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Wang P, Dong Z, Zhao S, Su Y, Zhang J, Ma Y, Diao C, Qian J, Cheng R, Liu W. Trends of the prevalence rate of central lymph node metastasis and multifocality in patients with low-risk papillary thyroid carcinoma after delayed thyroid surgery. Front Endocrinol (Lausanne) 2024; 15:1349272. [PMID: 38638135 PMCID: PMC11024326 DOI: 10.3389/fendo.2024.1349272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/06/2024] [Indexed: 04/20/2024] Open
Abstract
Background Active surveillance has been an option for patients with low-risk papillary thyroid carcinoma (PTC). However, whether delayed surgery leads to an increased risk of local tumor metastasis remain unclear. We sought to investigate the impact of observation time on central lymph node metastasis (CLNM) and multifocal disease in patients with low-risk PTC. Methods Patients who were diagnosed with asymptomatic low-risk PTC, and with a pathological maximum tumor size ≤1.5 cm by were included. The patients were classified into observation group and immediate surgery group, and subgroup analyses were conducted by observation time period. The prevalence of CLNM, lymph node (LN) involved >5, multifocal PTC and bilateral multifocal PTC were considered as outcome variables. The changing trend and risk ratio of prevalence over observation time were evaluated by Mann-Kendall trend test and Logistics regression. Results Overall, 3,427 and 1,860 patients were classified to the observation group and immediate surgery group, respectively. Trend tests showed that decreasing trends both on the prevalence of CLNM and LN involved >5 over the observation time, but the difference was not statistically significant, and the prevalence of multifocal PTC and bilateral multifocal PTC showed the significant decreasing trends. After adjustment, multivariate analysis showed no statistically significant difference between observed and immediate surgery groups in the four outcome variables. Conclusion In patients with subclinical asymptomatic low-risk PTC, observation did not result in an increased incidence of local metastatic disease, nor did the increased surgery extent in patients with delayed surgery compared to immediate surgery. These findings can strengthen the confidence in the active surveillance management for both doctors and patients.
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Affiliation(s)
- Pei Wang
- Department of Radiation Oncology, Cancer Institute, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
- Department of Medical Imaging, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhizhong Dong
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuyan Zhao
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanjun Su
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jianming Zhang
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunhai Ma
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Chang Diao
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jun Qian
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ruochuan Cheng
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wen Liu
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Disease of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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Ahmadi S, Alexander EK. Active Surveillance for Low-Risk Differentiated Thyroid Cancer. Endocr Pract 2023; 29:148-153. [PMID: 36270610 DOI: 10.1016/j.eprac.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 02/07/2023]
Abstract
Less aggressive treatment options, including hemithyroidectomy and active surveillance, have been accepted as treatment options for low-risk small, differentiated thyroid carcinoma (DTC). Multiple studies have shown a low rate of cancer growth and lymph node metastases and no evidence of distant metastases during active surveillance of low-risk small DTC. However, not all patients with low -risk small DTC are ideal or appropriate candidate for active surveillance. Patients with thyroid cancer adjacent to either the trachea or recurrent laryngeal nerve or those with evidence of extrathyroidal extension, a high-risk molecular profile, lymph node, or distant metastases are considered inappropriate candidates for active surveillance. In addition, there are other essential factors that clinicians should consider while recommending active surveillance, including patient financial and insurance status; availability of high-quality neck ultrasounds and experienced radiologists, endocrinologists, and surgeons; and patient preference, level of anxiety, and willingness to undergo prolonged surveillance and follow-up imaging.
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Affiliation(s)
- Sara Ahmadi
- Department of Medicine, Thyroid Section, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Erik K Alexander
- Department of Medicine, Thyroid Section, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kukulska A, Krajewska J, Gawkowska M, Paliczka-Cieslik E, Handkiewicz-Junak D, Kropińska A, Puch Z, Olczyk T, Roskosz J, Jarzab B. Thyroid remnant ablation with radioiodine activity of 30, 60, and 100 mCi in patients with differentiated thyroid cancer - a prospective comparison of long-term outcomes. Arch Med Sci 2022; 18:1241-1247. [PMID: 36160333 PMCID: PMC9479704 DOI: 10.5114/aoms.2020.97803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 06/24/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this prospective study was to evaluate long-term outcomes in differentiated thyroid cancer (DTC) patients postoperatively treated with distinct RAI activities of 30 mCi, 60 mCi, and 100 mCi. MATERIAL AND METHODS The analysis involved 277 low-risk and 46 intermediate-risk patients, who underwent radioiodine (RAI) ablation with 30 mCi, 60 mCi or 100 mCi under prospective, randomized clinical trials. Seventy-eight patients from the low-risk group received 30 mCi, whereas 125 and 74 patients received 60 mCi and 100 mCi, respectively. Regarding the intermediate-risk group, 20 patients were given 60 mCi, and 26 subjects were given 100 mCi. The mean time of follow-up was 11 years. RESULTS An excellent treatment response was obtained in 88%, 89% and 90% of low-risk patients treated with 30 mCi, 60 mCi, and 100 mCi, respectively, and in 85% of intermediate-risk patients, who were administered 60 or 100 mCi. An indeterminate response was achieved in 9.4% and 6.5%, whereas an incomplete structural response was obtained in 1.4% and 6.5% of low-risk and intermediate-risk patients, respectively. An incomplete biochemical response was observed only in 2.2% of intermediate-risk patients. The differences in treatment response regarding RAI activity were not significant. CONCLUSIONS RAI activity of 30 mCi demonstrates a comparable efficacy as 60 mCi and 100 mCi in low-risk DTC. RAI activity of 60 mCi seems to be effective in intermediate-risk DTC.
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Affiliation(s)
- Aleksandra Kukulska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
- Radiotherapy Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Jolanta Krajewska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Marzena Gawkowska
- Third Clinic of Radiotherapy and Chemotherapy, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Ewa Paliczka-Cieslik
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Daria Handkiewicz-Junak
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Aleksandra Kropińska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Zbigniew Puch
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Tomasz Olczyk
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Jozef Roskosz
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Barbara Jarzab
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
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Bojoga A, Koot A, Bonenkamp J, de Wilt J, IntHout J, Stalmeier P, Hermens R, Smit J, Ottevanger P, Netea-Maier R. The Impact of the Extent of Surgery on the Long-Term Outcomes of Patients with Low-Risk Differentiated Non-Medullary Thyroid Cancer: A Systematic Meta-Analysis. J Clin Med 2020; 9:jcm9072316. [PMID: 32708218 PMCID: PMC7408649 DOI: 10.3390/jcm9072316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022] Open
Abstract
Recently, the management of patients with low-risk differentiated non-medullary thyroid cancer (DTC), including papillary and follicular thyroid carcinoma subtypes, has been critically appraised, questioning whether these patients might be overtreated without a clear clinical benefit. The American Thyroid Association (ATA) guideline suggests that thyroid lobectomy (TL) could be a safe alternative for total thyroidectomy (TT) in patients with DTC up to 4 cm limited to the thyroid, without metastases. We conducted a meta-analysis to assess the clinical outcomes in patients with low-risk DTC based on the extent of surgery. The risk ratio (RR) of recurrence rate, overall survival (OS), disease-free survival (DFS) and disease specific survival (DSS) were estimated. In total 16 studies with 175,430 patients met the inclusion criteria. Overall, low recurrence rates were observed for both TL and TT groups (7 vs. 7%, RR 1.10, 95% CI 0.61-1.96, I2 = 72%), and no statistically significant differences for OS (TL 94.1 vs. TT 94.4%, RR 0.99, CI 0.99-1.00, I2 = 53%), DFS (TL 87 vs. TT 91%, RR 0.96, CI 0.89-1.03, I2 = 85%), and DSS (TL 97.2 vs. TT 95.4%, RR 1.01, CI 1.00-1.01, I2 = 74%). The high degree of heterogeneity of the studies is a notable limitation. Conservative management and appropriate follow-up instead of bilateral surgery would be justifiable in selected patients. These findings highlight the importance of shared-decision making in the management of patients with small, low-risk DTC.
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Affiliation(s)
- Andreea Bojoga
- National Institute of Endocrinology “C.I. Parhon”, 011863 Bucharest, Romania;
| | - Anna Koot
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
- Correspondence: ; Tel.: +31-651-637-081
| | - Johannes Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.B.); (J.d.W.)
| | - Johannes de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.B.); (J.d.W.)
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
| | - Peep Stalmeier
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.I.); (P.S.)
| | - Rosella Hermens
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Johannes Smit
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
| | - Petronella Ottevanger
- Department of Internal Medicine, Division of Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Romana Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.S.); (R.N.-M.)
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Krajewska J, Kukulska A, Oczko-Wojciechowska M, Kotecka-Blicharz A, Drosik-Rutowicz K, Haras-Gil M, Jarzab B, Handkiewicz-Junak D. Early Diagnosis of Low-Risk Papillary Thyroid Cancer Results Rather in Overtreatment Than a Better Survival. Front Endocrinol (Lausanne) 2020; 11:571421. [PMID: 33123090 PMCID: PMC7573306 DOI: 10.3389/fendo.2020.571421] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022] Open
Abstract
We are witnessing a rapid worldwide increase in the incidence of papillary thyroid carcinoma (PTC) in the last thirty years. Extensive implementation of cancer screening and wide availability of neck ultrasound or other imaging studies is the main reason responsible for this phenomenon. It resulted in a detection of a growing number of clinically asymptomatic PTCs, mainly low-risk tumors, without any beneficial impact on survival. An indolent nature of low-risk PTC, particularly papillary thyroid microcarcinoma (PTMC), and the excellent outcomes raise an ongoing discussion regarding the adequacy of treatment applied. The question of whether PTMC is overtreated or not is currently completed by another, whether PTMC requires any treatment. Current ATA guidelines propose less extensive preoperative diagnostics and, if differentiated thyroid cancer is diagnosed, less aggressive surgical approach and limit indications for postoperative radioiodine therapy. However, in intrathyroidal PTMCs in the absence of lymph node or distant metastases, active surveillance may constitute alternative management with a low progression rate of 1%-5% and without any increase in the risk of poorer outcomes related to delayed surgery in patients, in whom it was necessary. This review summarizes the current knowledge and future perspectives of active surveillance in low-risk PTC.
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Affiliation(s)
- Jolanta Krajewska
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
- *Correspondence: Jolanta Krajewska,
| | - Aleksandra Kukulska
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
- Radiotherapy Department, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Malgorzata Oczko-Wojciechowska
- Department of Genetic and Molecular Diagnostics of Cancer, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Agnieszka Kotecka-Blicharz
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Katarzyna Drosik-Rutowicz
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
- Radiotherapy Department, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Malgorzata Haras-Gil
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Barbara Jarzab
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Daria Handkiewicz-Junak
- Department of Nuclear Medicine and Endocrine Oncology, M.Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
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Lamartina L, Leboulleux S, Terroir M, Hartl D, Schlumberger M. An update on the management of low-risk differentiated thyroid cancer. Endocr Relat Cancer 2019; 26:R597-R610. [PMID: 31484161 DOI: 10.1530/erc-19-0294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 11/08/2022]
Abstract
Low-risk papillary cancers, which represent the vast majority of thyroid cancers diagnosed today, do not require aggressive treatment or follow-up. Initial treatment consists of a total thyroidectomy without prophylactic lymph node dissection. A hemithyroidectomy is an alternative in some patients with an intrathyroidal tumor and with a normal contralateral lobe at pre-operative neck ultrasonography. The use of post-operative radioiodine should be restricted to selected patients. Follow-up at 6-18 months is based on serum thyroglobulin (Tg), Tg-antibody determination and neck ultrasonography. In the absence of any abnormality (excellent response to treatment), the risk of recurrence is extremely low and follow-up may consist of serum TSH monitoring that is maintained in the normal range, and a Tg and Tg-antibody titer determination every year. There is no need for referral to a specialized center. In patients with detectable serum Tg or detectable Tg antibodies, the trend over time of these markers on levothyroxine treatment will dictate subsequent follow-up: a decreasing trend is reassuring, but an increasing trend should lead to imaging, starting with neck ultrasonography.
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Affiliation(s)
- Livia Lamartina
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | - Sophie Leboulleux
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | - Marie Terroir
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | - Dana Hartl
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
| | - Martin Schlumberger
- Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France
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