Active Surveillance in Adults with Low-Risk Papillary Thyroid Microcarcinomas: A Prospective Study

 

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Abstract

The acceptance and results of active surveillance in patients with low-risk papillary thyroid microcarcinomas (PTMC) are unknown in populations other than the Japanese population. This was the objective of the present prospective study. We selected patients ≥20 years who had thyroid nodules ≤1.2 cm with intermediate or high suspicion for malignancy on ultrasonography (US), not located near the recurrent laryngeal nerve and without extrathyroidal invasion or apparent lymph node metastases, whose cytology was suspicious (Bethesda V) or diagnostic (Bethesda VI) of papillary thyroid carcinoma. Patients who opted for active surveillance were followed up by biannual US. Fifteen patients (18.7%) readily opted for surgery and 12 (15%) for active surveillance. Fifty-three patients (66.2%) delegated the decision or wished to know the doctor’s preference before deciding. After the doctor had declared his/her preference for active surveillance, 50 patients decided to have this management and three to have surgery. Only 1/70 patients exhibited tumor progression (growth associated with a suspicion of extrathyroidal invasion) after 30 months of follow-up. Two patients decided to have surgery during follow-up, although the indication was not defined by the study. A>50% reduction in tumor volume was observed in three patients. The study shows that active surveillance can be well accepted if doctors were convinced that it is the best option for patients with low-risk PTMC. At least the short-term results reproduced those observed in other populations, with tumor progression being uncommon.

• References

• 1 Haugen BR, Alexander EK, Bible KC. et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid 2016; 26: 1-133
  CrossrefPubMedGoogle Scholar
• 2 Russ G, Bonnema SJ, Erdogan MF. et al. European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: The EU-TIRADS. Eur. Thyroid J 2017; 6: 225-237
  PubMedGoogle Scholar
• 3 Rosario PW, Ward LS, Graf H. et al. Thyroid nodules ≤ 1 cm and papillary thyroid microcarcinomas: Brazilian experts opinions. Arch Endocrinol Metab 2019; Sep 2. pii S2359-39972019005007102 10.20945/2359-3997000000166 [Epub ahead of print]
  PubMedGoogle Scholar
• 4 Ito Y, Miyauchi A, Kihara M. et al. Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation. Thyroid 2014; 24: 27-34
  CrossrefPubMedGoogle Scholar
• 5 Tuttle RM, Fagin JA, Minkowitz G. et al. Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surg 2017; 143: 1015-1020
  CrossrefPubMedGoogle Scholar
• 6 Sugitani I. Active surveillance for very low-risk papillary thyroid carcinoma: experience and perspectives from Japan. Ann Thyroid 2018; 3: 26
  CrossrefPubMedGoogle Scholar
• 7 Sanabria A. Active Surveillance in Thyroid microcarcinoma in a latin-american cohort. JAMA Otolaryngol Head Neck Surg 2018; 144: 947-948
  CrossrefPubMedGoogle Scholar
• 8 Oh HS, Ha J, Kim HI. et al. Active surveillance of low-risk papillary thyroid microcarcinoma: A multi-center cohort study in Korea. Thyroid 2018; 28: 1587-1594
  CrossrefPubMedGoogle Scholar
• 9 Rosario PWS, Mourão GF, Oliveira PHL. et al. Are papillary thyroid carcinomas that are candidates for active surveillance in fact classical microcarcinomas restricted to the gland? Eur. Thyroid J 2018; 7: 258-261
  PubMedGoogle Scholar
• 10 Rosario PW, de Faria S, Bicalho L. et al. Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma. J Ultrasound Med 2005; 24: 1385-1389
  CrossrefPubMedGoogle Scholar
• 11 Rosario PW, Tavares WC, Borges MA. et al. Ultrasonographic differentiation of cervical lymph nodes in patients with papillary thyroid carcinoma after thyroidectomy and radioiodine ablation: a prospective study. Endocr Pract 2014; 20: 293-298
  CrossrefPubMedGoogle Scholar
• 12 Lee HJ, Yoon DY, Seo YL. et al. Intraobserver and interobserver variability in ultrasound measurements of thyroid nodules. J Ultrasound Med 2018; 37: 173-178
  CrossrefPubMedGoogle Scholar
• 13 Rosario PW, Salles DS, Bessa B. et al. Contribution of scintigraphy and ultrasonography to the prediction of malignancy in thyroid nodules with indeterminate cytology. Arq Bras Endocrinol Metabol 2010; 54: 56-59
  CrossrefPubMedGoogle Scholar
• 14 Rosario PW. Thyroid nodules with atypia or follicular lesions of undetermined significance (Bethesda Category III): importance of ultrasonography and cytological subcategory. Thyroid 2014; 24: 1115-1120
  CrossrefPubMedGoogle Scholar
• 15 Rosario PW, Penna GC, Calsolari MR. Predictive factors of malignancy in thyroid nodules with repeatedly nondiagnostic cytology (Bethesda category I): value of ultrasonography. Horm Metab Res 2014; 46: 294-298
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Rocha TG, Rosario PW, Silva AL. et al. Ultrasonography classification of the american thyroid association for predicting malignancy in thyroid nodules>1 cm with indeterminate cytology: a prospective study. Horm Metab Res 2018; 50: 597-601
  Article in Thieme ConnectPubMedGoogle Scholar
• 17 Tuttle M, Morris LF, Haugen B. et al. AJCC Cancer Staging Manual. In: Amin MB, Edge SB, Greene FL. eds 8th ed. New York, NY: Springer; 2017: 1-19
  Google Scholar
• 18 Dixon PR, Tomlinson G, Pasternak JD. et al. The role of disease label in patient perceptions and treatment decisions in the setting of low-risk malignant neoplasms. JAMA Oncol 2019; 5: 817-823
  CrossrefPubMedGoogle Scholar
• 19 Ito Y, Miyauchi A, Kudo T. et al. Trends in the implementation of active surveillance for low-risk papillary thyroid microcarcinomas at Kuma Hospital: Gradual increase and heterogeneity in the acceptance of this new management option. Thyroid 2018; 28: 488-495
  CrossrefPubMedGoogle Scholar
• 20 Ito Y, Uruno T, Nakano K, Takamura Y. et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid 2003; 13: 381-387
  CrossrefPubMedGoogle Scholar
• 21 Kwon H, Oh HS, Kim M. et al. Active surveillance for patients with papillary thyroid microcarcinoma: a single center’s experience in Korea. J Clin Endocrinol Metab 2017; 102: 1917-1925
  CrossrefPubMedGoogle Scholar
• 22 Sakai T, Sugitani I, Ebina A. et al. Active surveillance for T1bN0M0 papillary thyroid carcinoma. Thyroid 2019; 29: 59-63
  CrossrefPubMedGoogle Scholar
• 23 Tessler FN, Middleton WD, Grant EG. et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017. 14 587-595
  Google Scholar
• 24 Brito JP, Ito Y, Miyauchi A. et al. A clinical framework to facilitate risk stratification when considering an active surveillance alternative to immediate biopsy and surgery in papillary microcarcinoma. Thyroid 2016; 26: 144-149
  CrossrefPubMedGoogle Scholar