CHLC – H. Curry Cabral

Hospital Curry Cabral

Centro Hospitalar Lisboa Central

Departamento de Cirurgia – Diretor Prof. Dr. Eduardo Barroso

Unidade de Cirurgia Endócrina

José Mário Coutinho

jmariocoutinho@gmail.com

Hospital Dona Estefânia

Maternidade Alfredo da Costa

Hospital Santo António dos Capuchos

Hospital Curry Cabral

Hosptal São José

Hospital Santa Marta

Protocolo de actuación en el Microcarcinoma Papilar de Tireoide.

¿Estamos tratando en exceso?

• According to World Health Organization, Papillary thyroid microcarcinomas (PTMCs) are papillary thyroid cancers (PTCs) measuring 1cm or less

Incidence of PTMC

US (Eco)

FNA

PET, CT, …

Incidence of PTMC

The increase in incidence of PTMC to more than 400% during the last 3 decades makes it to be the most commonly occurring PTC in the United States

Cramer JD, et al. Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry. Surgery 2010;148(6):1147–52 [discussion: 1152–3]. Hughes DT, et al. The most commonly occurring papillary thyroid cancer in the United States is now a microcarcinoma in a patient older than 45 years. Thyroid 2011;21(3):231–6)

Based on the Surveillance, Epidemiology, and End Results (SEER) data, papillary carcinomas 1 cm or less constituted about 30% of all papillary carcinoma in 1988 and about 40% in 2003.

Ries LAG, et al. SEER Cancer Statistics Review, 1975-2004, National Cancer Institute. [cited May 5, 2014] Bethesda, MD: http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007

Survival of PTMC

• In a study of 18,445 PTMC cases using a large national cancer database,– the 10-year overall survival was 94.6%– the 15-year overall survival 90.7%

– the 10-year disease-specific survival is approximately 99.5%,

Yu XM, et al. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann Surg 2011;254(4):653–60.

which means that 0.5% of the patients died of PTMC.

Risk factors in PTMC

Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

Risk factors in PTMC

A meta-analysis identified the following risk factors:

• clinical (rather than incidental) presentation (P < 0.0001),• multifocality (P < 0.0001) • lymph node involvement at diagnosis (P < 0.0001).

• The data on age as a risk factor are contradictory.

Gulben, K., Berberoglu, U., Celen, O. et al. (2008) Incidental papillary microcarcinoma of the thyroid–factors affecting lymph node metastasis. Langenbeck’s Archives of Surgery, 393,25.Yu, X.M., Wan, Y., Sippel, R.S. et al. (2011) Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Annals of Surgery, 254, 653–660.Roti, E., degli Uberti, E.C., Bondanelli, M. et al. (2008) Thyroid papillary microcarcinoma: a descriptive and meta-analysis study. European Journal of Endocrinology, 159, 659–673.

Risk factors in PTMCNon-incidental PTMC presented with aggressive characteristics similar to those of conventional PTC should be treated likewise..

Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

Risk factors in PTMC

PTMC > 6mm and

extrathyroidal extension

More frequentlyMultifocal

tumorsdistant

metastases

loco-regional disease

Lymph node involvement

persistent disease

Malandrino P, Pellegriti G, Attard M, Violi MA, Giordano C, Sciacca L, et al. Papillary thyroid microcarcinomas: a comparative study of the characteristics and risk factors at presentation in two cancer registries. J Clin Endocrinol Metab 2013; 98(4):1427-34

Treatment of PTMC

The optimal treatment of these patients remains controversial, ranging from observation alone to an aggressive treatment.

The lack of consensus is predominantly due to the general excellent overall prognosis.

Haymart MR, et al. Papillary thyroid microcarcinomas: big decisions for a small tumor. Ann Surg Oncol 2009;16(11):3132–9

Treatment of PTMC

• Surgery– Total Thyroidectomy / Near Total– Lobectomy (Hemithyroidectomy)– Completion thyroidectomy– Lymphadenectomy

• Observation without surgery

Given that long-term survival is nearly 100%, the objective of any treatment is to reduce the risk of loco-regional recurrence (2.5%) and distant metastases (0.4%), while minimizing iatrogenic morbidity.

Total/near total thyroidectomy

• Total or near-total thyroidectomy is preferred for most patients with PTMC as the initial surgery type especially for those present with

– multifocal lesions, – bilaterality, – capsule invasion, – and lymph node metastasis, – head and neck irradiation history

Lobectomy

• Thyroid lobectomy should only be performed in patients in whom it is certainly known that the tumor is unifocal and intrathyroidal without the presence of any lymph node or distant metastases.

• Cooper DS, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1167–214.

Total Thyroidectomy or Lobectomy?

Several studies have found that no survival benefits were evident after more extensive thyroidectomy of PTMC patients.

Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

Prophylactic central neck lymph node dissection?

author Central node involvementAttie JN – 1988 21 – 82%

Wada N – 2003 64%

Ito Y – 2007 40.5%

Some researchers reported that the central compartment lymph node metastasis of PTMC is very high, and routine central neck dissection is recommended

Attie JN. Modified neck dissection in treatment of thyroid cancer: a safe procedure. Eur J Cancer Clin Oncol 1988; 24: 315–24.Wada N, Duh QY, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003;237(3):399-407Ito Y, et al. Risk factors for recurrence to the lymph node in papillary thyroid carcinoma patients without preoperatively detectable lateral node metastasis: validity of prophylactic modified radical neck dissection. World J Surg 2007;31(11):2085-91.

So YK, et al. Prophylactic central lymph node dissection for clinically node-negative papillary thyroid microcarcinoma: influence on serum thyroglobulin level, recurrence rate, and postoperative complications. Surgery 2012; 151: 192-8.

So YK, et al. Subclinical lymph node metastasis in papillary thyroid microcarcinoma: a study of 551 resections. Surgery 2010; 148: 526-31

Prophylactic central neck lymph node dissection?

• Long term benefit of resection of occult microscopic nodal metastases is unclear.

• Hay ID, et al. showed that more aggressive nodal dissection failed to yield the anticipated reduction in recurrence rates in 900 PTMC patients that had initial treatment at Mayo Clinic during 1945-2004.

• There is no evidence that it improves recurrence or mortality rate, but it permits an accurate staging of the disease that may guide subsequent treatment and follow-up (IV, C)

Prophylactic central neck lymph node dissection?

• The 2009 American Thyroid Association guidelines recommend (recommendation rating: C) that prophylactic central neck dissection may not be appropriate for small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer.

• American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1167-214

Completion thyroidectomy

• A national, unselected, prospective cohort study in Denmark compared the recurrence between patients with lobectomy and completion thyroidectomy cases having incidental PTMC.

The study showed that the incidence of recurrence was not significantly different in the cases receiving completion thyroidectomy.

• Another study comparing the long term outcomes of TT versus LT also contend that completion thyroidectomy may not be recommended unless recurrence after LT is definitely detected in low-risk PTMC patients, and close follow-up is adequate in these patients.

Londero SC, Krogdahl A, Bastholt L, Overgaard J, Trolle W, Pedersen HB, et al. Papillary thyroid microcarcinoma in Denmark 1996-2008: a national study of epidemiology and clinical significance. Thyroid 2013;23(9):1159-64.

Lee J, Park JH, Lee CR, Chung WY, Park CS. Long-term outcomes of total thyroidectomy versus thyroid lobectomy for papillary thyroid microcarcinoma: comparative analysis after propensity score matching. Thyroid2013;23(11):1408-15

Revised ATAGuidelines for Patients with Thyroid Nodulesand Differentiated Thyroid Cancer

RECOMMENDATION 29• Completion thyroidectomy should be offered to those

patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. This includes all patients with thyroid cancer except those with small (<1 cm), unifocal, intrathyroidal, node-negative, low-risk tumors.

• Therapeutic central neck lymph node dissection should be included if the lymph nodes are clinically involved.Recommendation rating: B

Incidental microcarcinomas

This group should be monitored and observed periodically, but does not need to be actively treated until the tumors display more aggressive characteristics.

Ito Y, Tomoda C, Uruno T, et al. Papillary microcarcinoma of the thyroid: how should it be treated? World J Surg 2004; 28: 1115-21.

• Incidental microPTC are found in 2.2-49.9% (mostly 5–12%) of otherwise benign thyroid disease specimens, and the rate of detection is significantly affected by the thoroughness of histology

Neuhold, N., et al. (2011) Incidental papillary microcarcinoma of the thyroid – further evidence of a very low malignant potential: a retrospective clinicopathological study with up to 30 years of follow-up. Annals of Surgical Oncology, 18, 3430–3436. Erratum in: Ann Surg Oncol. 2011;18:3528..

Dunki-Jacobs, E., Grannan, K., McDonough, S. et al. (2012) Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology? American Journal of Surgery, 203, 140–144.

Observation without surgery

• Ito et al. reported that in 70% of 162 microcarcinoma patients under observation, the tumor size decreased or did not change at each follow-up.

• A recent observation trial showed that only 6.7% of low-risk PTMC definitely became enlarged during the five years of follow-up.

• These results and the high incidence of PTMC detected in autopsy studies indicated that observation was an attractive alternative to surgery for this group.

Ito Y, Tomoda C, Uruno T, et al. Papillary microcarcinoma of the thyroid: how should it be treated? World J Surg 2004; 28: 1115-21.

de Matos PS, Ferreira AP, Ward LS. Prevalence of papillary microcarcinoma of the thyroid in Brazilian autopsy and surgical series. Endocr Pathol 2006; 17: 165-73.

Ito Y, Miyauchi A. A therapeutic strategy for incidentally detected papillary microcarcinoma of the thyroid. Nat Clin Pract Endocrinol Metab 2007; 3: 240-8

Guideline Extent of surgery Prophylactic central neck dissection (PCND)

USA (ATA,2009)

TT for diameter >1 cm, or if any high risk features, or multifocal tumours <1 cm in diameterThyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases.

Near-total or total thyroidectomy without prophylactic central neck dissection may be appropriate for small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer. Recommendation rating: C

USA (NCCN,2014)

TT or lobectomy plus isthmusectomy (category 2B for both) and no radiation history,Tumor < 4cm, no cervical lymphnode metastases, no aggressive histological variant, no extrathyroidal extension, no macroscopic multifocality, no distant metastases

Radiation hystoryTumor > 4 cm,Poorly differentiated bilateral nodularity,extrathyroidal extension,distant metastases

Guideline Extent of surgery Prophylactic central neck dissection (PCND)

Europe (ETA,2006)

TT, except for unifocal tumours <1 cm diameter with no nodal or distant metastases, and no radiation history

Not recommended (could change staging and approach to management)

UK (BTA/RCP,2014)

Lobectomy for patients with unifocal tumours ≤1 cm diameter with nonodal or distant metastases, and no radiation history

TT for most other patients, multifocal microscopic tumours involving both lobesfamilial non-medullary thyroid cancer (FNMTC)Other risk factors

Patients with papillary microcarcinoma who present with cervical node metastases require total thyroidectomy and therapeutic lymph node dissection of the involved nodal compartment/s as with PTC >T1a

PCCND should be considered in patients withtumours that are multifocal, pT3 and with extra-thyroidal spread

Personalised Decision Making

Japan (JSTS/JAES, 2011)

Lobectomy when unifocal tumour diameter ≤2 cm with no nodal or distant metastases.

Observation without immediate surgery for microcarcinoma in absence of lymph-node metastases might be considered an option

TT moderately recommended when tumour diameter >4 cm

Routinely recommended

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