Diagnosis Of Papillary Microcarcinoma Research Articles

Patients\u2019 experiences of diagnosis and management of papillary thyroid microcarcinoma: a qualitative study

BackgroundIn recent years management practices in relation to low-risk papillary microcarcinoma (PMC) have been evolving with increased awareness of the potential overdiagnosis and overtreatment of PMCs, and guidelines recommendations for non-surgical management options such as active surveillance. This study aimed to develop an in-depth understanding of patients’ experiences of the communication of their PMC diagnosis, their treatment preferences and decision making.MethodsSemi-structured qualitative interviews with 25 patients diagnosed pre-operatively with PMC < 1 year since their diagnosis and treatment. Interviews were conducted between September 2015 and July 2016 and were audio-recorded and transcribed verbatim. Framework analysis method was used to analyse the data.ResultsThe diagnosis and treatment experience of PMC patients varied widely. The majority of patients were asymptomatic, and their PMC was initially detected via an imaging test requested for a reason unrelated to a thyroid disorder or symptom. Clinicians generally described PMC to patients as being a “small” or “slow-growing” cancer, and there was little evidence that clinicians had discussions about the possibility of overdiagnosis or overtreatment. Overall, surgery was the only option discussed and offered to patients. Patients preference for treatment was largely based on eliminating the possibility of the cancer spreading (thyroidectomy) or not wanting to be on thyroid replacement medication for the rest of their life (hemi-thyroidectomy). Many patients reported emotional and physical side-effects associated with their diagnosis and treatment, however patients generally indicated that active surveillance is not something they would have been interested in if it was offered to them.ConclusionsEvidence continues to emerge that many patients with PMCs may be overdiagnosed, and management guidelines are recommending more conservative management options for these patients. As a result, shared decision making around treatment options is vital so that patients are fully aware of the meaning of their diagnosis and their management options including active surveillance. Importantly, interventions to reduce unnecessary diagnoses of PMC are critically needed.

Clinicians' Views on Management and Terminology for Papillary Thyroid Microcarcinoma: A Qualitative Study

There is growing acceptance that the increase in thyroid cancer incidence is in part a result of overdiagnosis of small low-risk papillary microcarcinomas (PMCs) with indolent clinical course. Although surgery is the cornerstone treatment for patients with PMCs, recent management guidelines are shifting toward inclusion of more conservative treatments such as active surveillance. There is little evidence on clinicians' experience in managing PMC patients and their attitudes toward treatment options, including their willingness to accept a nonsurgical option. The aim of this study was to understand how clinicians perceive a diagnosis of PMC, potential changes to terminology, and the treatment options available to patients. This was a qualitative study using semi-structured interviews conducted between November 2015 and May 2016 with 22 clinicians (seven endocrinologists and 15 thyroid surgeons). Transcribed audio-recordings were thematically coded, and a framework method was used to analyze the data. Across a sample of clinicians who manage thyroid cancer patients, awareness of overdiagnosis and overtreatment of PMC was common. However, there was little acceptance of active surveillance to manage these patients. Clinicians did not feel comfortable recommending this management approach, as they were worried about the risk of metastases, did not feel that evidence to support this approach was strong enough, and also believed that patients currently have a high preference for surgery. The majority of clinicians did not believe that changing the terminology of this diagnosis was a viable strategy to reduce patients' anxiety and their perceived preference for more aggressive treatments. However, most clinicians felt that thyroid nodules <1 cm should not be biopsied, which could help minimize the risk of overdiagnosis of PMC. This study, based on a non-representative sample of 22 clinicians, which remains an important limitation, provides revealing insight into clinicians' management preferences and decision making for small low-risk thyroid cancers at a time when management guidelines and practices are evolving. It suggests that clinicians may not be ready to accept nonsurgical options, or changes in terminology, until evidence to support these options and changes is stronger.

Usefulness of CK19, HBME-1 and galectin-3 expressions in differential diagnosis of thyroid papillary microcarcinoma from benign lesions

To characterize the morphological features of thyroid papillary microcarcinoma (PMC) and assess the significance of expression of CK19, HBME-1, Galectin-3, CD56 and p63 in differential diagnosis of PMC from benign thyroid lesions. Clinicopathologic features of 78 cases PMC were reviewed. Immunohistochemical analysis of CK19, HBME-1, Galectin-3, CD56, and p63 in 78 cases of PMC and 48 cases of benign thyroid lesions (18 cases of papillary hyperplasia, 17 cases of nodular goiter and 13 cases of lymphocytic thyroiditis) was conducted. The patients were followed up for from 6 to 269 months after surgical operation. 69 cases nuclear atypia and overlapping nuclei (88.5%), 67 cases nuclear grooves (85.9%), 50 cases nuclear pseudoinclusions (64.1%) and 60 cases papillary architecture (76.9%) were detected in 78 cases of PMC. Moderate to strong co-expression of CK19, HBME-1 and galectin-3 was observed in 98.0% (50/51) in the PMC group but in none of the benign disease group. The expression of CD56 and p63 was negative in both groups. In the postoperative follow-up period of 6-269 months, 7 cases (9.0%) developed intrathyroid recurrence, 3 cases (3.8%) developed lymph node metastasis, no distant metastasis or death was observed. In 12 cases (15.4%) the PMC lesion smaller than 3 mm in diameter was not found by frozen section diagnosis. Overlapping nuclei, nuclear atypia, polar disorder, ground glass nuclei, nuclear grooves and nuclear pseudoinclusions are most important for the diagnosis of PMC with or without papillary architecture. The appearance of definite interstitial invasion, interstitial sclerosis and true complex papillary architecture are more helpful to make right diagnosis. Intraoperative frozen section is of limited value for a reliable diagnosis of PMC in diameter < or = 3 mm. Moderate to strong co-expression of CK19, HBME-1 and Galectin-3 is a very useful indicator for differential diagnosis of PMC from benign thyroid lesions.

Absence of theBRAFMutation in HBME1+ and CK19+ Atypical Cell Clusters in Hashimoto Thyroiditis

An association between Hashimoto thyroiditis and papillary thyroid carcinoma has been postulated for decades. We undertook this study to identify potential precursors of papillary thyroid carcinoma in Hashimoto thyroiditis using a combination of morphologic, immunohistochemical, and molecular techniques. For the study, samples from 59 cases of Hashimoto thyroiditis were stained with antibodies to HBME1 and cytokeratin (CK)19. Tiny HBME1+ and CK19+ atypical cell clusters were identified and analyzed for the BRAF mutation by the colorimetric Mutector assay and allele-specific polymerase chain reaction. HBME1+ and CK19+ atypical cell clusters were identified in 12 (20%) of 59 cases. The minute size (<1 mm) of the clusters and the incomplete nuclear changes precluded a diagnosis of papillary microcarcinoma. The atypical cell clusters from all 12 cases were negative for BRAF. The absence of the BRAF mutation in these atypical cell clusters suggests that they may not be preneoplastic. Caution should be exercised in interpreting positive HBME1 or CK19 staining in Hashimoto thyroiditis.

Risk Factors for Nodal Metastasis and Recurrence Among Patients with Papillary Thyroid Microcarcinoma: Differences in Clinical Relevance Between Nonincidental and Incidental Tumors

Papillary microcarcinoma (PMC) is a subgroup of papillary thyroid carcinoma (PTC) measuring 1.0 cm or less in diameter. Herein we focused on the search for risk factors predicting nodal metastasis and recurrence in PMCs, analyzing differences in presentation, treatment, and prognosis between nonincidental and incidental tumors. From January 1998 to May 2007, 149 patients had a diagnosis of PMC in our department. A cross-sectional study of 76 patients with nonincidental and 73 patients with incidental PMC was carried out. Demographic data, diagnostic results, tumor characteristics, risk assessment, surgical treatment, and postoperative and follow up results were evaluated. Cytology detected thyroid cancer and nodal involvement in nonincidental PMC. Mean tumor size was significantly larger in nonincidental PMC (7.5 vs. 4.2 mm), which was commonly found within a normal thyroid gland or Hashimoto's thyroiditis, while incidental PMC was associated with a multinodular goiter. TNM staging system showed a higher cancer stage (IVA) in nonincidental. At multivariate analysis, capsular invasion and a nonincidental diagnosis were the two independent factors significantly affecting nodal metastasis. All patients with nonincidental PMC underwent iodine-131 ablation therapy after surgery compared with 49 patients with incidental. Nodal metastasis at diagnosis was the only factor influencing recurrence which was found in three nonincidental cases: two in the lateral and one in the central neck compartments. Several PMCs presented with risk-free clinical courses. Some nonincidental tumors had a more aggressive behavior and a tendency to recurrence. In these cases, early detection and aggressive treatment are mandatory as for conventional PTC according to risk stratification and cancer stage.

Increasing incidence of thyroid cancer is due to increased pathologic detection

There has been a marked increase in the incidence of thyroid cancer worldwide over recent decades. Patients with retrosternal goiter (RSG) are not picked up generally by common surveillance techniques such as ultrasound. The aim of this project was to study the incidence of thyroid cancer in patients with RSG. This is a retrospective cohort study. Documented were patient demographics as well as the size, type, and numbers of thyroid cancers. The number of routine histologic blocks examined for multinodular goiter in the different time periods was also examined. Within a cohort of 13,793 thyroidectomies performed over 40 years, there were 2,260 patients (14%) who underwent surgery for RSG. The percentage of patients with RSG containing thyroid cancer increased from 3.6 to 7.5% (P < .05); however, once papillary microcarcinomas (PMC) (</=10 mm) were excluded there was no increase in cancer incidence (3.4-3.5%, P = .9). The increase in the number of PMC's diagnosed is associated with the increase in the routine number of blocks sampled over the 40-year time period (P < .01). This study has confirmed an increase in the incidence of thyroid cancer over 4 decades. However, that increase appears to be due to an increase in the diagnosis of PMC associated with increased sampling of resected specimens by pathologists, raising the possibility that the current epidemic of thyroid cancer may be largely manmade.

A Case of Papillary Thyroid Microcarcinoma Presenting as a Contralateral Cervical Lymph Node Metastasis

Papillary carcinomas account for 85~90% of all thyroid cancer s, with the tumor size considered an important prognostic factor. As the use of high-resolution ultrasonography and fine needle aspiration biopsy have increased, the diagnosis of papillary microcarcinomas of the thyroid gland; defined by the World Health Organization as being less than 1 cm in diameter, has increased. They are generally associated with an excellent prognosis, with distant metastasis being extremely rare. They usually remain clinically silent until their incidental histological diagnosis by autopsy or surgical material. The incidence discovered at autopsy varies between 3 and 36%. Cervical lymph node metastases from papillary microcarcinomas have often been discovered, which may be the first and sole manifestation of the disease, without clinical suspicion of a thyroid tumor. Herein, the case of a papillary thyroid microcarcinoma, diagnosed after a total thyroidectomy due to its first presentation as a contralateral cervical lymph node metastasis, without evidence of a clinical thyroid tumor, is described (J Kor Soc Endocrinol 20:507～512, 2005).