Surgical Strategy for Papillary Thyroid Microcarcinoma

Young Don Lee

doi:10.11106/jkta.2014.7.1.48

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Lee: Surgical Strategy for Papillary Thyroid Microcarcinoma

Review Article

J Korean Thyroid Assoc 2014;7(1):48-56.

Published online: 29 May 2014

DOI: https://doi.org/10.11106/jkta.2014.7.1.48

Surgical Strategy for Papillary Thyroid Microcarcinoma

Young Don Lee

Department of Thyroid Endocrine Surgery, Gachon University Gil Medical Center, Incheon, Korea

Correspondence: Young Don Lee, MD, PhD, Department of Thyroid Endocrine Surgery, Gachon University Gil Medical Center, 1198, Guwol-dong, Namdong-gu, Incheon 405-760, Korea Tel: 82-32-460-3275, Fax: 82-32-460-3247, E-mail: peacemk@gilhospital.com

Received 1 October 2013 Accepted 6 November 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Papillary thyroid microcarcinoma (PTMC), Risk factors, 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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