Indications and Strategy for Active Surveillance of Adult Low-Risk Papillary Thyroid Microcarcinoma: Consensus Statements from the Japan Association of Endocrine Surgery Task Force on Management for Papillary Thyroid Microcarcinoma

Abstract

Background: The question of how to manage patients with low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0) has recently become an important clinical issue. Two Japanese centers have conducted prospective clinical trials of active surveillance (AS) for low-risk PTMC since the 1990s, reporting favorable outcomes. This policy has thus seen gradual adoption worldwide to avoid overtreatment. Not all PTMCs are suitable for AS, however, and many physicians still hesitate to apply the management policy in daily clinical practice. A task force on management for PTMC created by the Japan Association of Endocrine Surgery collected and analyzed bibliographic evidence and has produced the present consensus statements regarding indications and concrete strategies for AS to facilitate the management of adult patients diagnosed with low-risk PTMC. Summary: These statements provide indications for AS in adult patients with T1aN0M0 low-risk PTMC. PTMCs with clinical lymph node metastasis, distant metastasis, recurrent laryngeal nerve (RLN) paralysis due to carcinoma invasion, or protrusion into the tracheal lumen warrant immediate surgery. Tumors suspected of aggressive subtypes on cytology are recommended for immediate surgery. Immediate surgery is also recommended for tumors adherent to the trachea or located along the course of the RLN. Practical strategies include diagnosis, decision-making, follow-up, and monitoring related to the implementation of AS. The rate of low-risk PTMC progression is lower in older patients. However, we recommend continuing AS as long as circumstances permit. Future tasks in optimizing management for low-risk PTMC are also described, including molecular markers and patient-reported outcomes. Conclusions: An appropriate multidisciplinary team is necessary to accurately evaluate primary tumors and lymph nodes at the beginning of and during AS, and to adequately reach a shared-decision with individual patients. If appropriately applied, AS of low-risk PTMC is a safe management strategy offering favorable outcomes and preserves quality of life at low cost.

Thermal Ablation for Papillary Thyroid Microcarcinoma: How Far We Have Come?

“…Noticeably, most recently, the Japan Association of Endocrine Surgery (JAES) updated the consensus statements about the indications and strategy for AS of low-risk PTMC patients, especially for the elderly population. 62 Similarly, AS has been recommended to low-risk PTMC patients in the 2015 revised version guideline of the American thyroid association (ATA), 63 and the cost-effective outcomes from the long-term follow-up have been recently determined. 64 , 65 The follow-up examinations like cervical ultrasonography are mandatorily required once every six months in the first two years which can significantly avoid overlooking the need for surgery due to disease progression.…”

Active Surveillance for Thyroid Cancer: A Qualitative Study of Barriers and Facilitators to Implementation

“…Patient expectations and societal beliefs about cancer were also commonly described barriers to implementation. Interventions to address some of these barriers are already underway, including establishing outcomes of active surveillance in US patients 8,9 , publication of protocols [23][24][25][26][27] , and physician education. Additional interventions should focus on physicians' and patients' beliefs about cancer, facilitating multidisciplinary approaches, and promoting societal-level acceptance of active surveillance.…”

A Nomogram Predicting Central Lymph Node Metastasis for Patients with Papillary Thyroid Cancer

“…for the elderly population 22,23 . As the cost-effective outcomes from the long-term follow-up have been recently determined, AS is gradually accepted as a positive management option by clinicians and patients in developed countries.…”

“…To date, with an increasing prevalence and overdetection rate of PTC around the world, the management of this disease becomes more precise and particularly crucial. For preventing unnecessary diagnostic workup and possible surgical intervention, the Japan Association of Endocrine Surgery (JAES) and the American Thyroid Association (ATA) separately updated the consensus statements and guidelines about the indications and strategy for active surveillance (AS) of low-risk PTMC (cT 1 N 0 M 0 ) patients, especially for the elderly population 22,23 . As the cost-effective outcomes from the long-term follow-up have been recently determined, AS is gradually accepted as a positive management option by clinicians and patients in developed countries.…”