Papillary Thyroid Microcarcinoma: Insights from a Cohort of 257 Thyroidectomized Patients

Abstract

Papillary thyroid microcarcinoma management evolved, and less aggressive strategies are now considered. Questions, however, remain on these tumors’ behavior, particularly on developing countries' real ground healthcare scenarios. Our aim is to gather insights on the natural history of papillary thyroid microcarcinoma on patients treated with thyroidectomy in Brazil. Consecutive patients diagnosed with papillary thyroid microcarcinoma had their clinical characteristics, interventions, and outcomes described. Patients were classified as incidental or nonincidental based on the diagnosis after or before surgery, respectively. A sum of 257 patients were included, 84.0% of which were women, and the mean age was of 48.3±13.5 years. The mean tumor size was of 0.68±0.26 cm, 30.4% were multifocal, 24.5% had cervical metastasis, and 0.4% distant metastasis. The nonincidental and incidental tumors differed in tumor size (0.72±0.24 and 0.60±0.28 cm, respectively, p=0.003) and in presence of cervical metastasis (31.3% and 11.9%, respectively, p<0.001). Male sex, nonincidental diagnosis, and younger age were independent predictors of cervical metastasis. After 5.5 years (P25–75 2.5–9.7) of follow-up, only 3.8% of patients had persistent structural disease (3.4% cervical). Predictors of persistent disease at multivariate analysis included cervical metastasis and multicentricity. In conclusion, incidental and nonincidental papillary thyroid microcarcinoma patients of the population studied displayed excellent outcomes. Cervical metastasis and multicentricity were frequent findings and prognostic factors for persistent disease.

Keywords

thyroid cancer - diagnosis - treatment

Publication History

Received: 14 October 2022

Accepted: 21 December 2022

Article published online:
16 February 2023

• References

• 1 Davies L, Welch HG.. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006; 295: 2164
• 2 Davies L, Welch HG.. Current thyroid cancer trends in the United States. JAMA Otolaryngology Head Neck Surg 2014; 140: 317-322
• 3 Ahn HS, Kim HJ, Welch HG.. Korea’s thyroid-cancer “epidemic” — screening and overdiagnosis. N Eng J Med 2014; 371: 1765-1767
• 4 La Vecchia C, Malvezzi M, Bosetti C. et al. Thyroid cancer mortality and incidence: a global overview. Int J Cancer 2014; 136: 2187-2195
• 5 Vaccarella S, Dal Maso L, Laversanne M. et al. The impact of diagnostic changes on the rise in thyroid cancer incidence: a population-based study in selected high-resource countries. Thyroid 2015; 25: 1127-1136
• 6 Li M, Brito JP, Vaccarella S.. Long-term declines of thyroid cancer mortality: an international age-period-cohort analysis. Thyroid 2020; 30: 838-846
• 7 Morris LGT, Sikora AG, Tosteson TD. et al. The increasing incidence of thyroid cancer: the influence of access to care. Thyroid 2013; 23: 885-891
• 8 Haymart MR, Banerjee M, Reyes-Gastelum D. et al. Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer. J Clin Endocrinol Metab 2018; 104: 785-792
• 9 Vaccarella S, Franceschi S, Bray F. et al. Worldwide thyroid-cancer epidemic? The increasing impact of overdiagnosis. N Eng J Med 2016; 375: 614-617
• 10 Miyauchi A.. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid. World J Surg 2016; 40: 516-522
• 11 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
• 12 Oda H, Miyauchi A, Ito Y. et al. Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid. Endocrine J 2017; 64: 59-64
• 13 Kong SH, Ryu J, Kim MJ. et al. Longitudinal assessment of quality of life according to treatment options in low-risk papillary thyroid microcarcinoma patients: active surveillance or immediate surgery (Interim Analysis of MAeSTro). Thyroid 2019; 29: 1089-1096
• 14 Moten AS, Zhao H, Willis AI.. The overuse of radioactive iodine in low-risk papillary thyroid cancer patients. Surg Oncol 2019; 29: 184-189
• 15 Scheffel RS, Zanella AB, Dora JM. et al. Timing of radioactive iodine administration does not influence outcomes in patients with differentiated thyroid carcinoma. Thyroid 2016; 26: 1623-1629
• 16 Nava CF, Scheffel RS, Zanella AB. et al. Reappraising the diagnostic accuracy of post-treatment wole-body scans for differentiated thyroid carcinoma. Horm Metab Res 2020; 52: 834-840
• 17 Nava CF, Zanella AB, Scheffel RS. et al. Impact of the updated TNM staging criteria on prediction of persistent disease in a differentiated thyroid carcinoma cohort. Archiv Endocrinol Metab 2019; 63: 5-11
• 18 Cooper DS, Doherty GM, Haugen BR. et al. Revised American thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009; 19: 1167-1214
• 19 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
• 20 Momesso DP, Tuttle RM.. Update on differentiated thyroid cancer staging. Endocrinol Metab Clin North Am 2014; 43: 401-421
• 21 Tuttle RM, Tala H, Shah J. et al. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American thyroid association staging system. Thyroid 2010; 20: 1341-1349
• 22 Vaisman F, Momesso D, Bulzico DA. et al. Spontaneous remission in thyroid cancer patients after biochemical incomplete response to initial therapy. Clin Endocrinol 2012; 77: 132-138
• 23 Brandi ML, Bilezikian JP, Shoback D. et al. Management of hypoparathyroidism: summary statement and guidelines. J Clin Endocrinol Metab 2016; 101: 2273-2283
• 24 Roti E, degli Uberti EC, Bondanelli M. et al. Thyroid papillary microcarcinoma: a descriptive and meta-analysis study. Eur J Endocrinol 2008; 159: 659-673
• 25 Liu LS, Liang J, Li JH. et al. The incidence and risk factors for central lymph node metastasis in cN0 papillary thyroid microcarcinoma: a meta-analysis. Eur Archiv Oto-Rhino-Laryngoly 2016; 274: 1327-1338
• 26 Zhang L, Wei W, Ji Q. et al. Risk factors for neck nodal metastasis in papillary thyroid microcarcinoma: a study of 1066 patients. J Clin Endocrinol Metab 2012; 97: 1250-1257
• 27 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
• 28 Mehanna H, Al-maqbili T, Carter B. et al. Differences in the recurrence and mortality outcomes rates of incidental and nonincidental papillary thyroid microcarcinoma: a systematic review and meta-analysis of 21 329 person-years of follow-up. J Clin Endocrinol Metab 2014; 99: 2834-2843
• 29 Leboulleux S, Tuttle RM, Pacini F. et al. Papillary thyroid microcarcinoma: time to shift from surgery to active surveillance?. Lancet Diabetes Endocrinol 2016; 4: 933-942
• 30 Sawka AM, Ghai S, Yoannidis T. et al. A prospective mixed-methods study of decision-making on surgery or active surveillance for low-risk papillary thyroid cancer. Thyroid. 2020; 30: 999-1007
• 31 Sasaki T, Miyauchi A, Ito Y. et al. Marked decrease over time in conversion surgery after active surveillance of low-risk papillary thyroid microcarcinoma. Thyroid 2020; 31: 217-223
• 32 Oda H, Miyauchi A, Ito Y. et al. Incidences of unfavorable events in the management of low-risk papillary microcarcinoma of the thyroid by active surveillance versus immediate surgery. Thyroid 2016; 26: 150-155
• 33 Smulever A, Pitoia F.. Active surveillance in papillary thyroid carcinoma: not easily accepted but possible in Latin America. Archiv. Endocrinol Metab 2019; 63: 462-469
• 34 Welch HG, Doherty GM.. Saving thyroids – overtreatment of small papillary cancers. N Eng J Med 2018; 379: 310-312
• 35 Durante C, Montesano T, Torlontano M. et al. Papillary thyroid cancer: time course of recurrences during postsurgery surveillance. J Clin Endocrinol Metab 2013; 98: 636-642