Journal List > J Korean Thyroid Assoc > v.7(1) > 1056567

Lee: Surgical Strategy for Papillary Thyroid Microcarcinoma

Abstract

It is generally agreed that papillary thyroid microcarcinoma (PTMC) demonstrates indolent biological behavior. But PTMCs include at least two biologically distinct subpopulations: indolent tumors with minimal or no potential for progression, and tumors with the propensity for aggressive behavior and dissemination. The ability to stratify those relatively few patients with aggressive PTMC from the vast majority who are low-risk is crucial to offer most appropriate clinical management. Risk factors such as tumor size, age, sex, tumor multifocality, vascular or capsular invasion, extrathyroidal extension, lymph node metastases, histological variants of papillary thyroid cancer (PTC), the presence of mutational markers, and incidentalness need to be considered for a risk-adapted algorithmic approach that would hope to achieve minimal morbidity while still anticipating optimal outcomes at less cost to the patient and to society. But risk factors for recurrence have not been confirmed because of such low recurrence rates, rare mortality rate, and several selection (or therapeutic) biases present in any retrospective series. Larger scale cohort studies showed that recurrence rates did not differ statistically between patients treated with unilateral lobectomy and those treated with bilateral resection, so long as complete tumor resection was achieved. Similarly, more aggressive nodal dissection failed to yield the anticipated reduction in recurrence rates. In conclusion, selection of the minority of PTMC who deserves more aggressive surgery is important, reserving less aggressive treatments for the other, the large majority cases. The ability to stratify those relatively few patients with aggressive PTMC from the vast majority who are low-risk is crucial to offer most appropriate surgical strategy.

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Table 1.
Summary of clinicopathologic characteristics of PTMC
Characteristics Frequency
Multifocality 7.1–56.8%
Bilaterality 2.9–48%
Cervical nodes metastasis 0–64%
Extracapsular extension 2–62.1°%
Distant Metastasis at Dx 0–3%
Recurrence 1–8.3%
Mortality 0–2.2%

Dx: diagnosis, PTMC: papillary thyroid microcarcinoma

Table 2.
Outcome and its prognostic factors of patients with PTMC
Authors Follow-up Year Series Recurrence Mortality Prognostic factors
Yu et al.27) 15 2011 18,445 ND 0.5% Age > 45, male, L/N metastasis, ETE
Lin et al.61) 2009 7,818 ND 0.12% Only increasing age
Noguchi et al.41) 15 2008 2,070 3.5% 0.6% Autoimmunity, size>6 mm, Age>56, L/N +
Lee et al.42) 12 2013 2,014 6.3% 0% ND
Yamashita et al.66) 11 1997 1,743 1.5% 0.2% Lymph node metastasis
Buffet et al.30) 6.5 2012 1,669 4% 0% L/N metastases, multifocality, male sex
Hay et al.2) 17.2 2008 900 6% (20 year) 0.3% Multicentricity, positive lymph node
Ross et al.34) 4 2009 661 6.2% 0.15% Multifocality, L/N metastasis
Ito et al.43) 10 2006 626 5.0% 0% ND
Pelizzo et al.56) 8.5 2006 403 6% 0.2% Size >0.5 cm, limited surgery
Baudin et al.1) 7.3 1998 281 3.9% ND Multifocality, limited operation
Chow et al.31) 10 2003 203 7.3% 1% Multifocality, limited surgery

ETE: extrathyroidal extension, L/N: lymph node, ND: no data, PTMC: papillary thyroid microcarcinoma

Table 3.
Clinical-pathological features of PTMC incidental or non–incidental in different series
Authors Diagnosis Patients Multicentric Bilateral Invasive L/N Mx. Distant Mx.
Londero et al.46) Incidental 250 52 (21%) ND 4 (2%) 6 (2%) 0 (0%)
Non-incidental 156 59 (38%)a ND 14 (9%)a 88 (56%)a 4 (3%)a
Baudin et al.1) Incidental 189 56 (30%) 25 (13%) 21 (11%) 41 (22%) 0 (0%)
Non-incidental 92 56 (61%)a 21 (23%)a 21 (23%)a 89 (91%)a 8 (8.6%)a
Roti et al.67) Incidental 52 10 (19%) 6 (11%) 8 (15%) 2 (4%) 0 (0%)
Non-incidental 191 68 (36%) 39 (20%) 34 (18%) 30 (16%) 4 (2%)
Pellegriti et al.32) Incidental 151 37 (24.5)% 22 (14.6%) 16 (10%) 24 (16%) 1 (0.7%)
Non-incidental 148 58 (39.2%)a 33 (22.3%) 38 (25%)a 66 (45%)a 7 (4.7%)
Lo et al.68) Incidental 75 9 (12%) ND 0 (0%) 0 (0%) 0 (0%)
Non-incidental 110 35 (32%)a ND 21 (19%)a 43 (39%)a 3 (2.7%)

a significantly different

L/N: lymph node, Mx.: metastasis, ND: no data, PTMC: papillary thyroid microcarcinoma

Table 4.
Comparison of outcome between the patients underwent total thyroidectomy and patients underwent limited surgery for PTMC in different series
Authors Follow up Year Series Result
Bilimoria et al.60) 5.8 2007 10,247 No difference in recurrence and mortality
Lin et al.61) ND 2009 7,818 No difference in mortality
Ito et al.62) 10 2010 2,638 No difference in recurrence
Lee et al.42) 12 2013 2,014 No difference in recurrence
Buffet et al.30) 6.5 2012 1,669 No difference in 10 year recurrence
Hay et al.2) 20 2008 900 No difference in 20 year recurrence
Pelizzo et al.56) 8.5 2006 403 Difference in recurrence
Baudin et al.1) 7.3 1998 281 Difference in recurrence
Chow et al.31) 10 2003 203 Increased recurrence after limited surgery

ND: no data, PTMC: papillary thyroid microcarcinoma

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