CI, 1.16-11.90) and poorly differentiated histology (HR, 71.80; 95% CI, 9.80-526.00). CONCLUSIONS AND RELEVANCE Patients with intermediate- and high-risk DTC might not benefit from thyrotropin suppression. This study provides the justification for a randomized trial.
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Affiliation(s)
- Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marvin Gershengorn
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Brianna Daley
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Athanasios Bikas
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Kenneth Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Leonard Wartofsky
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Mark Urken
- Institute of Head, Neck and Thyroid Cancer, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Eliza Dewey
- Institute of Head, Neck and Thyroid Cancer, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Robert Smallridge
- Department of Endocrinology and Cancer Center, Mayo Clinic, Jacksonville, Florida
| | - Ana-Maria Chindris
- Department of Endocrinology and Cancer Center, Mayo Clinic, Jacksonville, Florida
| | - Electron Kebebew
- Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, California
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Matrone A, Campopiano MC, Nervo A, Sapuppo G, Tavarelli M, De Leo S. Differentiated Thyroid Cancer, From Active Surveillance to Advanced Therapy: Toward a Personalized Medicine. Front Endocrinol (Lausanne) 2019; 10:884. [PMID: 31998228 PMCID: PMC6961292 DOI: 10.3389/fendo.2019.00884] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/03/2019] [Indexed: 12/22/2022] Open
Abstract
Differentiated thyroid cancer (DTC) is the most frequent endocrine malignancy and represents the most rapidly increasing cancer diagnosis worldwide. In the last 20 years, this increase has been mostly due to a higher detection of small papillary thyroid cancers, with doubtful effects on patients' outcome. In fact, despite this growth, cancer-related death remained stable over the years. The growing detection of microcarcinomas associated to the indolent behavior of these cancers led to the development of strategies of active surveillance in selected centers of different countries. Moreover, toward a more personalized approach in the management of DTC patients, surgical treatments became more conservative, favoring less extensive options in patients at low risk of recurrence. The rise in lobectomy in low-risk cases and the need to avoid further therapies, with controversial impact on recurrences and cancer-related death in selected intermediate risk cases, led to reconsider the use of radioiodine treatment, too. Since clinicians aim to treat different patients with different modalities, the cornerstone of DTC follow-up (i.e., thyroglobulin, thyroglobulin autoantibodies, and neck ultrasound) should be interpreted consistently with this change of paradigm. The introduction of novel molecular target therapies (i.e., tyrosine kinase inhibitors), as well as a better understanding of the mechanisms of immune checkpoint inhibitor therapies, is radically changing the management of patients with advanced DTC, in whom no treatment option was available. The aim of this review is to analyze the most recent developments of the management of DTC, focusing on several key issues: active surveillance strategies, initial treatment, dynamic risk re-stratification, and therapeutic options in advanced DTC.
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Affiliation(s)
- Antonio Matrone
- Endocrinology Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Antonio Matrone
| | - Maria Cristina Campopiano
- Endocrinology Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alice Nervo
- Oncological Endocrinology Unit, Department of Medical Sciences, School of Medicine, Cittá della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giulia Sapuppo
- Division of Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Martina Tavarelli
- Division of Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Simone De Leo
- Division of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
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Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2018; 52:233-243. [PMID: 32774084 PMCID: PMC7406552 DOI: 10.14744/semb.2018.15428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022]
Abstract
Papillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors with a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However, PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatment strategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate, and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option for PTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillance of low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression, and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting toward more conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidence extended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.
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Lamartina L, Montesano T, Falcone R, Biffoni M, Grani G, Maranghi M, Ciotti L, Giacomelli L, Ramundo V, Lomonaco C, Di Gioia CR, Piernatale L, Ronga G, Durante C. IS IT WORTH SUPPRESSING TSH IN LOW- AND INTERMEDIATE-RISK PAPILLARY THYROID CANCER PATIENTS BEFORE THE FIRST DISEASE ASSESSMENT? Endocr Pract 2018; 25:165-169. [PMID: 30383494 DOI: 10.4158/ep-2018-0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Guidelines recommend thyroid-stimulating hormone (TSH) suppression before the first response to treatment assessment in papillary thyroid cancer (PTC) patients. The aim of this study was to assess the rate of structural disease (SD) in low- and intermediate-risk PTC patients according to TSH levels measured 1 year after primary treatment. METHODS A consecutive, prospective series of low- and intermediate-risk PTC patients with 3-years follow-up was collected. TSH, thyroglobulin (Tg), antithyroglobulin antibodies (TgAb), and neck ultrasonography (US) 1 and 3 years after primary treatment were analyzed. Recurrence risk and disease status at 1 year were defined according to the American Thyroid Association (ATA) guidelines and as the presence or absence of SD after 3 years. Patients were grouped according to TSH level at 1 year: group 1, TSH <0.1 μUI/mL; group 2, TSH 0.1 to 0.5 μUI/mL; group 3, 0.5 to 2 μUI/mL; and group 4 >2 μUI/mL. RESULTS This study included 263 patients (70.9% female, median age 47.2 years) of whom the risk of recurrence was low in 170 (65%), intermediate-low in 63 (24%), and intermediate-high in 30 (11%). The response to initial treatment at 1 year was excellent in 149 (57%), biochemical incomplete in 18 (7%), indeterminate in 84 (32%), and structural incomplete in 12 (4%). Group 1 consisted of 53 (20%) patients, group 2 of 85 (32%), group 3 of 61 (23%), and group 4 of 64 (24%). The rate of SD at 1 and 3 years from primary treatment was not significantly different between TSH groups. CONCLUSION TSH suppression before the first response to treatment assessment does not appear to influence the rate of SD evaluated 1 and 3 years after primary treatment. ABBREVIATIONS ATA = American Thyroid Association; DTC = differentiated thyroid cancer; FTC = follicular thyroid cancer; LT4 = levothyroxine; PTC = papillary thyroid cancer; SD = structural disease; Tg = thyroglobulin; TgAb = antithyroglobulin antibodies; TSH = thyroid-stimulating hormone; US = ultrasonography.
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Lamartina L, Grani G, Durante C, Borget I, Filetti S, Schlumberger M. Follow-up of differentiated thyroid cancer - what should (and what should not) be done. Nat Rev Endocrinol 2018; 14:538-551. [PMID: 30069030 DOI: 10.1038/s41574-018-0068-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The treatment paradigm for thyroid cancer has shifted from a one-size-fits-all approach to more personalized protocols that range from active surveillance to total thyroidectomy followed by radioiodine remnant ablation. Accurate surveillance tools are available, but follow-up protocols vary widely between centres and clinicians, owing to the lack of clear, straightforward recommendations on the instruments and assessment schedule that health-care professionals should adopt. For most patients (that is, those who have had an excellent response to the initial treatment and have a low or intermediate risk of tumour recurrence), an infrequent assessment schedule is sufficient (such as a yearly determination of serum levels of TSH and thyroglobulin). Select patients will benefit from second-line imaging and more frequent assessments. This Review discusses the strengths and weaknesses of the surveillance tools and follow-up strategies that clinicians use as a function of the initial treatment and each patient's risk of recurrence.
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Affiliation(s)
- Livia Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Giorgio Grani
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Cosimo Durante
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Isabelle Borget
- Department of Biostatistic and Epidemiology, Gustave Roussy and University Paris-Saclay, Villejuif, France
| | - Sebastiano Filetti
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and University Paris-Saclay, Villejuif, France.
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Park JH, Lee YM, Lee YH, Hong SJ, Yoon JH. The prognostic value of serum thyroid-stimulating hormone level post-lobectomy in low- and intermediate-risk papillary thyroid carcinoma. J Surg Oncol 2018; 118:390-396. [PMID: 30114333 DOI: 10.1002/jso.25164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/18/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study was undertaken to determine the optimal thyroid-stimulating hormone (TSH) value associated with structural recurrence in patients with low-risk or intermediate-risk papillary thyroid carcinoma (PTC) who underwent thyroid lobectomy. METHODS Patients with PTC (n = 1047) who received thyroid lobectomy and central compartment node dissection were included in the study. RESULTS Structural recurrence occurred in 42 of the patients (4.0%), and no patient died of PTC. Multivariate analysis showed a primary tumor size (with a cut-off of 0.85 cm) and serum TSH level measured 1 year after the initial surgery (cut-off 1.85 mU/L) independently predicted structural recurrence. CONCLUSIONS TSH levels during the early postoperative period need to be monitored and maintained in the lower normal range even in patients with low- or intermediate-risk PTC undergoing thyroid lobectomy.
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Affiliation(s)
- Jae Hyun Park
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yi Ho Lee
- Department of Surgery, Hanyang University Hanmaeum Changwon Hospital, Gyeongnam, South Korea
| | - Suck Joon Hong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Ho Yoon
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
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Davies L, Sugino K, Sugitani I, Tomoda C. Re: "High Thyroid Cancer Mortality Rate in Japan: A Result of Nonaggressive Treatment Strategy, or Just an Aging Population?" By Magner (Thyroid 2018;28:818-819). Thyroid 2018; 28:820-822. [PMID: 29644937 DOI: 10.1089/thy.2018.0203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | - Iwao Sugitani
- 3 Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Abstract
OBJECTIVE To establish the long term outcomes of risk stratified management of differentiated thyroid cancer (DTC). BACKGROUND Guidelines for management of DTC lack a strong evidence base and expose patients to overtreatment. This prospective study of patients diagnosed with DTC between 1977 and 2012 describes the long term outcomes of a conservative risk stratified (AMES) management policy. METHODS Outcomes were analysed around patient and tumour characteristics, primary intervention (surgery ± radioiodine (RAI)), in terms of mortality, recurrence and reintervention. RESULTS Median follow-up in 348 patients was 14 years: mean age 48 (range 10-91) years, 257 (73.9%) female, 222 (68.3%) papillary cancer, tumour size 3.4 ± 2.0 cm (mean ± SD). 89 (25.6%) AMES high risk, 116 (33.3%) TNM stage III/IV and 16 (4.6%) had distant metastases. Primary surgery comprised lobectomy in 189 (54.3%): 11 (5.8%) patients had subsequent completion total thyroidectomy with cancer present in five. Primary nodal surgery was performed in 142 (40.8%) patients. 35 (13.5%) low and 43 (48.3%) high risk patients received RAI following initial surgery. Overall disease specific survival (DSS) was 92.1% at 10 years and 90.7% at 20 years. DSS at 20 years was 99.2% in low risk cases. AMES risk scoring predicted both survival and recurrence. Patients receiving RAI and AMES high risk were significantly associated with increased risk of death and recurrence. CONCLUSIONS Routine total thyroidectomy and RAI are not justifiable for low risk DTC. Treatment should be tailored to risk and AMES risk stratification remains a simple reliable clinical tool.
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