Surgery For Differentiated Thyroid Cancer Research Articles

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.

Active Surveillance Versus Thyroid Surgery for Differentiated Thyroid Cancer: A Systematic Review.

Background: Active surveillance has been proposed as an appropriate management strategy for low-risk differentiated thyroid cancer (DTC), due to the typically favorable prognosis of this condition. This systematic review examines the benefits and harms of active surveillance vs. immediate surgery for DTC, to inform the updated American Thyroid Association guidelines. Methods: A search on Ovid MEDLINE, Embase, and Cochrane Central was conducted in July 2021 for studies on active surveillance vs. immediate surgery. Studies of surgery vs. no surgery for DTC were assessed separately to evaluate relevance to active surveillance. Quality assessment was performed, and evidence was synthesized narratively. Results: Seven studies (five cohort studies [N = 5432] and two cross-sectional studies [N = 538]) of active surveillance vs. immediate surgery, and seven uncontrolled treatment series of active surveillance (N = 1219) were included. One cross-sectional study was rated fair quality, and the remainder were rated poor quality. In patients with low risk (primarily papillary), small (primarily ≤1 cm) DTC, active surveillance, and immediate surgery were associated with similar, low risk of all-cause or cancer-specific mortality, distant metastasis, and recurrence after surgery. Uncontrolled treatment series reported no cases of mortality in low-risk DTC managed with active surveillance. Among patients managed with active surveillance, rates of tumor growth were low; rates of subsequent surgery varied and primarily occurred due to patient preference rather than tumor progression. Four cohort studies (N = 88,654) found that surgery associated with improved all-cause or thyroid cancer mortality compared with nonsurgical management, but findings were potentially influenced by patient age and tumor risk category and highly susceptible to confounding by indication; eligibility for, and receipt of, active surveillance; and timing of surgery was unclear. Conclusions: In patients with small low-risk (primarily papillary) DTC, active surveillance and immediate surgery may be associated with similar mortality, risk of recurrence, and other outcomes, but methodological limitations preclude strong conclusions. Studies of no surgery vs. surgery are difficult to interpret due to clinical heterogeneity and potential confounding factors and are unsuitable for assessing the utility of active surveillance. Research is needed to clarify the benefits and harms of active surveillance and determine outcomes in nonpapillary DTC, larger (>1 cm) cancers, and older patients.

Is Maintaining Thyroid-Stimulating Hormone Effective in Patients Undergoing Thyroid Lobectomy for Low-Risk Differentiated Thyroid Cancer? A Systematic Review and Meta-Analysis.

Simple SummaryIn order to reduce the recurrence rate after surgical treatment of differentiated thyroid cancer (DTC), suppression of thyroid-stimulating hormone (TSH) or maintenance of a certain level after surgery are important. However, the effectiveness of TSH maintenance in the mid to lower reference range (0.5–2 mU/L) in patients undergoing thyroid lobectomy for low-risk DTC is uncertain. In this systematic review and meta-analysis, we compared and analyzed the recurrence rate according to whether TSH maintenance was performed in patients who underwent thyroid lobectomy for low-risk DTC. There was no difference in the recurrence rate with or without TSH control. Therefore, the recommendation to maintain TSH to reduce the recurrence rate after thyroid lobectomy is still controversial.There is no clear evidence that post-operative maintenance of thyroid-stimulating hormone (TSH) in the mid to lower reference range (0.5–2 mU/L) improves prognosis in patients undergoing thyroid lobectomy for low-risk differentiated thyroid cancer (DTC). The purpose of this systematic review and meta-analysis was to compare and analyze the recurrence rate according to whether the serum TSH level was maintained below 2 mU/L in patients who underwent thyroid lobectomy for low-risk DTC. Clinical data and outcomes were collected from MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. The inclusion criteria were related studies on TSH maintenance or serum TSH concentration after surgery for DTC. Seven observational studies with a total of 3974 patients were included in this study. In the patients who received TSH maintenance less than 2 mU/L, the recurrence rate during the follow-up period was 2.3%. A subgroup analysis of five studies showed that the odds ratio for recurrence in patients who received TSH maintenance was 1.45 (p-value = 0.45) compared to patients who did not receive TSH maintenance. In conclusion, the evidence for the effectiveness of post-operative TSH maintenance less than 2 mU/L in patients undergoing thyroid lobectomy for low-risk DTC is insufficient.

Effect of Thyroid-Stimulating Hormone Suppression on Muscle Function After Total Thyroidectomy in Patients With Thyroid Cancer.

ContextThyroid-stimulating hormone (TSH) suppression is recommended to reduce tumor recurrence following surgery for differentiated thyroid cancer (DTC). However, prolonged subclinical hyperthyroidism caused by levothyroxine treatment has deleterious effects on various organs.ObjectiveTo evaluate the relationships of TSH concentration with muscle mass, muscle strength, and physical performance related to sarcopenia in patients with DTC undergoing TSH suppression following surgery.MethodsWe studied 134 patients of >60 years who were undergoing TSH suppression therapy following surgery for DTC. We evaluated muscle mass and muscle function-related parameters and diagnosed sarcopenia using the threshold for Asian people.ResultsThe participants were 68.3 ± 7.2 years old and 36/134 (26.9%) were diagnosed with sarcopenia. They were allocated to high-TSH and low-TSH groups using a threshold concentration of 0.40 μU/mL, and grip strength was significantly lower in the low-TSH group. The data were further analyzed according to age and sex, and in the low-TSH group, male participants and those of <70 years were found to have significantly lower grip strength.ConclusionsLow-TSH concentrations is associated with low grip strength, and this is most pronounced in individuals of <70 years of age. Therefore, muscle function should be considered an adverse effect of TSH suppression in patients with DTC who undergo TSH suppression therapy, especially in men of <70 years.

Impact of body mass index on short-term outcomes after differentiated thyroid cancer surgery: a nationwide inpatient database study in Japan

IntroductionRecent studies have shown worse post-operative outcomes following several surgeries in underweight or obese patients. However, the association between body mass index (BMI) and short-term outcomes following thyroid cancer surgery remains unclear because of the small number of patients, deficits in background data known as risk factors (e.g. cancer stage, operative procedure, intraoperative device use and hospital volume) and categorisation of BMI.Methods We identified patients who underwent thyroidectomy for differentiated thyroid cancer from July 2010 to March 2017 using a Japanese nationwide inpatient database. We used restricted cubic spline (RCS) analyses to investigate potential non-linear associations between BMI (without categorisation) and outcomes: post-operative complications (local and general), duration of anaesthesia, post-operative length of hospital stay and hospitalisation costs. The analyses were adjusted for demographic and clinical backgrounds including the above-stated factors. We also performed multivariable regression analyses for the outcomes with categorisation of BMI.Results Among 59,671 eligible patients, the median BMI was 22.9 kg/m2 (interquartile range (IQR), 20.7–25.6 kg/m2). In total, 3860 patients (6.5%) had local complications and 787 patients (1.3%) had general complications. Although there were no significant associations with local complications, such as bleeding, recurrent laryngeal nerve paralysis and surgical site infection, the occurrence of general complications was significantly associated with higher BMI. BMI showed a linear association with the duration of anaesthesia and U-shaped associations with post-operative length of stay and hospitalisation costs. The lowest points of the U-shaped curves occurred at a BMI of approximately 24 kg/m2. The multivariate regression analyses showed consistent results with the RCS analyses.Discussion/conclusion Whereas RCS analyses revealed no significant associations between BMI and post-operative local complications, obesity was significantly associated with the occurrence of general complications. The linear association between BMI and duration of anaesthesia corresponds to previous studies. Although post-operative length of stay and total hospitalisation costs demonstrated U-shaped associations, the slight differences would not be clinically important. Even if surgeons must pay attention to general complications in obese patients undergoing thyroid cancer surgery as well as other surgeries, underweight and overweight patients can undergo thyroidectomy as safely as patients with normal BMI.

Pros and cons of hemi-thyroidectomy for low-risk differentiated thyroid cancer.

The debate regarding the surgical management of low-risk differentiated thyroid cancer (DTC) is ongoing. The recommended extent of surgery in DTC is based on an assessment of the predicted risk of recurrence and recent guidelines reflect an evolving philosophy of de-escalation of surgical management, informed by a growing understanding of the determinants of tumour biology and important prognostic factors. However, our current clinical and pathological risk stratification processes are imperfect and hence there is significant variation in clinical practice. Surgeons face the challenge of finding the balance between avoiding overtreatment, minimizing complications and providing adequate oncological management. This article discusses the nuances of the current management guidelines as well as the important considerations in preoperative decision making.

A comparison of the platelet index, neutrophil-lymphocyte and platelet-lymphocyte ratios of patients with differentiated thyroid cancer and nodular hyperplasia

Aim: In our study, it was aimed to determine the usability of the inexpensive, fast and easily accessible platelet index, NLR (Neutrophil to Lymphocyte ratio) and PLR (Platelet to Lymphocyte ratio) as predictive values in patients with differentiated thyroid cancer and nodular hyperplasia. Materials and Methods: The data of 454 patients operated due to differentiated thyroid cancers and nodular hyperplasia at our clinic between 2010 and 2020 and a control group consisting of 120 healthy individuals were retrospectively examined. The data of the patients and the control group were statistically analyzed. Results: The study included a total of 574 participants including 314 patients who received differentiated thyroid cancer surgery, 140 patients who received surgery due to thyroid nodular hyperplasia and a control group consisting of 120 healthy individuals. There was no significant difference among the groups in terms of age. There was a dominance of the female sex among the groups, but the difference was insignificant. There was no significant difference among the groups in terms of their MPV, PLR or NLR values. However, the PDW (Platelet Distribution Width) values were significantly higher among the differentiated thyroid cancer patients. Conclusion: In our study, we observed that the MPV, PLR and NLR values varied, but the differences were not statistically significant. The PDW values were significantly high. Considering the current literature, we concluded that, among the existing parameters, NLR is a more reliable constant value at the stage of diagnosis.

Long-term treatment-related morbidity in differentiated thyroid cancer: a systematic review of the literature.

BackgroundDifferentiated thyroid cancer (DTC) occurs in relatively young patients and is associated with a good prognosis and long survival. The management of this disease involves thyroidectomy, radioiodine therapy, and long-term thyroid-stimulating hormone suppression therapy (THST). The long-term effects of the treatment and the interaction between subclinical hyperthyroidism and long-term hypoparathyroidism are poorly understood. This review sought to examine the available evidence.MethodsA PubMed search was carried out using the search terms “Thyroid Neoplasms” AND (“Thyroxine” OR “Hypocalcemia” OR “Thyrotropin”). Original English language articles published in the last 30 years studying the morbidity from thyroid-stimulating hormone (TSH) suppression and hypoparathyroidism following a surgery for DTC were retrieved and reviewed by 2 authors.ResultsOf the 3,000 results, 66 papers including 4,517 patients were selected for the present study. Studies reported on a range of skeletal (included in 34 studies, 1,647 patients), cardiovascular (17 studies, 957 patients), psychological (10 studies, 663 patients), and other outcomes (10 studies, 1,348 patients). Nine of 26 studies on patients who underwent THST showed a reduction in bone density, and 13 of 23 studies showed an increase in bone turnover markers. Skeletal effects were more marked in postmenopausal women. There was no evidence of increased fracture risk, and only little data were available on hypoparathyroidism. Four of five studies showed an increased left ventricular mass index on echocardiography, and one study showed a higher prevalence of atrial fibrillation (AF). There was little difference in basic physiological parameters and limited literature regarding symptoms or significant events. Six studies showed associations between long-term TSH suppression and impaired quality of life. Impaired glucose metabolism and prothrombotic states were also found in DTC patients.ConclusionThere is limited literature regarding long-term DTC treatment-related morbidity, particularly regarding the effects of long-term hypocalcemia. Most studies have focused on surrogate markers and not on clinical outcomes. A large prospective study on defined clinical outcomes would help characterize the morbidity of treatment and stimulate research on tailoring treatment strategies.

TSH Suppression after Differentiated Thyroid Cancer Surgery and Osteoporosis

TSH Suppression after Differentiated Thyroid Cancer Surgery and Osteoporosis

TSH Suppression after Differentiated Thyroid Cancer Surgery and Osteoporosis

TSH Suppression after Differentiated Thyroid Cancer Surgery and Osteoporosis

Predictive factors related to the recurrence at US-guided fine needle aspiration in postoperative patients with differentiated thyroid cancer

The recent American Thyroid Association management guidelines suggest cervical ultrasonography (US) surveillance in patients with differentiated thyroid cancer (DTC). This study was conducted to identify predictive factors that can determine whether subsequent fine needle aspiration guided by ultrasound (US-FNA) is indicated in patients with lesions detected by US after surgery for DTC. Retrospective analysis at a university-based tertiary hospital. We reviewed 207 cases of postoperative US-FNA in 180 patients diagnosed with DTC. We examined the relationship between US-FNA histology and clinical factors, imaging abnormalities found by US and with other modalities and pathological staging. US-FNA recurrence was positive in 56 (27%) cases and negative in 151 (73%) cases. The mean lesion size for FNA was 0·83 cm (range 0·2-2·9 cm). Univariate analysis indicated that tumour recurrence on US-FNA is associated with elevated stimulated thyroglobulin (sTg) levels, with the initial size of the primary tumour, with abnormal US findings, including the ipsilateral site, level III or IV location and extrathyroidal extension, and with other imaging abnormalities. However, multivariate analysis revealed an independent association between recurrence on FNA and suspicious US findings (OR 9·410; 95% CI 3·322-26·654; P<0·001) and elevated serum sTg (OR 5·001; 95% CI 1·067-23·485; P =0·041). Findings on US that were discriminating for recurrent nodules at the thyroidectomy site were abnormalities that were not oval shape or which had an irregular margin. Calcifications or cystic change showed a low sensitivity of 14%. US-FNA for diagnosis of recurrence after surgery for DTC may be limited to patients with elevated sTg or with lesions that have specific suspicious US findings.

Preoperative serum thyroid stimulating hormone levels in well-differentiated thyroid carcinoma is a predictive factor for lateral lymph node metastasis as well as extrathyroidal extension in Korean patients: a single-center experience

It has been known that thyroid stimulating hormone (TSH) stimulates the growth or development of thyroid malignancy and higher serum TSH has association with both thyroid cancer incidence and advanced tumor stage. However, the role of TSH in high-risk features of well-differentiated thyroid cancer was not fully evaluated especially in Asian population. The purpose of our study is to evaluate the association of preoperative serum TSH levels with the advance of differentiated thyroid cancer and its high-risk clinicopathological features in Korean patients. We evaluated 554 patients retrospectively who underwent thyroidectomy and diagnosed as differentiated thyroid cancer during a 3-year period at Pusan National University Hospital. The preoperative TSH levels were significantly higher in the patients with extrathyroidal extension (P = 0.002) and those with lateral lymph node metastasis (P = 0.007). As the increase of the serum TSH concentration, there were significant rising trends in the prevalence of extrathyroidal extension (P = 0.009). In the patients with TSH ≥ 2.5 mIU/L, the prevalences of extrathyroidal extension (P = 0.006) and lateral lymph node metastasis (P = 0.024) were also significantly higher. Using multiple logistic regression, preoperative TSH level was a predictive factor for the presence of extrathyroidal extension (P = 0.008) and lateral lymph node metastasis (P = 0.025). Hashimoto's thyroiditis itself was not associated with the status of extrathyroidal extension and lateral lymph node metastasis. In conclusion, preoperative TSH levels were associated with lateral lymph node matastasis, a novel finding, and extrathyroidal extension in well differentiated thyroid cancer and might be useful as a preoperative supplementary marker for determining the optimal extent of differentiated thyroid cancer surgery in Korean patients.