Elsevier

Surgery

Volume 167, Issue 1, January 2020, Pages 46-55
Surgery

Thyroid
Active surveillance of low-risk papillary thyroid cancer: A meta-analysis

Presented at the American Association of Endocrine Surgeons 40th Annual Meeting, April 7–9, 2019, Los Angeles, CA.
https://doi.org/10.1016/j.surg.2019.03.040Get rights and content

Abstract

Background

This study evaluates the safety and efficacy of active surveillance for low-risk papillary thyroid carcinoma.

Methods

MEDLINE, EMBASE, and PubMed were searched from inception for relevant studies of active surveillance for low-risk papillary thyroid carcinoma, defined as T1a or T1b, N0, M0 disease. Main outcomes of interest were growth of primary tumor, metastatic spread, thyroid cancer-related mortality, and disease recurrence after delayed thyroid surgery.

Results

Nine publications with 4,156 patients were included. Primary analysis of the 9 studies revealed pooled proportion of tumor growth during active surveillance to be 4.4% (95% confidence interval 3.2–5.8%). The pooled rate of metastatic spread to cervical nodes was 1.0% (95% confidence interval 0.7–1.4%), and pooled mortality due to thyroid cancer was 0.03% (95% confidence interval 0.0005–0.2%). Eight studies assessed incidence of delayed thyroid surgery with pooled proportion of 9.9% (95% confidence interval 6.4–14.0%). The main indication for surgery was patient preference, not disease progression, at 51.9% (95% confidence interval 44.9–58.9%). The pooled proportion of recurrence after delayed thyroid surgery was 1.1% (95% confidence interval 0.1–3.8%).

Conclusion

Active surveillance appears to be a safe alternative to surgery for the management of low-risk papillary thyroid carcinoma, without increased risk of recurrence or death. This strategy allows for avoidance of exposure to surgical risk and need for subsequent thyroid replacement therapy.

Section snippets

Background

The increasing incidence of thyroid cancer worldwide is attributed in large to increased utilization of ultrasound and technical advances coupled to formal population screening programs.1, 2, 3, 4 Although the incidence of papillary thyroid cancer (PTC) has been rapidly increasing, the associated mortality has not changed substantially in North America.2 This can be attributed to the fact that the majority of PTC diagnosed incidentally by imaging are papillary thyroid microcarcinoma (PTMC)

Data search and study selection

A systematic search was conducted of EMBASE, MEDLINE, and PubMed (from inception to September 2018) for English language publications using the keywords “active surveillance,” “microcarcinoma”, “cancer,” and “thyroid carcinoma.” The references of relevant literature were also reviewed for applicable publications. All publications were reviewed independently by 2 team members and assessed for inclusion. All discrepancies between reviewers were resolved by consensus. Inclusion criteria included

Study selection

A total of 2,821 articles were identified, and 65 articles selected for full text review as outlined in Fig 1. In full text review, 12 studies met inclusion criteria, with 9 publications included for analysis, and 3 excluded as they contained duplicate populations.

Individual study characteristics

A total of 9 publications were included for final analysis. All publications were cohort studies; 4 were prospective, and 5 were retrospective in design. Across the 9 studies, a total of 4,156 patients were followed with AS after

Discussion

In this meta-analysis, 4.4% (95% CI 3.2–5.8%) demonstrated growth of their tumor with only 1.0% (95% CI 0.7–1.4%) developing cervical lymph node metastasis and 0.04% (95% CI 0.002–0.2%) developing metastatic disease. Most importantly, the pooled mortality related to thyroid cancer was 0.03% (95% CI 0.0005–0.2%). For the 9.9% (95% CI 6.4–14.0%) of patients undergoing DTS during surveillance only 1.1% (95% CI 0.1–3.8%) developed recurrent disease. These results are limited with regards to tumor

Funding/Support

None to declare.

Conflict of interest/Disclosure

Dr. T. McMullen is a paid consultant with Galapagos LLC and has received speaker fees from Novartis. No other competing interests are declared.

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