Low-risk Papillary Thyroid Carcinoma Research Articles

Publications on ultrasound-guided thermal ablation for thyroid nodules from 2000 to 2022: a bibliometric analysis

Background Thyroid nodules are increasingly treated with minimally invasive surgery. Thermal ablation could efficiently treat patients with benign thyroid nodules, recurrent thyroid cancer, and low-risk papillary thyroid carcinoma. This research aims to explore the research field of thermal ablation for thyroid nodules using bibliometric analysis. Methods The web of science core collection (WoSCC) database was utilized from its inception to 1 October 2022, to collect research articles and reviews on ultrasound-guided thermal ablation for thyroid nodules. We applied the R package ‘bibliometrix’ to summarize the main findings, calculate the occurrences of the top keywords and visualize the international collaboration networks. The co-authorship and co-occurrence analyses were conducted with VOSviewer software. CiteSpace was used to identify the top references and keywords with the highest citation bursts. Results A total of 820 publications from 32 countries were retrieved. The annual number of related publications showed an increasing trend. China, Italy, and Korea were the most contributing countries. The University of Ulsan College of Medicine in Korea was the most productive institution, and Jung Hwan Baek published the maximum number of articles. The International Journal of Hyperthermia was the most productive journal. ‘Papillary thyroid micro-carcinoma (PTMC)’ and ‘association guideline’ were the most frequently used keywords in the field of thermal ablation for thyroid nodules, which indicated the potential hot research topics and frontiers in the future. Conclusion This bibliometric study conducts a comprehensive analysis of publications on thermal ablation for thyroid nodules, which aids investigators in discovering potential research directions.

Clinical outcomes of radiofrequency ablation for solitary T1aN0M0 versus T1bN0M0 papillary thyroid carcinoma: a propensity-matched cohort study

Objective To conduct a cohort study comparing the treatment outcomes of radiofrequency ablation (RFA) therapy for solitary T1aN0M0 (T1a) versus T1bN0M0 (T1b) papillary thyroid carcinoma (PTC). Methods This retrospective analysis comprised 310 patients with low-risk PTC undergoing RFA classified into T1a (n = 272) and T1b (n = 38) groups according to the tumor size. A comparative analysis between the two groups was conducted for the volume reduction ratio (VRR), volume, local tumor progression (LTP), and recurrence-free survival (RFS) before and after 1:2 propensity score matching (PSM). Cox analysis was conducted to examine the influence of several variables, including T1b, on recurrence following RFA for PTC. Results The total VRR was 99.99 ± 0.11% throughout the median follow-up duration of 26 months, and the overall incidence of LTP was 2.58% (8/310). No irrecoverable complications occurred after RFA. The variations between the T1a and T1b groups following PSM were insignificant in terms of volume (p = 0.574), VRR (p = 0.574), complete disappearance rate (p = 0.210), LTP incidence (p = 1.000), and RFS rate (p = 0.610). The correlation between T1b and LTP continued to be insignificant (p = 0.686). No distant metastasis or delayed surgery occurred. Conclusions The presence of T1b did not influence the patients’ prognoses following RFA for T1N0M0 PTC. After appropriate patient selection and adequate preoperative assessment, RFA has the potential to serve as an effective therapy for individuals with T1a and T1b PTC.

Thirty years of active surveillance for low-risk thyroid cancer, lessons learned and future directions.

Active Surveillance is a non-invasive strategy designed to identify a minority of patients with low-risk papillary thyroid carcinoma who might experience clinical progression and benefit from additional definitive treatments. Global experience suggests that these tumors typically show minimal changes in size during active surveillance, often demonstrating very slow growth or even size reduction. Moreover, the rate of lymph node metastases is low and can be effectively managed through rescue surgery, without impacting cancer-related mortality. However, despite 30 years of experience demonstrating the safety and feasibility of active surveillance for appropriately selected patients, this approach seems to have limited adoption in specific contexts. This limitation can be attributed to various barriers, including disparities in access to accurate information about the indolent nature of this disease and the prevalence of a maximalist mindset among certain patients and medical settings. This review aims to revisit the experience from the last three decades, provide current insights into the clinical outcomes of active surveillance trials, and propose a systematic approach for its implementation. Furthermore, it intends to emphasize the importance of precise patient selection and provides new perspectives in the field.

SAT514 Thyroid Neoplasia in Hispanic Americans: A Three-Part Study Design

Abstract Disclosure: R. Zweifler: None. J.G. Sanchez: None. D. Kuriloff: None. E.P. Liao: None. L. Poretsky: None. Background: Alternatives to surgery for thyroid microcarcinomas and symptomatic benign thyroid nodules include active surveillance and radiofrequency ablation (RFA). However, there is paucity of information regarding these management options for Hispanic Americans. Current data suggest that non-white Americans present with larger cancer-harboring nodules making the use of active surveillance less certain. Furthermore, no RFA studies to date specifically address this population. This study will create a registry of Latinx patients with thyroid neoplasms and investigate these nonsurgical interventions for benign and malignant lesions.Methods: This study involves a registry of adult Hispanic Americans with thyroid nodules and two branching studies. The registry will collect results of FNA, prior ultrasound, and thyroid function tests. Subjects will fill out THYPRO39 (thyroid-specific quality of life questionnaire), LUMP (laryngopharyngeal measure of perceived sensation questionnaire), and have cosmetic scorings. Evaluation will recur every 6 months. Eligible subjects may enroll in one of the branching studies. The first is active surveillance for registry patients diagnosed with small, low-risk papillary thyroid carcinoma wherein subjects would be monitored every 6 months with ultrasound as an alternative to surgery. Inclusion criteria are solitary thyroid nodule ≤ 1cm, well-defined tumor margin, tumor surrounded by ≥ 2 mm of normal thyroid parenchyma, and previous ultrasound-documented stability. Exclusion criteria are metastases to regional lymph nodes, local tumor invasion, tumor growth by 3 mm or ≥50% in volume, appearance of new nodules, or other thyroid or parathyroid disease requiring surgery. The outcomes are percentage change in volume and rates of conversion to surgery. The second branching study is RFA for subjects with benign symptomatic nodules. This subset would exclude subjects who are or planning to become pregnant, breastfeeding, have a cardiac pacemaker/defibrillator, have a nodule that is not predominantly solid, or who are on anticoagulants or dual anti-platelet therapy. Subjects would have visits at 1, 3, 6, 12, and 18 months for ultrasound, thyroid function tests, questionnaires, and cosmetic scorings. The primary endpoint is percent change of nodule size from baseline to 12 months. Adverse events, total ablation time, power emitted per subject, and conversion to surgery within 18 months will also be documented. After 12 months, if a nodule has not reduced by 50%, repeat ablation will be offered. Discussion: We hypothesize that active surveillance is a valid alternative to surgery for small, low risk papillary thyroid carcinoma and that RFA is a safe and effective alternative to surgery for benign, symptomatic thyroid nodules in Hispanic Americans. Our results will broaden knowledge of a population that has been under-represented in this field. Presentation Date: Saturday, June 17, 2023

Contralateral Low-to-Intermediate Suspicion Nodule Is Not a Contraindication for Lobectomy in Patients with Papillary Thyroid Carcinoma.

Background: The optimal extent of surgery for unilateral papillary thyroid carcinoma (PTC) with contralateral nodules remains unclear. This study evaluated the long-term outcomes in a large cohort of patients with unilateral PTC and contralateral low-to-intermediate suspicious nodules who underwent lobectomy. Methods: This retrospective cohort study included patients with unilateral PTC who underwent lobectomy between January 2016 and December 2017 at Asan Medical Center in Korea. Patients were divided into two groups, those with and without contralateral nodules at the time of lobectomy: the Present group and the Absent group. All contralateral nodules observed at the time of surgery and during follow-up were evaluated. Results: The study cohort consisted of 1761 patients (1879 nodules), including 700 (39.8%) with and 1061 (60.2%) without contralateral nodules. The median size of the contralateral nodules was 0.5 cm. After a median follow-up of 59 months, the median growth of the contralateral nodules in the Present group was 0.1 cm (range, -3.4 to 4.7 cm). Of the contralateral nodules present at the time of lobectomy, 54.7% remained unchanged, decreased in size, or disappeared; whereas 14.8% increased ≥0.3 cm. Of the 700 patients with contralateral nodules, 20 (2.9%) were diagnosed with contralateral PTC. The 5-year contralateral PTC disease-free survival rates in patients with and without contralateral nodules were 98.2% and 99.3% (p = 0.003), respectively, whereas the 5-year recurrence-free survival rates did not differ significantly in these two groups. Of the 39 patients who underwent completion thyroidectomy, 2 (5.1%) experienced permanent hypocalcemia. Conclusions: Lobectomy may be a safe and feasible initial treatment option for patients with unilateral low-risk PTC and contralateral low-to-intermediate suspicious nodules.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach.

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Survival outcomes of low-risk papillary thyroid carcinoma at different risk levels: a corollary for active surveillance.

This study aims to compare the outcomes of active surveillance (AS) in low-risk papillary thyroid carcinoma (PTC) patients with different tumor sizes and lymph node metastasis status, in order to establish appropriate management strategies. By analyzing these results, this study provides valuable insights for the effective management of such patients, addressing the issues and challenges associated with AS in practical clinical practice. The study utilized the SEER database supported by the National Cancer Institute of the United States, extracting data of PTC diagnosed between 2000 and 2015. Statistical analyses were conducted using inverse probability weighting (IPTW) and propensity score matching (PSM), including Kaplan-Meier survival curves and Cox regression models, to evaluate the impact of different tumor sizes and lymph node metastasis status on thyroid cancer-specific survival (TCSS). A total of 57,000 PTC patients were included, with most covariates having standardized mean differences below 10% after IPTW and PSM adjustments. The TCSS of PTC with a diameter smaller than 13mm is significantly better than that of tumors with a diameter larger than 13mm, regardless of the presence of lymph node metastasis. Among PTC cases with a diameter smaller than 13mm, the TCSS of patients is similar, regardless of the presence of lymph node metastasis. However, in PTC cases with a diameter larger than 13mm, the presence of lateral neck lymph node metastasis (N1b stage) significantly impacts the TCSS, although the absolute impact on TCSS rate is minimal. The treatment strategy of AS is safe for patients with T1a stage papillary thyroid microcarcinoma (PTMC). However, for patients with T1b stage, if the tumor diameter exceeds 13mm or there is lymph node metastasis in the lateral neck region, the TCSS will be significantly affected. Nevertheless, the absolute impact on survival is relatively small.

Impact of lymphovascular invasion on otherwise low-risk papillary thyroid carcinomas: a retrospective and observational study

PurposePresence of venous vascular invasion is a criterion of intermediate risk of recurrence in papillary thyroid carcinoma (PTC). However, the presence and type of vascular invasion (lymphatic or venous) is often underreported and its impact on PTCs without other risk features remains unknown. The aim of this study was to evaluate the impact of both lymphatic and venous invasion on the risk of recurrence/persistence on otherwise low-risk PTCs.MethodsRetrospective study including patients with otherwise low-risk PTCs but with vascular invasion, diagnosed between 2013 and 2019. The persistence/recurrence during the follow-up was evaluated. Pathology was reviewed to confirm the presence of lymphovascular invasion and determine the type of invasion.ResultsA total of 141 patients were included. Lymphovascular invasion was confirmed in 20.6%. After surgery, 48.9% (N = 69) of the patients received radioactive iodine (RAI). The median follow-up time was 4 [3–6] years. Overall, 6 (4.2%) patients experienced persistent/recurrent disease in the neck, including 3 with lymphovascular invasion, confirmed as “only lymphatic”. Overall, patients with tumors harboring lymphovascular invasion had sensibly more persistent/recurrence disease compared with those without lymphovascular invasion (10.3% vs 2.7%, p = 0.1), especially in the subgroup of patients not treated with RAI (20% vs 1.6%, p = 0.049) [OR 15.25, 95% CI 1.24-187.85, p = 0.033].ConclusionLymphovascular invasion, including lymphatic invasion only, is associated with a sensibly higher risk of persistent/recurrent disease in otherwise low-risk PTCs, namely in patients not treated with RAI. Lymphatic invasion could have a role in risk-stratification systems for decision making.

Impact of lymphovascular invasion on otherwise low-risk papillary thyroid carcinomas: A retrospective and observational study

Impact of lymphovascular invasion on otherwise low-risk papillary thyroid carcinomas: A retrospective and observational study

Comparison of patient-reported outcomes between active surveillance and immediate surgery for low-risk papillary thyroid carcinoma: A longitudinal study with one-year follow-up

Comparison of patient-reported outcomes between active surveillance and immediate surgery for low-risk papillary thyroid carcinoma: A longitudinal study with one-year follow-up

Long-Term outcomes of active surveillance for low-risk papillary thyroid carcinoma: is lifelong follow-up necessary?

Long-Term outcomes of active surveillance for low-risk papillary thyroid carcinoma: is lifelong follow-up necessary?

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer.

This study examines the trends in the management of thyroid cancer and clinical outcomes in the Southwestern region of The Netherlands from 2010 to 2021, where a regional collaborative network has been implemented in January 2016. Retrospective cohort study. This study encompasses all patients diagnosed with thyroid cancer of any subtype between January 2010 and June 2021 in 10 collaborating hospitals in the Southwestern region of The Netherlands. The primary outcome of this study was the occurrence of postoperative complications. Secondary outcomes were trends in surgical management, centralization, and waiting times of patients with thyroid cancer. This study included 1186 patients with thyroid cancer. Median follow-up was 58 [interquartile range: 24-95] months. Surgery was performed in 1027 (86.6%) patients. No differences in postoperative complications, such as long-term hypoparathyroidism, permanent recurrent nerve paresis, or reoperation due to bleeding were seen over time. The percentage of patients with low-risk papillary thyroid carcinoma referred to the academic hospital decreased from 85% (n = 120/142) in 2010 to 2013 to 70% (n = 120/171) in 2014 to 2017 and 62% (n = 100/162) in 2018 to 2021 (P < .01). The percentage of patients undergoing a hemithyroidectomy alone was 9% (n = 28/323) in 2010 to 2013 and increased to 20% (n = 63/317; P < .01) in 2018 to 2021. The establishment of a regional oncological network coincided with a de-escalation of thyroid cancer treatment and centralization of complex patients and interventions. However, no differences in postoperative complications over time were observed. Determining the impact of regional oncological networks on quality of care is challenging in the absence of uniform quality indicators.

Impact of vascular invasion on otherwise low-risk papillary thyroid carcinomas: a retrospective and observational study

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Construction and validation of nomograms to reduce completion thyroidectomy by predicting lymph node metastasis in low-risk papillary thyroid carcinoma

ContextMore than 5 central lymph nodes metastases (CLNM) or lateral lymph node metastasis (LLNM) indicates a higher risk of recurrence in low-risk papillary thyroid carcinoma (PTC) and may lead to completion thyroidectomy (CTx) in patients initially undergoing lobectomy. ObjectiveTo screen potentially high-risk patients from low-risk patients by using preoperative and intraoperative clinicopathological features to predict lymph node status. MethodsA retrospective analysis of 8301 PTC patients in Wuhan Union Hospital database (2009–2021) was performed according to the 2015 American Thyroid Association (ATA) and 2021 National Comprehensive Cancer Network (NCCN) guidelines, respectively. Logistic regression and best subsets regression were used to identify risk factors. Nomograms were established and externally validated using the Differentiated Thyroid Cancer in China cohort. ResultsMore than 5 CLNM or LLNM was detected in 1648 (19.9%) patients. Two predictive models containing age, gender, maximum tumor size, free thyroxine (FT4) and palpable node (all p < 0.05) were established. The nomogram based on NCCN criteria showed better discriminative power and consistency with a specificity of 0.706 and a sensitivity of 0.725, and external validation indicated that 76% of potentially high-risk patients could achieve preoperative conversion of surgical strategy. ConclusionsModels based on large cohorts with good predictive performance were constructed and validated. Preoperative low-risk (T1-2N0M0) patients with age younger than 40 years, male gender, large tumor size, low FT4 and palpable nodes may be at high risk of LLNM or more than 5 CLNM, and they should receive more aggressive initial therapy to reduce CTx.

Barriers and Facilitators to the Choice of Active Surveillance for Low-risk Papillary Thyroid Cancer in China: A Qualitative Study Examining Patient Perspectives.

Internationally, several clinical practice guidelines recommend active surveillance as a non-surgical management strategy for select patients with low-risk papillary thyroid carcinoma. However, patient's decision making when choosing active surveillance as a management approach is not well understood. Thus, our aim was to examine the barriers and facilitators to selecting active surveillance amongst patients with low-risk papillary thyroid carcinoma in China. Thirty-nine participants diagnosed with low-risk papillary thyroid carcinoma were purposively recruited between July - Nov 2021 for semi-structured interviews; 24 of whom rejected and 15 patients chose 'active surveillance' as a management approach in our sample. Inductive content analysis illustrated emerging themes. Audit trails, member checks and thematic discussions were used to assert rigor. Barriers and facilitators were classified as patient-related, disease-related, and external factors. Patient-related factors included patient's knowledge, attitudes and emotions. Disease-related factors included the response to having cancer, the constant state of being diseased and perceived value of the thyroid gland. External factors included the residual effects of surgery, the active surveillance protocol and physicians' recommendations. Patient's the acceptability of the active surveillance as a management approach are complex with many influencing factors. The public acceptance of active surveillance as a disease management approach needs to be improved, through the presentation of active surveillance as an evidence-based and optimized dynamic management strategy. Clinicians must address their patients' psychological struggles when patients choosing active surveillance and patients require more attention and supportive intervention.

Invited Commentary: Patient-Reported Outcomes in Patients with Low-Risk Papillary Thyroid Carcinoma: Cross-Sectional Study to Compare Active Surveillance and Immediate Surgery.

Invited Commentary: Patient-Reported Outcomes in Patients with Low-Risk Papillary Thyroid Carcinoma: Cross-Sectional Study to Compare Active Surveillance and Immediate Surgery.

Optimal thyrotropin level for low-risk papillary thyroid carcinoma after ultrasound-guided radiofrequency ablation

Purpose Maintaining an optimal thyroid stimulating hormone (TSH) level is important in the postoperative management of papillary thyroid carcinoma (PTC). However, there is little evidence for TSH target levels in patients undergoing radiofrequency ablation (RFA). This study aimed to determine the optimal TSH level for management in low-risk patients who underwent RFA. Methods This retrospective propensity score-matched cohort study included patients with low-risk PTC who underwent RFA from January 2014 to December 2018. The patients were categorized into two groups based on the range of TSH levels: low (≤2 mU/L) and high (>2 mU/L) TSH levels. Local tumor progression and disease-free survival (DFS) were compared between the low TSH and high TSH groups, using propensity score analyses based on patient- and tumor-level characteristics. Univariate analyses were performed to select risk factors for tumor progression. Results Overall, our study included 516 patients with low-risk PTC who underwent RFA with a long-term follow-up of 5-years. During follow-up, the overall incidence rate of local tumor progression was 4.8% (25/516), with no significant difference between the matched groups (7/106 [6.6%] vs. 5/53 [9.4%], p = 0.524). DFS did not differ between the two groups (p = 0.5). Moreover, TSH level was not regarded as a significant predictor of tumor progression after Cox analysis; primary tumor size was the only relevant risk factor. Conclusion This large propensity-matched study revealed no association between TSH levels and tumor progression. Thus, for patients with low-risk PTC who underwent RFA, the optimalTSH level is recommended at the euthyroid range.

Similar Outcomes in Low-Risk Papillary Thyroid Carcinomas that Require Conversion Surgery Following Active Surveillance Versus Immediate Surgery

Similar Outcomes in Low-Risk Papillary Thyroid Carcinomas that Require Conversion Surgery Following Active Surveillance Versus Immediate Surgery

Rigorous radiofrequency ablation can completely treat low-risk small papillary thyroid carcinoma without affecting subsequent surgical management.

Minimally invasive therapies are gaining interest because of the indolence and excellent prognosis of low-risk papillary thyroid carcinoma (PTC). This study aimed to evaluate the outcomes of radiofrequency ablation (RFA) for low-risk PTC and to determine the effects of ablation on subsequent surgical management. A medical record review was conducted including patients with low-risk PTC who underwent surgery after RFA from July 2015 to July 2021. Demographic characteristics, tumor characteristics, ablation procedures, surgical findings, and pathological changes were reviewed for all patients. The primary outcomes were surgical and pathological changes in post-ablation patients. Of the 10 patients with 11 PTCs, 9 (90%) were women; the median (SD) patient age was 41.5 (8.2) years. The maximum diameter range of PTCs was 3.0-12.0 mm. All 10 patients underwent rigorous RFA procedure involving a four-step approach, and had received surgical management. Intraoperatively, no patients had muscle and nerve injuries, and mild adhesion of the post-ablation lesions with the anterior cervical muscle was observed in two cases. Histopathologically, no residual PTCs were observed in the ablated areas in all patients. Central lymph node metastasis (LNM) was found in three (30.0%, pN1a). Occult PTCs were observed in three cases (30.0%). Our findings suggest that low-risk small PTCs can be completely treated with rigorous RFA, which does not affect subsequent surgical management, if necessary. RFA may be a treatment option, but occult PTCs and clinically negative LNMs may be overlooked. Long-term follow-up data are necessary to further identify its efficacy. • RFA can completely treat low-risk small PTC. • RFA does not affect the subsequent surgical management if necessary. • Because occult PTCs and clinically negative LNMs may be overlooked by RFA, long-term follow-up data are necessary to further identify its efficacy.

Hemithyroidectomy in Papillary Thyroid Cancers: A Prospective, Single Institutional Surgical Audit and Contemplating on the Clinical Implications of 2015 American Thyroid Association Guidelines.

Papillary thyroid carcinoma (PTC) contributes to 88% of thyroid malignancies and its extent of surgical management has been a topic of debate in the past 2 decades. American thyroid association (ATA) recommendations have been periodically updated for its robust and evidence-based management. We present our experience in implementing 2015 ATA guidelines, assessment of surgical outcomes of hemithyroidectomy in PTC ≤ 4cm and contemplating on the potential clinical implications of 2015 ATA guidelines. A prospective study in a cohort of Bethesda class V and VI PTC with nodule ≤ 4cm who underwent Hemithyroidectomy between 2012 and 2020. Data on thyroid nodule evaluation, management, histopathology and follow up were used for risk stratification. Of 37 patients, 27 (72.9%) were low risk and 10 (37%) were intermediate risk ATA group. 4 (40%) intermediate risk patients had structural incomplete response and underwent completion thyroidectomy. 1 (2.7%) out of 4 completion surgery patients required adjuvant radio-ablation iodine (RAI) and 3 patients were under surveillance. Overall, 2 (5.4%) of 37 patients, 1 each from low and intermediate groups were given remnant RAI in view of aggressive histology, old age and unwillingness for a completion surgery. During follow up of 4.94 ± 2.4 years, 35 (94.5%) showed excellent response and 2 (5.4%) showed biochemical incomplete response. The difference in RFS between two groups was statistically significant with p < 0.001. Thyroid preserving surgery combined with real time risk stratification seems appropriate for low and intermediate risk PTC ≤ 4cm.