Contemporary Management of Recurrent Nodal Disease in Differentiated Thyroid Carcinoma

Editorial: Does Every Thyroid Cancer Patient Need Surgery?

In the management of malignant thyroid disorders, the standard primary treatment is thyroidectomy, a surgical resection of the thyroid gland. This procedure has been performed for over a century. Hence, it comes as no surprise that it is not only exceedingly well-described in the literature. This issue of Rambam Maimonides Medical Journal includes an article by Chaturvedi et al. that challenges the standard widely-practiced clinical inclination toward surgery as the first and best option for all patients with early thyroid cancer. This editorial discusses the issues raised by the authors and points out the importance of ongoing research to determine when standards of care should be modified in the light of low-risk disease.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

Efficacy of posttreatment radioiodine scanning in patients with differentiated thyroid cancer

BACKGROUND

Differentiated thyroid cancers often require radioiodine treatment followed by posttreatment scan. We aimed in this study to assess the utility of the posttreatment radioiodine scan in this population.

METHODS

An analysis of patients who received radioiodine treatment at Rambam Campus, during 2006-2013. Scans showing remnant normal thyroid tissue were considered as normal. Positive uptake was defined as uptake in the lateral neck or distant sites.

RESULTS

A total of 455 patients were analyzed, 68% had T1-T2 and 28% had positive lymph nodes. Positive uptake in the lateral neck was recorded in 52 (11.4%) and in distant sites in 41 (9%) patients. Tracheal invasion, esophageal invasion, nerve invasion, and N1b classification were associated with a positive scan (P < .05). A positive radioactive iodine scan was not related to poor prognosis.

CONCLUSIONS

Posttreatment scans are positive in only 20% of patients. Locally invasive tumor and positive nodes are associated with positive scans.

Differentiated Thyroid Cancer: How Do Current Practice Guidelines Affect Management?

BACKGROUND

International best-practice guidelines recommend completion thyroidectomy and radioiodine remnant ablation (RRA) for patients with differentiated thyroid cancer (DTC) > 4 cm or with specific risk factors. Patients with DTC < 1 cm without risk factors are recommended for lobectomy alone. Indications for aggressive surgery and RRA are less clearly defined for tumours measuring 1-4 cm. A personalised approach to decision-making is recommended.

OBJECTIVES

This study assesses therapeutic approaches to DTC as compared to the current British Thyroid Association (BTA) clinical practice guidelines. We ascertained the effect of equivocal guidance in the 1-4 cm tumour cohort on contemporary practice patterns.

METHODS

Data were obtained from a prospectively maintained thyroid cancer database of patients treated for DTC in a tertiary referral centre at the University Hospital Galway. Consecutive patients attending a dedicated thyroid cancer clinic between August 2014 and August 2017 were included. Clinicopathological characteristics and management strategies were assessed.

RESULTS

Ninety-four percent (n = 168/178) of patients were surgically managed in adherence with guidelines. A minority (n = 10) received surgery not aligned with guidelines. Ninety-seven percent (n = 172/178) of RRA treatment decisions were in accordance with guidelines. The BTA guidelines recommended a personalised decision-making approach for 18.0% (n = 32) and 44.9% (n = 80) of surgery and RRA treatment decisions, respectively. The more aggressive, treatment-driven approach was typically favoured by the multidisciplinary team, with 97% (n = 31/32) undergoing completion thyroidectomy and 100% (n = 80) proceeding to RRA.

CONCLUSIONS

Management of DTC at our institution closely adheres to contemporary clinical practice guidelines. The finding of more aggressive management in those requiring a personalised decision-making approach highlights the requirement for improved risk stratification in this cohort to ratio-nalise management strategies.

The Treatment of Advanced Thyroid Cancer in the Age of Novel Targeted Therapies

Until recently, patients with advanced thyroid cancers had limited options for systemic treatment. With the introduction of tyrosine kinase inhibitors (TKIs) as a promising new class of targeted therapies for thyroid cancer, suddenly patients with advanced disease were given new options to extend survival. Guidelines worldwide have been updated to include general indications for these newer agents, but questions remain regarding which agent(s) to select, when to begin treatment, and how long therapy should continue. Additionally, the true impact of TKIs on overall survival and quality-of-life in thyroid cancer patients needs further clarification. As familiarity with approved agents and longer-term data become available, better strategies for implementation of these targeted drugs will evolve to optimize benefit for patients living with metastatic disease.