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Description : a 2019 article from surgical clinics of north america journal about Extent of Surgery for Low-Risk Differentiated Thyroid Cancer

Tags : PTC, Thyroidectomy, Thyroid Nodule, Papillary Thyroid Carcinoma

Published on : May 01, 2020 | Views : 1373 | Downloads : 6

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Extent of Surgery for Low-Risk Differentiated ThyroidCancer Section of Endocrine Surgery, Department of Surgery, Indiana University Division of Endocrine Surgery, Department of Surgery, University of Wisconsin-Madison Surgical Clinics of North America Journal- 2019 Presenter: Anahita Mirzasadeeghi, MD
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INTRODUCTION Thyroid cancer→ the fifth most common cancer in women 3.1% of all new cancer cases in the United States Incidence:- 1975: 4.9 per 100,000→ stable until the early 1990s- 2009: 14.3 per 100,000 Increasing incidence attributed to:- overdiagnosis of small differentiated tumors- radiation - unrecognized environmental exposure Mortality rate→ stable→ 0.5 deaths per 100,000
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Overdiagnosis → detection of indolent/ very slow-growing cancers that are unlikely to cause symptoms or death→ results from several factors:- increased use of cervical US and other cross-sectional imaging- development of FNA- increased scrutiny of thyroid specimens after surgical resection Overdiagnosis is detrimental when it leads to overtreatment To prevent overtreatment, the extent of surgery recommended for patients with low-risk differentiated thyroid cancer (DTC) currently takes a less-is-more approach
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Risk of Recurrence Historically, a vast majority of patients with low-risk DTC were treated with:- total thyroidectomy- radioactive iodine (RAI)- thyroid hormone suppression therapy Now→ Tx is:- more individualized- based on multiple factors, including risk of recurrence and survival The American Thyroid Association (ATA) guidelines reviewed in this article propose a 3-tiered risk stratification system for DTC
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The most recent ATA guidelines describe an additional category very low risk of recurrence:- papillary thyroid cancers≤ 1 cm- w/o clinically evident metastases/ local invasion- w/o cytologic/ molecular evidence of aggressive histology
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Goals of Treatment According to 2015 ATA guidelines→ 5 goals of initial therapy for DTC patients:1. Improve overall and disease-specific survival2. Reduce the risk of persistent/recurrent disease3. Permit accurate staging4. Minimize treatment-related morbidity5. Minimize unnecessary therapy This article: - explores the recommended extent of surgery for very low-risk and low-risk DTC- critically examines the literature and discusses the controversy over the appropriate extent of resection according to risk of recurrence and size of the cancer
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VERY LOW-RISK DIFFERENTIATED THYROID CANCER have 2 main management options: 1. active surveillance2. thyroid lobectomy If surgical resection is chosen for a thyroid cancer ≤1 cm with no high-risk features→ thyroid lobectomy is the preferred Tx unless→ clear indications for resection of the contralateral lobe Total thyroidectomy → should be reserved for patients at risk of more aggressive disease:- Hx of head and neck radiation- positive family Hx of thyroid cancer- clinically detectable cervical LN metastasis
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Active surveillance: - nonsurgical management option for patients with very lowrisk DTC - newly endorsed by the 2015 ATA guidelines Evidence supporting active surveillance: - observational trial at Kuma Hospital, Japan of more than 2000 patients with very low-risk PTC who underwent either active surveillance or immediate surgery- Eligible patients included those with papillary microcarcinoma w/o any of the following features:LN or distant metastasis, ETE, high-grade cytology, growth during a previous observation, location near the recurrent laryngeal nerve, and attachment to the trachea
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Of the 1235 patients surveilled with serial US examinations:- 8% had tumors increase in size by 3 mm or more over 10 years- 3.8% developed novel LN metastasis - 15% of patients underwent surgery for either progression of disease or change in patient preference- All patients who experienced progression of disease were treated successfully with surgery→ No recurrence and no death of thyroid cancer- patients who underwent immediate surgery had a significantly increased rate of temporary vocal cord paralysis as well as temporary and permanent hypoparathyroidism compared with patients who underwent active surveillance
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This and other studies demonstrate that active surveillance:- is a viable management option with excellent oncologic outcomes for select patients- allows patients to avoid potentially unnecessary surgical risk active surveillance:closely monitoring the known thyroid cancer with serial US performed every 6 months for 1 year to 2 years followed by annual US examinations to monitor for growth/spread
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LOW-RISK DIFFERENTIATED THYROID CANCER: 1 CM TO 4 CM More controversial Surgical options:- more traditional→ total thyroidectomy- newly endorsed→ thyroid lobectomy Arguments are explored for total thyroidectomy vs thyroid lobectomy for patients with DTC measuring 1-4 cm w/o high-risk features:gross ETE, incomplete tumor resection, distant metastasis, L≥ N3 cm, and follicular thyroid cancer with extensive vascular invasion
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Arguments for Total Thyroidectomy Multifocality and contralateral disease benefit of total thyroidectomy → ability to eradicate possible contralateral disease if the cancer is multifocal multifocality, the presence of 2 or more anatomically separate foci of cancer within the thyroid gland, can be present in 18% to 87% of cases Pyo and colleagues:- found that the greater total combined surface area of each tumor predicts LN metastasis and tumor behavior even in papillary microcarcinomas Mazeh and colleagues: - 57% of patients with PTC measuring 0.3 cm to 7.0 cm have multifocal disease- The presence of multifocality in 1 lobe has also been shown to be a risk factor for PTC in the contralateral lobe regardless of tumor size The European Society of Endocrine Surgeons → total thyroidectomy in the setting of multifocality to reduce the risk of local recurrence
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Potential for second surgery Another benefit of total thyroidectomy→ avoiding the need for a second surgery Those who initially undergo a thyroid lobectomy are at risk of needing a completion thyroidectomy and second GA if any of the following is found on final pathology: - gross ETE- metastasis to regional LNs - vascular invasion - aggressive histologic variants Dhir and colleagues:- after thyroid lobectomy, 53% of patients have intermediate-risk disease on final histopathology→ require completion thyroidectomy
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Total thyroidectomy:- allows for a single surgery- facilitates Tx with RAI for patients found at intermediate risk or high risk of recurrence
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Adequacy of resection total thyroidectomy→ a single surgery may provide a more oncologically adequate resection Oltmann and colleagues: Post-op RAI uptake scan→ significantly higher thyroid remnant uptake after completion thyroidectomy compared with total thyroidectomy → single-stage total thyroidectomy may be more oncologically adequate than lobectomy followed by completion thyroidectomy
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Detection of residual or recurrent thyroid cancer Total thyroidectomy → has the benefit of facilitating detection of persistent or recurrent thyroid cancer. The ATA guidelines recommend routine use of serum thyroglobulin and either a neck US/ whole-body scan to assess post-op disease status after total thyroidectomy Thyroglobulin levels→ facilitate the ability to assess the adequacy and completeness of surgical resection→ If detectable immediately after a total thyroidectomy→ persistent or residual thyroid cancer thyroid lobectomy → - serum thyroglobulin is less useful and uptake scans no longer are recommended- RAI uptake scans cannot be performed because of the residual thyroid lobe - US is the mainstay of detection of recurrence US performance by high-volume endocrine surgeons is more accurate than those performed by non-specialists
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Arguments for Thyroid Lobectomy Avoidance of thyroid hormone replacement thyroid lobectomy→ patients may remain euthyroid and not require thyroid hormone supplementation Cox and colleagues:up to 73% of patients who have a lobectomy may require thyroid hormone supplementation because they have a TSH level greater than 2 mIU/L at some point during the first post-op year 2015 ATA guidelines→ maintaining post-op TSH level less than 2 mlU/L in patients with low-risk DTC
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Little impact on quality of life Another potential benefit of lobectomy→ lack of impact on QOL→ which may or may not be related to thyroid hormone changes After total thyroidectomy→ most patients report: - weight gain - fatigue - dry or coarse skin - extremity edema- astheniaalthough having a euthyroid state Rosato and colleagues:incidence of asthenia after:- lobectomy→ None- total thyroidectomy→ 25%
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Decreased risks of complications thyroid lobectomy→ decreased risk of postoperative complications such as hematoma, seroma, fever, nausea, vomiting, dehydration, urinary retention, and urinary tract infection compared with total thyroidectomy the risk of hypocalcemia is significantly higher after total thyroidectomy Ryu and colleagues:less vocal and throat dysfunction, voice roughness, jitter, and strain after thyroid lobectomy compared with total thyroidectomy
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Equivalent recurrence and survival For patients with low-risk DTC measuring 1 cm to 4 cm, thyroid lobectomy and total thyroidectomy have been shown in multiple studies to have equivalent survival and recurrence, although this area is controversial A recent systematic review of the literature on this topic → comparable oncologic outcomes between lobectomy and total thyroidectomy in patients with PTC measuring 1 cm to 4 cm
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Additional Considerations Surgeon-performed ultrasonography Cervical US is paramount to preoperative surgical planning Cervical US→ examine thyroid nodule features, including:- location- evidence of local invasion or intrathoracic extension- investigate contralateral nodules- survey cervical LNs in the central and lateral compartments CarneiroPla and Amin:surgeon-performed US altered the pre-op management of 45% of patients due to identification of central or lateral LN metastasis or other high-risk features that were not mentioned on pre-consultation US
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Molecular testing Although not all patients will or need to undergo molecular testing of thyroid nodules, the use of molecular testing for indeterminate nodules is increasing For instance:- a patient with a known BRAF mutation, which has a strong association with ETE, LN metastasis, advanced stage, recurrent or persistent disease, and loss of RAI avidity→ should undergo a total thyroidectomy- TERT promoter mutations have been associated with advanced or aggressive thyroid cancer- Patients with RET/PTC rearrangement may have a better prognosis
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Cost effectiveness Some studies found total thyroidectomy most cost effective in patients with indeterminate thyroid nodules and patients with “suspicious PTC” FNA Conversely, some studies found initial lobectomy the most cost effective in patients with low risk, 1cm to 4cm PTC w/o clinically apparent high-risk features
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Patient preference The decision about the appropriate extent of surgery for patients with low-risk DTC 1 cm to 4 cm also should consider individual patient preference
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LOW-RISK DIFFERENTIATED THYROID CANCER: GREATER THAN 4 CM the most recent ATA guidelines continue to recommend total thyroidectomy for DTC greater than 4cm Total thyroidectomy also is recommended for cancers with any high-risk features, including:- gross ETE- clinically apparent metastatic disease to LNs or distant sites One of the driving factors for this recommendation is the ability to perform RAI remnant ablation postoperatively Ruel and colleagues:concluded that there is a reduced risk of death when RAI is administered in intermediate-risk cancers
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SUMMARY the appropriate extent of surgery for patients with low-risk DTC is complex and constantly under debate Several factors should be considered in the decision-making process, including:multifocality, contralateral disease, the potential for a seconding surgery, postoperative surveillance, the need for thyroid hormone replacement, quality of life, risk of complications, ultrasound findings, molecular test results, and costs Ultimately, understanding what is most important to each patient is critical to aligning the treatment decision with patient preferences and values
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THANK YOU FOR YOUR ATTENTION!