Active surveillance for PTMC warranted for the UK population?

Epidemiology of Thyroid Cancer.

Journal of Ultrasound in MedicineEarly View Practice ParameterFull Access AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck First published: 05 May 2023 https://doi.org/10.1002/jum.16251AboutReferencesRelatedInformationPDFSections Introduction Indications Qualifications and Responsibilities of Personnel Request for the Examination Specification of the Examination Documentation Equipment Specification Quality and Safety Acknowledgments Collaborative Subcommittees AIUM Clinical Standards CommitteeReferencesPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck was developed (or revised) by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but are not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with recognition that deviations may occur depending on the clinical situation. Indications Indications for an ultrasound (US) examination of the thyroid and extracranial head and neck include, but are not limited to1: Evaluation of the location and characteristics of palpable neck masses and thyroid nodules. Evaluation of abnormalities detected by other imaging examinations, such as thyroid nodules and/or other neck masses that satisfy criteria for a thyroid ultrasound examination that are detected on computed tomography (CT), positron emission tomography (PET), PET/CT, magnetic resonance imaging (MRI), or other ultrasound examinations (eg, carotid duplex).1 Evaluation of the presence, size, location, and sonographic features of the thyroid gland.2 Evaluation of congenital hypothyroidism, including search for and characterization of orthotopic and/or ectopic thyroid tissue.3, 4 Evaluation of patients at high risk for thyroid malignancy. Imaging of previously detected thyroid nodules that meet criteria for follow-up.5 Evaluation of the thyroid gland for suspicious focal pathology before neck surgery for nonthyroidal disease.6 Evaluation of the thyroid gland for suspicious focal pathology before radioiodine ablation of the gland for hyperthyroidism. Evaluation for regional nodal metastases in patients with proven or suspected thyroid carcinoma before surgical or other management.7 Evaluation for recurrent locoregional metastatic disease and/or nodal metastases after lobectomy, hemi- or total thyroidectomy for thyroid carcinoma.5 Evaluation of known or suspected thyroid cancer (usually papillary microcarcinoma not undergoing surgical resection) that is being monitored periodically with ultrasound active surveillance/active monitoring for disease progression (eg, increase in nodule size, development of nodal metastatic disease, or extrathyroidal extension). Guidance for aspiration biopsy or other interventional procedure performed on thyroid abnormalities or other neck masses.8, 9 Evaluation for causes of relevant laboratory abnormalities, such as abnormalities of parathyroid or thyroid function, elevation of thyroglobulin, hypercalcemia, and so on. Assessment of the location, number, and size of enlarged parathyroid glands in patients with known or suspected hyperparathyroidism, including patients who have undergone previous parathyroid surgery or ablative therapy who have recurrent signs or symptoms of hyperparathyroidism.10, 11 Localization of autologous parathyroid gland implants. Evaluation of masses of the parotid and submandibular glands.12, 13 Evaluation of non-neoplastic conditions of the parotid and submandibular glands, including, but not limited to, sialolithiasis, infection, and autoimmune processes.14-16 Nodal evaluation, including staging, evaluation of response to therapy, and monitoring after therapy, in select patients with head and neck malignancies, including, but not limited to, head and neck primary squamous cell carcinoma, primary salivary malignancy, and melanoma.17-19 Evaluation for supraclavicular nodal metastasis in patients with lung cancer or other infraclavicular primary malignancies at risk for metastasis.20, 21 Nodal evaluation in pediatric patients with cervical lymphadenopathy, including, but not limited to, evaluation for necrosis and abscess formation in the setting of acute lymphadenitis.22, 23 Imaging of ultrasound-detectable vascular abnormalities (such as vascular tumors and vascular malformations) of the head and neck.24 Evaluation of torticollis in neonates and infants25; or Evaluation of adult and pediatric head and neck soft tissue masses including, but not limited to, thyroglossal duct cyst, branchial cleft cyst, lymphatic malformation, thymic ectopia/cyst, hemangioma, primary neck masses, including neurogenic tumors (neuroblastoma, schwannoma, neurofibroma), rhabdomyosarcoma, leukemia/lymphoma, metastatic disease (rhabdomyosarcoma, neuroblastoma, thyroid cancer, etc),26 and phlebectasia.27 Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines28 in accordance with AIUM accreditation policies.29 Sonographers performing the ultrasound examination should be appropriately credentialed30 in the specialty area in accordance with AIUM accreditation policies.29 Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32.31 Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed health care provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local health care facility requirements. Specification of the Examination Sonographic evaluations of the neck may be comprehensive or may be problem-focused, as appropriate for the patient and clinical scenario. Whenever possible, comparison should be made with prior sonograms and/or other appropriate imaging studies. Thyroid Evaluation The examination should be performed with the neck in as much hyperextension as tolerated by the patient, with or without a towel or other support under the neck or shoulders. Upright positioning may be helpful in patients who cannot tolerate neck hyperextension in the supine position. The right and left lobes of the thyroid should be imaged in longitudinal and transverse planes. Recorded images should include transverse images of the superior, mid, and inferior portions of the right and left thyroid lobes; longitudinal images of the medial, mid, and lateral portions of both lobes; and a transverse image of the isthmus. The size of each thyroid lobe should be recorded in three dimensions: anteroposterior (AP), transverse, and longitudinal. The thickness (AP measurement) of the isthmus on the transverse view should be recorded. Color Doppler can be used to supplement grayscale evaluation of either diffuse or focal thyroid abnormalities. It is often necessary to extend imaging to include the soft tissues above the isthmus, for example, to evaluate a pyramidal lobe of the thyroid, a thyroglossal duct cyst, or palpable abnormality. Similarly, it is important to visualize components of the gland that extend toward or into the superior mediastinum. In this effort, use of tightly curved array transducers may be helpful. The roles of strain and shear-wave elastography and contrast-enhanced ultrasound (CEUS), although potentially helpful, have not been established definitively. Thyroid abnormalities should be imaged in a way that allows for reporting and documentation of the following: Localized or diffuse parenchymal echotexture (eg, homogeneous vs heterogeneous) and, if relevant, vascularity (hyperemia) of the thyroid parenchyma should be noted.32, 33 There are multiple thyroid nodule risk-stratification systems (RSSs) in existence. Images of thyroid nodules should be acquired such that relevant focal nodules can be classified based on whatever RSS is used by the interpreting physician. For example, the ACR Thyroid Imaging, Reporting and Data System (TI-RADS) RSS employs the following sonographic features: composition (solid and/or cystic components); echogenicity; size (in AP, transverse, and longitudinal dimensions); margins (smooth, ill-defined, irregular, or demonstrating extrathyroidal extension); nodule orientation (eg, taller than wide); and presence and type of echogenic foci and/or calcifications.8, 34, 35 Although the ultrasound features that determine risk in children are the same as those used in adults, to date, none of the RSSs have been specifically endorsed for the pediatric population.9, 36, 37 Examination of relevant neck compartments for adenopathy may be helpful in determining the need for biopsy in the setting of thyroid nodules. Comprehensive evaluation of central and lateral compartment cervical lymph nodes is strongly recommended for patients with known or suspected thyroid cancer.38, 39 This comprehensive evaluation may occur at the time of the initial thyroid ultrasound, the time of an ultrasound-guided biopsy, or as a separate ultrasound evaluation to assist in potential surgical or other management decisions. Institutions are encouraged to have consistent practices to ensure that patients receive a comprehensive nodal evaluation when indicated (see Section 8). In patients who have undergone lobectomy, hemithyroidectomy (lobectomy and isthmectomy), or thyroidectomy, the thyroid bed should be imaged in transverse and longitudinal planes, and abnormal solid or cystic masses should be measured and reported. Again, examination of relevant neck compartments and the adjacent soft tissue is important to look for locoregional metastatic disease in the setting of prior thyroid malignancy. Patients with known or suspected thyroid malignancy who are undergoing active surveillance or active monitoring with ultrasound must be evaluated for progression (eg, interval increase in surveillance nodule size, development of extrathyroidal extension, multifocal disease, or locoregional nodal metastases).40-43 Cervical Lymph Node Evaluation Sonographic examination of cervical lymph nodes may be comprehensive or focused, as appropriate for the patient and clinical scenario. Specific nodes that are imaged and the extent of imaging documentation will vary based on the clinical indication. Please see above for nodal evaluation with respect to thyroid-related indications. The size and location of abnormal lymph nodes should be documented, and suspicious nodal morphology including, but not limited to, calcification, cysts' focal echogenic areas that are unrelated to a fatty hilum, and abnormal blood flow should be documented.44 Round shape and absence of an echogenic hilum, although reported in malignant nodes, are findings with poor specificity in thyroid cancer.45, 46 Location of abnormal lymph node(s) should be documented with annotations and/or enough visual information to be able to describe the location according to the image-based nodal classification system developed by the American Joint Committee on Cancer and the American Academy of Otolaryngology—Head and Neck Surgery, or in a fashion that allows the referring clinician to convert the location of abnormal nodes to that system.47 Node evaluation should be performed at centers with experienced personnel. Lymph node size varies with nodal compartment (eg, level 2 nodes are often larger than other lateral compartment nodes), and nodal size is often less important in the evaluation of malignancy than nodal morphology. Enlarged cervical nodes can be seen in lymphoma and other malignancies but are often reactive and are seen in acute and chronic infectious and inflammatory disease processes such as postviral syndromes and Hashimoto thyroiditis. In the pediatric population, cervical lymph node size, echotexture, vascularity, and potential nodal suppuration or abscess-formation evaluation are important in the evaluation of acute lymphadenitis.22, 23 Parathyroid Evaluation Parathyroid ultrasound helps guide surgical planning by localizing enlarged parathyroid glands in patients with primary hyperparathyroidism and helping to predict single versus multiple gland enlargement. Examination for suspected parathyroid enlargement due to adenomas, hyperplasia, or, extremely rarely, parathyroid carcinomas should include images posterior to and just inferior to the right and left thyroid lobes, typical parathyroid gland locations. In addition to typical locations, enlarged parathyroid glands and parathyroid adenomas may be ectopic, and the examination may need to be extended to include imaging from the hyoid to the sternum and along the carotid sheath. Abnormalities of the thyroid and cervical nodes should be documented because concomitant thyroid and/or cervical node pathology may be contraindications to minimally invasive parathyroidectomy.10, 11, 48 The examination should be performed with the neck hyperextended and should include longitudinal images from the right and left carotid arteries to the midline, as well as transverse images from the carotid artery bifurcation superiorly to the thoracic inlet inferiorly. Normal parathyroid glands are often not visualized using available sonographic technology; however, enlarged parathyroid glands may be detected. Gentle compression with the ultrasound transducer, asking the patient to swallow during real-time imaging, and the addition of color Doppler imaging (to evaluate for polar rather than central blood flow that is more typical of lymph nodes) are imaging techniques that may make it easier to identify enlarged parathyroid glands. Parathyroid glands may be located below the clavicles or in the mediastinum, and angling smaller footprint, tightly curved array transducers inferiorly from the sternal notch can aid in diagnosis of enlarged inferior parathyroid glands. Approximately 1%–3% of parathyroid adenomas may be retrotracheal; instructing the patient to swallow and/or turn their head to the opposite side may be helpful in identifying these ectopic parathyroid glands. Rarely, parathyroid adenomas may be intrathyroidal. When parathyroid abnormalities are visualized, their number, size, measurements in three dimensions, and location and relationship to the thyroid gland, if applicable, should be documented.6, 49 Parotid and Submandibular Evaluation Sonographic evaluation of the major salivary glands may be comprehensive or focused, as appropriate for the patient and clinical scenario. The parotid and submandibular glands are evaluated in two planes, although anatomic limitations due to the mandible and external ear often require oblique planes. A lower frequency transducer may be helpful to visualize the deep aspects of the parotid gland. Color Doppler may be added, when appropriate, for the evaluation of diffuse or focal abnormalities. Overall echotexture (eg, homogeneous or heterogeneous) and measurements of the parotid and submandibular glands should be performed, when appropriate, such as in the evaluation of autoimmune disease or gland asymmetry. Salivary ductal dilation and calculi should be reported. When possible, a dilated salivary gland duct should be traced to the level of obstruction. Description of focal abnormalities/masses within the salivary glands should include size in three dimensions, margins, echogenicity, composition, and internal blood flow. Intraparotid lymph nodes and their morphologic appearance (normal or abnormal) should be reported.50 Sonographic Guidance of Head and Neck Procedures Sonographic guidance may be used for aspiration and/or biopsy of thyroid/parathyroid/salivary gland abnormalities, lymph nodes, and other masses of the head and neck or for other interventional procedures including, but not limited to, preoperative localization and ultrasound-guided treatment of masses with various ablation methods.51 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination.52 Equipment Specification Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment.53 Extracranial head and neck ultrasound studies are usually conducted with a linear transducer. The equipment should be adjusted to operate at the highest clinically appropriate frequency, realizing that there is a trade-off between resolution and beam penetration. For most patients, mean frequencies of 10–14 MHz or greater are preferred, although some patients may require a lower-frequency transducer for depth penetration. For evaluation of deep or large structures, a curved transducer may be necessary. For morphologic evaluation of small, superficial lesions, higher frequency transducers, with a small footprint, may be necessary. Additionally, a small-footprint, tightly curved array transducer may be helpful for evaluation of the inferior aspect of the central neck to evaluate for inferior central or upper mediastinal adenopathy and inferior parathyroid glands (Section 5.3). Resolution should be of sufficient quality to evaluate the internal morphology of visible lesions. Doppler frequencies should be set to optimize flow detection. Diagnostic information should be optimized while keeping total sonographic exposure as low as reasonably achievable. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment-performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices.29 ALARA Principle The potential benefits and risks of each examination should be considered. The ALARA (As Low as Reasonably Achievable) principle54 should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety.55 Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM's Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel.56 Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice.29 Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Mark Lupo, MD ACR Michelle L. Melany, MD, FACR, Chair Javad Azadi, MD Helena Gabriel, MD Safwan Halabi, MD SPR Sosamma Methratta, MD Cicero Silva, MD SRU Malak Itani, MD Kathryn McGillen, MD AIUM Clinical Standards Committee James M. Shwayder, MD, JD, Chair Rachel Bo-ming Liu, MD, Vice Chair Bryann Bromley, MD, FAIUM Rachel Bo-ming Liu, MD, FACEP, FAIUM Juliana Gevaerd Martins, MD Creagh T. Boulger, MD, FAIUM John R. Eisenbrey, PhD, FAIUM Rob Goodman, MB, BChir Margarita V. Revzin, MD, MS, FSRU, FAIUM Oliver Daniel Kripfgans, PhD, FAIUM Jean Lea Spitz, MPH, CAE, RDMS, FAIUM, FSDMS Nirvikar Dahiya, MD, FAIUM John Stephen Pellerito, MD, FACR, FAIUM, FSRU Ethan J. Halpern, MD, FAIUM Original copyright, 1994; revised, 1998, 2003, 2006, 2007, 2013, 2014, 2018, 2022 References 1Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Thyroid ultrasound and diffuse Ultrasound for primary imaging of congenital J. Thyroid abnormalities by in neonates with congenital et al. American Thyroid management for adult patients with thyroid nodules and thyroid the American Thyroid on thyroid nodules and thyroid Thyroid JD, et al. thyroid ultrasound is indicated in patients undergoing for primary Cancer The of in thyroid Thyroid nodules. JK, et al. Thyroid ultrasound reporting white paper of the ACR thyroid imaging, reporting and system JD, ultrasound be used as the primary for the localization of parathyroid disease prior to surgery for primary A review of Clinical of ultrasound and for preoperative localization of parathyroid in patients with primary Imaging the major salivary glands. Imaging of salivary gland et al. of salivary gland to the diagnosis of toward diagnostic T. diagnostic and of salivary gland using a T. conditions of the salivary glands. Ultrasound evaluation of malignant and cervical lymph Ultrasound et al. between and imaging for squamous cell carcinoma nodes with in the The of ultrasound in the of cervical lymph node metastases in clinically squamous cell carcinoma of the head and Cancer Imaging et al. The of ultrasound in and a diagnosis in patients with lung a two single et al. of external of the neck after and scanning in the preoperative of patients with and color Doppler of cervical in L. and chronic cervical in Imaging of vascular of the head and MD, M. the of the of pediatric neck Ultrasound R. in a diagnostic Training American Institute of Ultrasound in Medicine Standards and Guidelines for the Accreditation of Ultrasound American Institute of Ultrasound in Medicine of American Institute of Ultrasound in Medicine 42 CFR Diagnostic diagnostic laboratory and other diagnostic Middleton WD, et al. Hashimoto sonographic of the of Hashimoto thyroiditis. The review of imaging features and biopsy techniques with et al. of thyroid nodules detected at Society of Radiologists in ultrasound Radiology et al. thyroid are with from and et al. for children with thyroid nodules and thyroid Thyroid Middleton WD, et al. ACR thyroid imaging, reporting and system white paper of the ACR of papillary thyroid comparison of ultrasound imaging and et al. of preoperative in the surgical management of initial and papillary thyroid et al. for papillary thyroid microcarcinoma in is related to the progression of papillary microcarcinoma of the thyroid under Thyroid et al. of in the management of papillary microcarcinoma of the thyroid by active surveillance versus Thyroid of papillary thyroid microcarcinoma should be our treatment and of of malignant neck and Cancer Imaging Langer JE, neck after thyroidectomy for papillary thyroid in the diagnosis of recurrent and metastatic Ultrasound et al. Ultrasound criteria of malignancy for cervical lymph nodes in patients for thyroid nodal classification for evaluation of neck metastatic Imaging of the parathyroid glands. Ultrasound et al. features of parathyroid primary Imaging of the salivary glands. et al. of metastatic lymph nodes in the neck from papillary thyroid carcinoma with practice parameter for documentation of an ultrasound Ultrasound Routine Quality Assurance of Clinical Ultrasound version American Institute of Ultrasound in Medicine Low Reasonably American Institute of Ultrasound in Medicine American Institute of Ultrasound in Medical Ultrasound American Institute of Ultrasound in Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as well as Safe and Use of Ultrasound Coupling American Institute of Ultrasound in Medicine of before in an following and Thyroid ultrasound monitoring for thyroid MD, MD, MD, MD, MD, MD, Pediatric and neck and and Neck after for Head and Neck MD, MD, MD, Mark MD, MD, MD, Stephen MD, MD, MD, MD, MD, The of a primary thyroid carcinoma on patients with head and neck squamous cell M. MD, MD, MS, MD, J. MD, Head Neck

Introduction:Papillary thyroid microcarcinoma (PTMC) is the most common subtype of thyroid cancer, generally associated with a favorable prognosis. Radiofrequency ablation (RFA) is emerging as a minimally invasive alternative to surgery, particularly for patients unsuitable for active surveillance and surgery. This report presents the first documented case of RFA for PTMC in Indonesia.Case report:A 40-year-old woman presented with a palpable thyroid nodule on the right side of her neck. Thyroid ultrasound and thyroid core needle biopsy confirmed PTMC. The patient underwent RFA using a 5-mm probe tip and 50-Watt power, employing the “moving shot” technique. The procedure was successful, with no reported complications. Follow-up assessments showed a significant reduction in tumor volume of 95.38%, from 0.264 ml to 0.012 ml, with no signs of progression at 12 months.Discussion:RFA provides a minimally invasive alternative to active surveillance with advantages, giving patient definitive treatment. Compare to surgery, this treatment have advantage such as shorter procedure time, lower procedural costs, reduced blood loss, and preservation of thyroid function, leading to faster recovery. However, wider adoption in Indonesia remains limited by the need for trained operators and access to advanced ultrasonography equipment. Strengthening workforce training, improving infrastructure, and generating long-term outcome data are essential for broader implementation.Conclusion:This case highlights RFA as a safe and effective treatment for PTMC, particularly for patients who do not wish to undergo active surveillance management for low risk thyroid cancer. Further studies are necessary to assess its long-term efficacy and feasibility.

In recent times, it has been reported that thyroid cancer is increasing.[1] Interestingly, this increase has been not restricted to any particular gender, age, or socioeconomic status. In the past decade, the use of ultrasound of the neck has become common. This has led to the increasing diagnosis of incidental thyroid nodules, or incidentalomas also called as 'a disease of modern technology'.[2] Another special situation is the widespread availability of positron emission tomography(PET), which has also resulted in the diagnosis of PET-detected thyroid incidentaloma, which poses another unique challenge to the treating physician. Therefore, it has been argued that the increase in diagnosis of thyroid cancer is attributable to detection of early, indolent cases, not from an actual increase in occurrence. Additionally, this rapid increase in the prevalence of thyroid cancers cannot be explained in the setting of stable underlying environmental risk factors and also the genetic changes leading to neoplasia are unlikely to happen very rapidly. The most dramatic report on this issue was published in the New England Journal of Medicine, which reported a remarkable increase in thyroid cancer diagnoses from the Republic of Korea.[3] The article highlights a popular concern in that country; as the incidence of thyroid cancer reportedly increased 15-fold between 1993 and 2011. Indeed the authors state that thyroid cancer is the most common cancer diagnosed in the Republic of Korea, with 40,000 cases diagnosed in the year 2011 alone! The most common type of thyroid cancer detected was papillary thyroid cancer. The authors attribute this to the wide-spread screening of people for thyroid cancer with a relatively cheap and noninvasive investigation, that is, ultrasonography (USG) thyroid as well as increased awareness of their population about diagnosis and treatment of cancers in early stages. At the same time, the report also stresses that despite the increase in prevalence, the mortality did not increase. This led those authors to suggest the possibility of over-diagnosis and to consider whether such an intensive screening thyroid cancer will indeed help in improving mortality, morbidity, quality of life, and overall outcome. This increasing concern about over-diagnosis has been addressed from other parts of the world. For example from Australia, where there was a rapid increase in the diagnosis of thyroid cancer. A study was carried out in Queensland, and the authors reported that the age-standardized incidence increased from 2.2/100,000 to 10.6/100,000 between 1982 and 2008. The increase was true for both early stage and advanced cancers, though the rise in incidence was higher for early-stage cancers.[4] Can it therefore be argued that this increase in early diagnosis rather than the late detection could be an advantage for the patients with thyroid cancer? Undoubtedly, thyroid cancer is best diagnosed early. In addition, with current advances in thyroid surgery and radioiodine therapy, the prognosis of thyroid cancer when appropriately treated is very good. Despite that, thyroid cancer surgery, especially, radical total thyroidectomy does result in complications like hoarseness of voice and hypoparathyroidism, not to mention permanent hypothyroidism. Hence, there is a distinct reason to be concerned about the benefits and risks of treatment of thyroid cancer. Little is understood about the true incidence and prevalence of thyroid cancer in India. Earlier, it was reported in India that the age-adjusted incidence rates of thyroid cancer per 100,000 are about 1 for males and 1.8 for females, and that the commonest type of thyroid cancer is papillary thyroid cancer, followed by follicular thyroid cancer.[56] The report about prevalence of thyroid malignancy in India comes from the eight city study that focused on the prevalence of thyroid dysfunction. About 0.1% of subjects from this study gave a history of thyroid malignancy.[7] As expected in a disease which is treated with a favorable outcome/survival, prevalence rates of present or past disease are higher than the incidence. More studies are needed from India, as both these reports have limitations. However, this clearly indicates that the problem of thyroid cancers in India (with an incident rate of 1-1.8 per 100,000) is grossly underestimated when compared to that in Australia (incidence 10.6/100,000 population) and Korea (incidence 70 per 100,000 population). Therefore, is it likely that in India, problem of thyroid cancer need not necessarily be that of over diagnosis but rather of under-diagnosis. Additionally, these clinical studies from Republic of Korea and Australia may not necessarily be applicable to the Indian settings. For example, it has been reported that the outcomes of treatment are poorer in iodine deficient regions due to higher prevalence of undifferentiated cancers in these areas.[8] Hence, the makers of clinical guidelines now have to walk a thin line that avoids over-diagnosis, at the same time avoids the perils of under-diagnosis. Rather than focusing on genetic preoperative diagnosis; especially in a country where it is difficult to even implement ultrasound-guided fine-needle aspiration cytology in all cases of thyroid nodules, it is important to generate an India-specific data of the present scenario. It is also prudent to develop a country-specific approach to the management of commonly encountered subsets of thyroid malignancy. The papillary thyroid microcarcinoma is for instance, a case in point. While thyroid lobectomy/hemithyroidectomy is advised in recommendations by American Thyroid Association for small, low-risk, isolated, intrathyroidal papillary carcinomas in the absence of cervical nodal metastases,[9] if a multifocal carcinoma is diagnosed, would that not require completion thyroidectomy?[10] On the other hand, given that some papillary thyroid microcarcinomas, especially those harboring mutations, could be more rapidly progressive, these lesions arguably need a more aggressive management approach. Preoperative genetic testing has been shown to be effective.[11] However, genetic testing being expensive, it can hardly be considered a routine option in a developing country like India. What then, is the correct diagnostic approach in India? Well, the obvious answer is that more data is required. A nationwide study on the clinical features and prognosis of thyroid cancer in India is important. A similar study has been carried out in chronic pancreatitis, another puzzling and mysterious disease; and this clarified many aspects of the disease among Indians.[12] Also, it is important to undertake population studies that ascertain the true incidence and prevalence of thyroid cancer in India. There have been past attempts to write consensus statements on management of thyroid nodules in India.[13] The future efforts to form guidelines to tackle the issue of thyroid malignancy should weigh the benefit of a favorable prognosis from early diagnosis and treatment with the risk of causing a physical, psychological, and financial burden from unnecessary screening. The time is ripe to take this work forward to the next level and to collaboratively work for the betterment of subjects affected with, or those at risk of thyroid cancers in India. Source of Support: Nil Conflict of Interest: None declared.

BackgroundOvertreatment of papillary thyroid microcarcinoma (PTMC) has become a common concern. This study aimed to compare clinicopathological features between PTMC and papillary thyroid carcinoma (PTC) and to explore whether surgery can confer significant survival benefits in all patients with PTC or PTMC.MethodsData of 145,951 patients with PTC registered in Surveillance, Epidemiology, and End Results (SEER) database and 8,751 patients with PTC in our institution were retrospectively collected. Patients with tumors less than 10 mm in diameter were classified as PTMC cohort and the rest as PTC cohort. Clinicopathological features between PTMC and PTC were compared on the basis of SEER cohort and validated with institutional data. Survival analysis was conducted to explore the effect of surgery on the prognosis of patients. To minimize potential confounders and selection bias, we performed propensity score matching (PSM) analysis to match more comparable cohorts.ResultsCompared with PTC, PTMC exhibited the following characteristics: more common in women and whites, older age at diagnosis, lower proportion of follicular variants, intraglandular dissemination, extraglandular and capsular invasion, higher proportion of multifocality, fewer lymph node and distant metastases, and higher cancer-specific survival (CSS) and overall survival (OS) (all p-value < 0.05). Regarding treatment, patients with PTMC received a lower proportion of radiotherapy, chemotherapy, and total thyroidectomy but a higher proportion of lobectomy and/or isthmectomy. There was no significant difference in CSS for patients with PTMC at stage T1N0M0 with or without surgery (P = 0.36).ConclusionGenerally, PTMC showed higher biological indolence than PTC, which meant a higher survival rate for patients in both OS and CSS. For patients with PTMC at staged T1N0M0, active surveillance (AS) may be a potentially feasible management strategy. However, the maintenance of good medical compliance and the management of psychological burden cannot be ignored for patients included in AS.

Many controversies exist regarding screening and treatment of thyroid cancer (TC), especially papillary thyroid microcarcinoma (PTMC). The aim of this study was to evaluate patients' psychological distress and sleep disturbance throughout thyroid nodule (TN) screening, diagnosis, and treatment. A total of 2834 participants (1153 participants with TNs) were enrolled during the screening phase, and 1105 individuals with TNs (87 individuals with TC) were enrolled during the diagnosis phase. Of the 87 TC patients, 66 underwent immediate operation (OP), and 21 patients with PTMC opted for active surveillance (AS). Four validated scales were applied to quantify the outcome indicators at prescreening, postscreening, postdiagnosis, and posttreatment. Higher psychological distress and sleep disturbance were found postscreening than prescreening in subjects with TNs, but no differences in those without nodules. Compared with postscreening, higher scores of psychological distress and sleep disturbance were identified in patients with suspicious TC treated with fine needle aspiration (FNA) or with AS. Lower psychological distress and sleep disturbance were noted for patients with benign nodules than for TC patients. OP for TC, especially PTMC, did not alleviate psychological distress or sleep disturbance compared with the same parameters in patients who underwent AS. Based on the findings of impaired psychological health and sleep quality, screening for TNs in adults who show no symptoms should be performed with caution. Psychological distress and sleep disturbance should also be taken into consideration when FNA is performed for suspected TC or OP for papillary thyroid cancer, especially PTMC.

Papillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors with a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However, PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatment strategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate, and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option for PTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillance of low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression, and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting toward more conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidence extended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.

Papillary thyroid microcarcinoma(PTMC)of the thyroid is defined as papillary thyroid carcinoma measuring<1 cm. The incidence of differentiated thyroid cancer is increasing greatly. However, roughly half of this increase is attributable to the identification of PTMC. Serum thyroid stimulating hormone, thyroid ultrasound and ultrasound guided thyroid fine needle aspiration cytology(FNAC)are still the cornerstone for its diagnosis. The active surveillance approach in which active treatment is delayed until the cancer shows signs of substantial progression could be considered in selected patients with low-risk PTMC. Active surgery is still the first line treatment for other PTMC patients, although thermal ablation may be an alternative option for low-risk patients with PTMC. (Chin J Endocrinol Metab, 2018, 34: 353-358) Key words: Papillary thyroid microcarcinoma; Active surveillance; Thermal ablation

Thyroid nodules are common. Thyroid cancer is rarer. No guidelines exist for management of thyroid nodules in the Indian context and these recommendations are intended for this purpose. The consensus committee reviewed important articles, including previously published consensus statements. Management points were scored according to the level of evidence. These guidelines cover the clinical evaluation and include the interpretation of imaging and fine needle aspiration cytology of thyroid nodules. The guidelines also cover the management of special situations like thyroid incidentalomas, cystic thyroid lesion and nodules detected during pregnancy. The consensus guidelines represent a summary of current medical evidence for thyroid nodule management and the committee has attempted to optimize the guidelines for the clinical practice setting in India.

The incidence of thyroid cancer has been rapidly increasing in recent years largely due to improved diagnostic methods. There is evidence to suggest that in papillary thyroid microcarcinoma (PTMC), active surveillance (AS) is comparable in effectiveness compared to immediate surgery (IM). We conducted a survey of Clinicians and Surgeons from Australia and New Zealand to assess the role of AS in the management of PTMC. A short electronic survey was created on the platform Survey Monkey, separate links containing the survey were sent to various medical societies to be distributed to its members. The list of medical societies included: General Surgeons Australia, Endocrine Society of Australia, Australian and New Zealand Endocrine Surgeons, Australian and New Zealand Head and Neck Cancer Society and New Zealand Association of General Surgery. We received 110 complete responses, which demonstrated that 63% of clinicians will discuss AS with patients diagnosed with PTMC. Surgeons are more likely to discuss AS compared to endocrinologists (P=0.03). Forty-eight percent of respondents report managing patients with AS in the past year, those who are able to perform thyroid ultrasounds are more likely to utilise AS (P=0.03). Common perceived barriers to AS include patient anxiety, lack of access to regular follow-up and lack of patient compliance. Our survey shows that Australian and New Zealand clinicians are generally aware of AS as a treatment option for PTMC, but there remain considerable barriers for common implementation.

The recent sharp increase in thyroid cancer incidence is mainly due to increased detection of small papillary thyroid microcarcinoma (PTMC). Due to the indolent nature of the disease, active surveillance (AS) of low-risk PTMCs is suggested as an alternative to immediate surgery to reduce morbidity from surgery. For appropriately selected PTMC patients, AS can be a good management option and surgical intervention can be safely delayed until progression occurs. Many considerations must be taken into account at the time of initiation of AS, including radiological tumor characteristics and clinical characteristics of the patient. A specialized medical team should be assembled to monitor patients during AS with an appropriate follow-up protocol. The fact that some patients require surgery for disease progression after long-term follow-up is a major drawback of the current AS protocol. Evaluation of tumor kinetics by three-dimensional tumor volume measurement during the initial 2–3 years of AS may be helpful for discrimination of PTMCs that need early surgical intervention. In this review, we will discuss the clinical outcomes of surgical intervention and AS, considerations during AS, and unresolved questions about AS.

BackgroundA Korean Multicenter Prospective cohort study of Active Surveillance or Surgery (KoMPASS) for papillary thyroid microcarcinomas (PTMCs) has been initiated. The aim is to compare clinical outcomes between active surveillance (AS) and an immediate lobectomy for low-risk PTMCs. We here outline the detailed protocol for this study.MethodsAdult patients with a cytopathologically confirmed PTMC sized 6.0 to 10.0 mm by ultrasound (US) will be included. Patients will be excluded if they have a suspicious extra-thyroidal extension or metastasis of a PTMC or multiple thyroid nodules or other thyroid diseases which require a total thyroidectomy. Printed material describing the prognosis of PTMCs, and the pros and cons of each management option, will be provided to eligible patients to select their preferred intervention. For the AS group, thyroid US, thyroid function, and quality of life (QoL) parameters will be monitored every 6 months during the first year, and then annually thereafter. Disease progression will be defined as a ≥3 mm increase in maximal diameter of a PTMC, or the development of new thyroid cancers or metastases. If progression is detected, patients should undergo appropriate surgery. For the lobectomy group, a lobectomy with prophylactic central neck dissection will be done within 6 months. After initial surgery, thyroid US, thyroid function, serum thyroglobulin (Tg), anti-Tg antibody, and QoL parameters will be monitored every 6 months during the first year and annually thereafter. Disease progression will be defined in these cases as the development of new thyroid cancers or metastases.ConclusionKoMPASS findings will help to confirm the role of AS, and develop individualized management strategies, for low-risk PTMCs.

Clinicopathologic characteristics of incidental thyroid carcinoma in euthyroid patients receiving total thyroidectomy for multinodular goiter: A retrospective cohort study.

Background: Two Japanese prospective trials of active surveillance (AS) for adult patients with low-risk papillary thyroid carcinoma (PTC) ≤1 cm (cT1aN0M0 PTMC) have verified the safety of AS in oncological control and its superiority over immediate surgery with respect to unfavorable outcomes. Thus, AS has been accepted as an alternative to immediate surgery for asymptomatic papillary thyroid microcarcinomas (PTMCs). However, the real-world clinical approach for PTMC is unknown. Thus, this study aimed to investigate the current state of management of asymptomatic PTMCs in Japan.Methods: We conducted a questionnaire survey on the actual treatment patterns for adult patients with low-risk PTMCs. The subjects were member institutions of the Japan Association of Endocrine Surgery (JAES) or Japanese Society of Thyroid Surgery (JSTS), including the departments of surgery and head and neck surgery (HNS).Results: Responses were obtained from 134 institutes, where 72.4% of Japanese thyroid cancer cases operated by surgeons were treated. For suspicious tumors on ultrasound, 18 responders (13.4%) conducted cytological examination routinely, while 69 (51.5%) and 40 (27.8%) conducted it only for tumors >5 and >10 mm, respectively. After the diagnosis, 42 responders (31.3%) recommend AS, 35 (26.1%) recommend immediate surgery as the management, and 52 (38.8%) allowed patients to decide the treatment course. The present responders tended to recommend surgery for PTMCs that were located adjacent to the dorsal surface of the thyroid, were multiple, or measured almost 10 mm in size. At these institutions, 1176 patients with PTMC underwent surgery in 2017, accounting for 18.1% of surgeries for PTC. During the succeeding three months, 310 of 576 (53.8%) PTMC patients underwent AS. The treatment strategies did not differ between the departments (Surgery or HNS). The institutions that have six or more surgeons, that were located in metropolitan areas, or that were certified by JAES or JSTS performed AS more actively.Conclusion: More than 50% of low-risk PTMCs are on AS in Japan. However, the indication and recommendation for AS vary significantly between institutions. To improve the implementation of this management modality, physicians and patients should be further educated, and the sociomedical environment should be improved.

Thyroid cancer incidence is increasing throughout the world. Most studies attribute this rise entirely to the increase in papillary carcinoma, the most common thyroid malignancy in iodine-sufficient areas. A variety of nonetiological factors such as changes in clinical practice may affect the incidence of thyroid cancer and some researchers have suggested that this rise is only apparent due to an increase in diagnostic activity. Since data on the epidemiology of thyroid cancer in Spain are scarce, the main goal of this study was to analyze changes in thyroid cancer presentation, incidence, and prevalence in Vigo (northwestern Spain) between 1978 and 2001, and to investigate the relationship between the incidence rates and trends in tumor size and thyroid surgery. In this descriptive epidemiologic study, an analysis was carried out on new thyroid cancer cases obtained from the Pathology Registry of the University Hospital of Vigo (500,000 inhabitants). Trends in age, sex, thyroid surgery, histological type, tumor size, and incidence rates were calculated. The prevalence of thyroid cancer was determined in three cross-sectional surveys. The rate of population undergoing thyroid surgery significantly increased over time. Out of 322 new primary thyroid cancers, papillary thyroid cancer (PTC) was the predominant type (76%). The age-standardized incidence rate shows a significant increase in females: 1.56 per 100,000 year (1978 to 1985) to 3.83 (1986 to 1993) and 8.23 (1994 to 2001); and in males: 0.33, 1.19, and 2.65, respectively. PTC was mainly responsible for this pattern and was the result of both the increase in micropapillary thyroid carcinoma (MPTC) incidence and in PTC measuring more than 1 cm. Besides MPTC cases, no significant variations were observed in tumor size over time. In northwestern Spain, the incidence of thyroid cancer is increasing. These data should be taken into account when planning health resources for these patients. Our results may reflect the contribution that other factors, besides increased diagnostic activity, have made to the rise in thyroid cancer incidence in our region. Additional studies are needed to explain the rise in PTC incidence throughout the world and to search for potential risk factors that are currently unrecognized.