Thyroid Cancer No Unneeded Surgery 101; Low Risk= No or Less Surgery
DR.G comments on this review article on low risk papillary thyroid cancers
Juan P Brito et al
BMJ 2014; 348
1.Patients with these small localized papillary thyroid cancers have a 99% survival rate at 20 years. In view of the excellent prognosis of these tumors, they have been denoted as low risk.
2. The incidence of these low risk thyroid cancers is growing, probably because of the use of imaging technologies capable of exposing a large reservoir of subclinical disease.
3. Despite their excellent prognosis, these subclinical low risk cancers are often treated aggressively.
4. Surgery is traditionally viewed as the cornerstone treatment for these tumors.
5.There is less agreement about the extent of surgery (lobectomy vs near total thyroidectomy) and whether prophylactic central neck dissection for removal of lymph nodes is needed.
6. Many of these tumors are treated with radioactive iodine ablation and thyrotropin suppressive therapy, which—although effective for more aggressive forms of thyroid cancer—have not been shown to be of benefit in the management of these lesions.
7. The future of promising alternative non-surgical minimally localized invasive therapies (ethanol ablationPEI and radiofrequency ablationRFA), and active surveillance, all of which form part of a more individualized treatment approach for low risk papillary thyroid tumors.
Ethanol ablation for primary low risk cancers
RFA ablation of thyroid recurrent cancer lymph nodes.
9. Delayed risk stratification, aims to classify patients who are falsely staged intermediate or high risk more accurately. A retrospective analysis that evaluated the predictive value of this approach found that about 50% of intermediate-high risk patients were re-categorised as low risk after the first visit.
10. Molecular based markers have the potential to improve the diagnosis of thyroid nodules and the risk stratification of thyroid cancers.
11.Minimally invasive therapy for patients with low risk thyroid cancer when surgery is neither indicated nor desired.
12.Ultrasound guided percutaneous ethanol ablation PEI involves the direct intratumoral injection of 95% ethanol under careful ultrasound guidance.
13. Although this technique is effective and safe (small risk of temporary hoarseness) for benign cystic thyroid nodules and nodal metastasis in papillary thyroid cancer
limited evidence is available on its efficacy in low risk thyroid cancer.
14. A case series described three patients, with five intrathyroid foci of papillary microcarcinoma, whose biopsy confirmed papillary thyroid cancer lesions were treated by ethanol ablation within the intact thyroid.
The lesions became avascular and smaller and one disappeared. These promising results are limited.
15.Thermal ablation with radiofrequency ablation RFA or lasers may be a better alternative treatment for thyroid cancer owing to its predictable and well defined area of necrosis.
16. Radiofrequency ablation is another possible non-invasive treatment for primary low risk papillary thyroid cancer.
17. This technique has been used successfully to ablate tumors in the liver, lung, and kidney.92
18. Recent studies found that it is safe and effective in the treatment for symptomatic benign thyroid nodules and is effective in treating locoregional recurrence of thyroid cancers.
Recent reports from Korea for primary treatment of low risk thyroid cancer showed good results.
19. Two large Japanese observational studies of 1465 patients with thyroid cancer were conducted on the basis of the hypothesis that most low risk papillary thyroid cancers do not need immediate or eventual thyroid surgery.
20. Patients were offered the option of active surveillance or thyroidectomy.
21.Active surveillance were followed closely with neck ultrasound at six months and then annually for 1-19 years. Few patients had lymph node metastasis (<2%) or experienced asymptomatic lesion growth (5%).
22. No cases of disease specific mortality were seen in the observed patients. None of the other traditional risk factors for lymph node metastasis (multicentricity or size at diagnosis) were linked to any adverse outcomes.
23. Following the example of these Japanese studies, the Memorial Sloan-Kettering Cancer Center in New York City and other centers have begun an active surveillance program for patients with low risk papillary thyroid cancer who do not wish to proceed with surgery.96
24. Active surveillance protocols have also been developed for recurrent localized disease after thyroidectomy. These two studies support the hypothesis that most low risk thyroid cancer lesions follow an indolent course and that many can be monitored safely without active intervention.
25. Ideally, low risk papillary thyroid cancer should be managed in a way that achieves the lowest risk of mortality and morbidity with the lowest burden of treatment.
26. It is important to understand what the patient wants and needs, and what is most appropriate in the individual context.
27. Some patients might even opt for active surveillance because for them a surgical intervention brings more burden than benefit.
28. Many others may, in the future, decide for minimally invasive treatments (such as ultrasound guided percutaneous ethanol ablation or thyroid tumor RFA ablation) as these therapies become better understood and are more widely practiced.
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Richard Guttler MD,FACE ECNU