ENDO 2018: 100th Endocrine Society Annual Meeting :

The Future of Surgery in Differentiated Thyroid Cancer

A startling increase in the incidence of papillary thryoid cancers is challenging endocrinologists to revisit standard approaches to care, which may be unnecessary for many patients with low-risk thyroid nodules smaller than 4 cm.1,2 

Among the 40-60% of new thyroid cancer diagnosed annually, 67% of patients will have small nodules (< 2 mm), which has been attributed to the introduction of highly sensitive thyroid ultrasound imaging and guided fine-needle aspiration, begging the question,2 what's the risk of malignancy?

Arriving at the most appropriate treatment for differentiated thyroid cancer is complex, controvercial, and increasingly is driven by a patient-centric approach to care so as to achieve optimal outcomes that preclude unnecessary testing or excessive treatment for the majority of patients receiving a diagnosis of differentiated papillary thyroid cancer.

Before the start of ENDO 2018, the American Thyroid Association sponsored a satellite program—Challenging the minimalist approach to surgical interventions in differentiated thyroid cancer with a panel of experts:

  • Ralph P. Tufano, MD, MBA, the Charles W. Cummings MD Professor of otolaryngology-head and neck surgery at the Johns Hopkins Medical Institutes in Baltimore, Maryland
  • Mona Sabra, MD, professor of clinical medicine at Weill Cornell Medical College and at Memorial Sloan Kettering Cancer Center 
  • Carmen C. Solorzano, MD professor of surgery, and director of the endocrine surgery center at Vanderbilt University Medical Center, in Nashville, Tennesee, 

"Our discussion centered around the need for thyroid cancer management to be handled in a team approach that includes the endocrinologist, surgeon, and patient, in order to arrive at the best value proposion for treatment," Dr. Tufano told EndocrineWeb.  

Thyroid Cancer Overdiagnosis and Overtreatment

Total thyroidectomy has been associated with a high risk of complications and a better outcome with unilateral versus bilaterial thyroid dissection.1

Active surveillance can be considered a reasonable and responsible approach, particularly for certain patients, such as for pregnant women, where as lobectomey may be preferred for pateints with microcarcinomas: T1b/T2 for which mortality is 1.1% annually.2

The current criteria for active surveillance is: 

  • ultrasound; operator-dependant
  • local—centralized near trachea; concern about growth with nerve involvement and tissue infultration.
  • age of patient

The ideal circumstance is for patient to receive care at high volume centers, but this is not generalizable unles the capability is available to gather a complete team, and includes the willling involvement of the patient.1

Directed Therapies to Stratify and Individualize Care

"For patients deemed appropriate for active surviellance, follow up with an endocrinologist is reasonable provided the patient returns at prescribed intervals for their check-up," said Dr. Tufano, and communication with these patients is essential as they should be made aware that surgery is always a future option.1

Lobectomy without removal of lymph is preferred so long as the patient is informed of the possibility for a total thyroidectomy if a determination of lymph invovlement is made during the procedure. Again clear and ongoing communication with the patient is criticael. "These patients should be advised that their thyroid nodule management may be adjusted over time in repsonse to any change in pathology," he said. 

"If you appropriately select patients for lobesectomy, the possibility of a total thyroidectoymy should be low," Dr. Tufano said.

Evaluating patient characteristics, including age and location of nodule, and an understanding patient's mental outlook with regard to surgery (ie, a minimalist or a maximalist) rather than treating patients in a silo.1

 

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