Treatment Decision Making in Papillary Thyroid Microcarcinoma

Giuseppe Navarra; Guido Nicola Zanghì; Francesco Freni; Bruno Galletti; Francesco Galletti; Grazia Pagano; Andrea Cogliandolo; Alberto Barbera; Salvatore Lazzara; Gianlorenzo Dionigi

doi:10.16956/jes.2018.18.2.110

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Navarra, Zanghì, Freni, Galletti, Galletti, Pagano, Cogliandolo, Barbera, Lazzara, and Dionigi: Treatment Decision Making in Papillary Thyroid Microcarcinoma

Review Article

J Endocr Surg. 2018;18(2):110-120.

Published online: 5 June 2018

DOI: https://doi.org/10.16956/jes.2018.18.2.110

Treatment Decision Making in Papillary Thyroid Microcarcinoma

Giuseppe Navarra¹, Guido Nicola Zanghì², Francesco Freni³, Bruno Galletti³, Francesco Galletti³, Grazia Pagano¹, Andrea Cogliandolo¹, Alberto Barbera¹, Salvatore Lazzara¹, Gianlorenzo Dionigi⁴

¹Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

²Department of Surgery, Policlinico Vittorio Emanuele University Hospital - General Surgery and Oncology Unit, University of Catania, Catania, Italy

³Division of ENT Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

⁴Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

Correspondence to Gianlorenzo Dionigi Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Via C. Valeria 1, Messina 98125, Italy. E-mail: gdionigi@unime.it

No potential conflict of interest relevant to this article was reported.

Received 18 February 20182 April 2018 Accepted 14 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

The objective of this article is to detail the treatment for papillary thyroid microcarcinoma (PTMC). The literature presents only few contributions, with controversial results, about comparison between ‘active surveillance’ and surgery. Hemithyroidectomy is the treatment of choice for PTMC. Thyroidectomy is indicated in cases of multifocality, extrathyroid tumor growth, and familial PTMCs. Active surveillance can only be done under well-defined and controlled conditions. Collected findings and agreements with the patient must be precisely documented, also for medico-legal reasons. An observation of PTMC seems most appropriate for patients >60 years of age. In the case of observation of a PTMC, a lifelong examination of the tumor disease must be carried out, since tumor growth or metastases can still occur after 10–15 years. The follow-up periods for the ‘active surveillance’ proposed from the literature review are too short to conclude this as a real alternative.

Keywords: Papillary thyroid microcarcinoma, Surgery, Thyroid nodule

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Fig. 1.

Schematic representation of the anatomical relationship between a PTMC of the thyroid gland, the tracheal wall, the RLN and strap muscles to plan the further course of therapy (active surveillance vs. surgery). Risk of ‘tracheal’ infiltration by a PTMC: (A) angle at high risk; (B) almost right angle - middle risk; (C) round shape tumor angle - low risk. Risk of infiltration of ‘soft tissue and muscles’ by PTMC: (D) small PTMC contained in the isthmus; (E) isthmus PTMC extending anteriorly to connective tissue; (F) lobe PTMC extending laterally to connective tissue. Risk of infiltration of ‘RLN’ by PTMC: (G) intrathyroidal - low risk; (H) posterior PTMC - high risk (modified from reference 15). PTMC = papillary thyroid microcarcinoma; RLN = recurrent laryngeal nerve.

Table 1.

Literature review for active surveillance for papillary microcarcinomas of the thyroid gland

Study	Year	No. of patients	Follow-up (mon)	PTMC unchanged (%)	Tumor progress ≥3 mm (%)	Surgery (%)	LN metastases (%)	Local recurrence (%)	Survival (%)
Ito et al. (5)	2003	162	48.7	70	11.1	34.6	12.3	−	100
Ito et al. (11)	2014	1,235	75	−	8	16	38	1.1	100
Kwon et al. (6)	2017	192	30.1	69	14	13	29	−	100
Tuttle et al. (7)	2017	291	25	87.6	3.8	3.4^†	0	0	100
Kim et al. (30)	2018	127	26	−	19.8	−	−	−	100
Miyauchi et al. (31)	2018	1,211	120	−	3.5–60^∗	−	−	−	−

PTMC = papillary thyroid microcarcinoma; LN = lymph node.

^∗ The age decade-specific disease progression rates at 10 years of active surveillance were 36.9% (20s), 13.5% (30s), 14.5% (40s), 5.6% (50s), 6.6% (60s), and 3.5% (70s); the respective lifetime disease progression probabilities were 60.3%, 37.1%, 27.3%, 14.9%, 9.9% and 3.5% according to the age at presentation

^† Operation due to tumor progression or patient request.

Table 2.

Recommendations of various guidelines for the treatment of papillary microcarcinomas of the thyroid gland

Study	Year	Suggestion
Italian Endocrine Society of Surgery (20)	2017	Hemithyroidectomy
American Thyroid Association (16)	2015	Hemithyroidectomy
British Thyroid Association (19)	2014	Hemithyroidectomy
Japanese Society of Thyroid Surgeons/Japan Association of	2010	Observation or surgery from
Endocrine Surgeons (22)		‘low-risk’ PTMC^∗
German Society Surgery (21)	2012	Hemithyroidectomy
Canadian Society of Otolaryngologist-Head and	2014	Hemithyroidectomy^†
Neck Surgeons (OHNS) and		Thyroidectomy
Endocrinologists (33)		Observation
Consensus - Chinese Association of Thyroid Oncology (32)	2017	Lobectomy+isthmusectomy

PTMC = papillary thyroid microcarcinoma.

^∗ Low-risk PTMC: carcinomas without distant or lymph node metastases and without symptoms

^† Hemithyroidectomy (47%) or total thyroidectomy (43%) for a newly diagnosed PTMC in a low risk patient. Observation was the preferred method for managing PTMC detected incidentally after hemithyroidectomy (76%).

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