Diagnosis and treatment of low-risk papillary thyroid microcarcinoma

Jae Hoon Moon; Young Joo Park

doi:10.5124/jkma.2018.61.4.232

J Korean Med Assoc > Volume 61(4); 2018 > Article

Moon and Park: Diagnosis and treatment of low-risk papillary thyroid microcarcinoma

Original Article

J Korean Med Assoc 2018; 61(4): 232-240.

Published online: April 17, 2018

DOI: http://dx.doi.org/10.5124/jkma.2018.61.4.232

Diagnosis and treatment of low-risk papillary thyroid microcarcinoma

Jae Hoon Moon, MD¹, Young Joo Park, MD²

¹Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

²Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

Corresponding author: Young Joo Park E-mail: yjparkmd@snu.ac.kr

Received March 02, 2018 Accepted March 16, 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Recent guidelines for the treatment of thyroid nodules and differentiated thyroid cancer include active surveillance as an alternative option for the treatment of low-risk papillary thyroid microcarcinoma (PTMC). PTMC is defined as having a tumor diameter of ≤1 cm, and low-risk PTMC is defined as PTMC without currently known risk factors (e.g., metastases, local invasion, or cytologic evidence of aggressive disease). Some researchers have suggested that active surveillance can be the first-line treatment of low risk PTMC based on reports showing that the oncological outcomes of active surveillance and immediate surgery were similarly excellent and that immediate surgery can occasionally be accompanied by surgical complications. Nonetheless, many concerns still exist about the full implementation of active surveillance in current clinical practice because the biology of PTMC still has not been fully elucidated and there is little evidence regarding the longterm prognosis of active surveillance. In this review, we discuss the current concept of low-risk PTMC and its treatment modalities, comparing immediate surgery and active surveillance in terms of clinical applications, prognosis, adverse effects, quality of life, and medical costs. This review aims to enable healthcare providers to provide patients with well-balanced information about immediate surgery and active surveillance for the treatment of low-risk PTMC.

Key words: Thyroid gland; Carcinoma; papillary; Diagnosis; Therapy

Table 1.

Contraindications for the active surveillance of papillary thyroid microcarcinomas

Type	Contraindication
Clinical high-risk features	N1 (may present on imaging studies) or M1 (very rare) Signs or symptoms of invasion to the recurrent laryngeal nerve or trachea
	High-grade malignancy on cytology (very rare) Cases showing progression signs such as size enlargement or a novel appearance of lymph node metastasis during active surveillance
Features unsuitable for observation, although it is unclear whether they are associated with biological aggressiveness	Imaging studies indicate that the tumor may invade the trachea or recurrent laryngeal nerve

Reproduced from Miyauchi et al. Thyroid 2018;28:23-31, with permission from Mary Ann Liebert [12].

Table 2.

A risk stratified approach to decision making in probable or proven papillary thyroid microcarcinoma

Candidates for observation	r Tumor/neck US characteristics	Patient characteristics	Medical team characteristics
Ideal	Solitary thyroid nodule Well-defined margins Surrounded by ≥ 2 mm normal thyroid parenchyma	Older patients (>60 years) Willing to accept an active surveillance approach Understands that a surgical intervention	Experienced multidisciplinary management team High quality neck ultrasonography
	No evidence of extrathyroidal extension Previous US documenting stability cN0 cM0	may be necessary in the future Expected to be compliant with followup plans Supportive significant others (including other members of their health care team) Life-threatening co-morbidities	Prospective data collection Tracking/reminder program to ensure proper followup
Appropriate	Multifocal papillary microcarcinomas Subcapsular locations not adjacent to RLN without evidence of extrathyroidal extension Ill defined margins	Middle aged patients (18-59 years) Strong family history of papillary thyroid cancer Child bearing potential	Experienced endocrinologist or thyroid surgeon Neck ultrasonography routinely available
	Background ultrasonographic findings that will make follow up difficult (thyroiditis, non-specific lymphadenopathy, multiple other benign appearing thyroid nodules) FDG avid papillary microcarcinomas
Inappropriate	Evidence of aggressive cytology on FNA (rare) Subcapsular locations adjacent to RLN Evidence of extrathyroidal extension Clinical evidence of invasion of RLN or trachea (rare) N1 disease at initial evaluation or identified during followup M1 disease (rare) Documented increase in size of ≥3 mm in a confirmed papillary thyroid cancer tumor	Young patients (<18 years) Unlikely to be compliant with followup plans Not willing to accept an observation approach	Reliable neck ultrasonography not available Little experience with thyroid cancer management

Reproduced from Brito et al. Thyroid 2016;26:144-149, with permission from Mary Ann Liebert [20]. US, ultrasonography; RLN, recurrent laryngeal nerve; FDG, fluorodeoxyglucose; FNA, fine-needle aspiration.

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