Selective Treatment of Differentiated Thyroid Carcinoma

Abstract

Over a period of 20 years 84 papillary and 82 follicular carcinomas operated on by one surgeon and examined by one pathologist were documented prospectively, treated selectively, and followed for 1 to 20 years (median 7 years). Tumors with a low risk of recurrence or incurable disease-i.e., papillary carcinoma pT1-3 N0 M0 (n = 56) and minimally invasive follicular carcinoma (n = 37)-were treated by a limited-radicality hemithyroidectomy or total thyroidectomy without radioiodine in 79 of the 93 cases (85%). No unfavorable course was observed, and only one curable recurrence (1.3%) developed contralaterally after hemithyroidectomy for papillary cancer. Of the remaining 73 patients, including 100% of those with nodal involvement, 65 (89%) underwent total thyroidectomy with radioiodine. Total thyroidectomy was achieved in 34% of the cases by completion thyroidectomy, based on definitive histologic examination. No instance of a serious, potentially incurable recurrence and no tumor-related death was observed in patients with a papillary TNM stage I+II or with a minimally invasive follicular carcinoma. Five of the patients (6%) with papillary carcinoma, all with TNM stage III or IV, and seven of the patients (8.5%) with follicular carcinoma, all grossly invasive and pT3 or pT4, had tumor-related deaths following total thyroidectomy in all and with remnant ablation in 10 cases. A potentially curable node recurrence occurred in two patients 1 and 10 years, respectively, after primary treatment. Permanent hypoparathyroidism (n = 4) (2.4%) and permanent recurrent laryngeal nerve palsy (n = 2) (1.2%) were observed only in patients with a grossly invasive follicular carcinoma and concomitant benign recurrent goiter. We conclude that (1) hemithyroidectomy or total thyroidectomy without radioiodine is adequate for papillary carcinoma pT1-3 N0 and minimally invasive follicular carcinoma; (2) there were no nodal recurrences in tumors recognized as node-negative; and (3) extracapsular excision of one or both lobes can be carried out technically with low morbidity. The study confirms the prognostic value of age-related TNM classification for papillary carcinoma; classification of follicular thyroid carcinoma as minimally invasive or grossly invasive proved to be useful.

Non-suppressed thyrotropin and elevated thyroglobulin are independent predictors of recurrence in differentiated thyroid carcinoma

“…In addition, our patients' characteristics are comparable to previous hospital or register based cohorts (7,14). Moreover, female-to-male ratio, percentage of follicular tumors or frequency of recurrences in our study group do not differ markedly from previous studies (7,15,16). The histology of the tumor is one of the major prognostic factors identified.…”

“…The mean age of our patients was closer to that of patients studied by Matsubayashi et al (19), but we could not show any significant difference between TILs and tumor recurrence. Several studies (14,15,21) have shown that an unfavorable outcome is associated with age. We found that age over 60 years was related to a higher risk of tumor recurrence and cause-specific mortality, confirming previous findings (14,17).…”

Long-Term Follow-Up After Complete Resection of Well-Differentiated Cancer Confined to the Thyroid Gland

“…14,19,20,[24][25][26][27][28][29]31 Indeed, recommendations and consensus guidelines advocating total or near-total thyroidectomy in high-risk PTCs, but not necessarily in single, small, low-risk, intrathyroidal lesions, are not based on evidence demonstrating improved DSS, but rather on an understanding of the disease being multifocal with an increased risk of recurrence and the option to treat small residual thyroid cancer with RIA more effectively. 42,43 In addition, proponents of limited resection base their strategy on publications reporting increased postsurgical complications with more extensive resection.…”

“…Indeed, many investigators found that more extensive resection of DTC with total or near-total thyroidectomy results in a lower incidence of local recurrences, although it does not influence DSS. [15][16][17][18][19][20][21] Recently, Bilimoira et al 22 showed a survival benefit after total thyroidectomy over lobectomy in PTC larger than 1 cm analyzing a cancer registry database. Proponents of limited resection base their strategy on publications reporting that postsurgical complications increased with more extensive resection.…”

Are prognostic scoring systems of value in patients with follicular thyroid carcinoma?

“…In our series, it is a good prognostic system, although it was outperformed by the EORTC system. Gemsenjäger et al (45), in a study on 84 papillary and 82 follicular carcinomas, also found it to be valuable as a prognostic system. Although it is not the most predictive system, it has the advantage of being internationally recognized making the comparison between series easier.…”