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Effectiveness of routine ultrasonographic surveillance of patients with low-risk papillary carcinoma of the thyroid.

ABSTRACT: BACKGROUND:Over the last 15 years, there has been a change in clinical practice for the detection of recurrence in all patients with papillary thyroid cancer (PTC). In the past, recurrence was detected by clinical examination supplemented with fine-needle aspiration cytology; however, routine neck ultrasonography (US) and measurements of serum thyroglobulin were introduced for follow-up in 2000 and are now used widely for recurrence surveillance. The aim of this study was to describe the effectiveness of this changing trend in the use of routine surveillance ultrasonography for the detection of recurrence in low-risk PTC at a single institution. METHODS:Patients undergoing total thyroidectomy for PTC between January 2000 and December 2010 were identified from an institutional database. Of these, 752 (43.1%) were categorized as low risk by the risk stratification of the American Thyroid Association and included for analysis. The number of US examinations per patient per year of follow-up was then determined. The number of recurrences and deaths from disease was recorded similarly. RESULTS:The median age was 48 years (range, 16-83) and the median follow-up was 34 months (range, 1-148). Between 2003 and 2012, the number of US examinations per patient-year of follow-up increased by 5.3-fold. Over the same time period, 3 structural recurrences (clinically evident neck masses or nodes) were detected with no disease-related deaths. CONCLUSION:At our institution, the annual rate of neck US examination increased by 5.3-fold per low-risk PTC patients between 2003 and 2012. Despite this increase, only 3 structural recurrences were detected. The routine use of neck US for surveillance of low-risk PTC patients requires review.

SUBMITTER: Wang LY

PROVIDER: S-EPMC4991630 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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Effectiveness of routine ultrasonographic surveillance of patients with low-risk papillary carcinoma of the thyroid.

Wang Laura Y LY Roman Benjamin R BR Palmer Frank L FL Tuttle R Michael RM Shaha Ashok R AR Shah Jatin P JP Patel Snehal G SG Ganly Ian I

Surgery 20151231 5

<h4>Background</h4>Over the last 15 years, there has been a change in clinical practice for the detection of recurrence in all patients with papillary thyroid cancer (PTC). In the past, recurrence was detected by clinical examination supplemented with fine-needle aspiration cytology; however, routine neck ultrasonography (US) and measurements of serum thyroglobulin were introduced for follow-up in 2000 and are now used widely for recurrence surveillance. The aim of this study was to describe the ...[more]

PMID: 26747227

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Project description:Background: Active surveillance is established as an alternative to surgery for papillary thyroid microcarcinomas, but inclusion criteria and mortality risk for pursuing a nonsurgical approach have not been clearly defined. To gauge the feasibility of expanding active surveillance thresholds, we investigated the effects of increasing size and age on disease-specific survival (DSS) in a large nonoperative thyroid cancer cohort, compared against a matched group of surgical patients. Methods: Papillary thyroid carcinoma patients staged T1-4N0M0 were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 1975 and 2015, stratified by nonsurgical and surgical management. Propensity score matching was performed to adjust for imbalances in covariates. Multivariable models were constructed using restricted cubic splines to model nonlinear relationships of age and tumor size with DSS. Results: Overall, 1453 nonoperative patients and 54,718 surgical patients met the inclusion criteria. Collectively, increasing age and size after certain thresholds independently led to greater differences in DSS between nonsurgical and surgical patients. For younger ages (14-55 years), surgical approach compared with nonsurgical approach was not associated with any difference in the 10-year DSS among 0-4 cm cancers (99.8% vs. 100%, p = 0.470), 4.1-6 cm cancers (98.8% vs. 100%, p = 0.599), or >6 cm cancers (97.3% vs. 100%, p = 0.718). Older patients with larger tumors (>75 years, >6 cm) demonstrated the greatest difference in DSS (48.1% vs. 91.3%, p < 0.001). Similar results were found when applying propensity score matching. For age, restricted cubic spline plots showed minimal relative survival hazard in nonoperative cases beginning after age 60 years, with a change point illustrating acceleration in relative hazard beyond age 72 years. For size, relative survival hazard was observed after 2.0 cm and increased slowly with nodule growth up to an inflection point of 4.5 cm. Beyond this, mortality risk escalated with each additional year without plateau. Conclusions: Increasing age and size lead to progressively greater mortality risk without surgery, but only beyond certain thresholds. We define escalating gradients at which a nonsurgical approach may be deemed appropriate, and beyond which survival benefits from surgery become apparent. Such findings reconcile controversial observations regarding age and size in active surveillance and further reshape evolving treatment paradigms in thyroid cancer.

Project description:ImportanceActive surveillance is sometimes considered as a disease management option for individuals with small, low-risk papillary thyroid carcinoma.ObjectiveTo assess whether patient age is associated with progression of low-risk papillary thyroid carcinoma (tumor growth or incident metastatic disease) in adults under active surveillance.Evidence reviewEight electronic databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Emcare, PsycINFO, Web of Science, and ClincalTrials.gov) were searched from inception to March 2019, supplemented with a hand search. Two investigators independently screened citations, reviewed full-text articles, and abstracted data. Additional data were sought from authors. Random-effects meta-analyses were performed using incidence data (statistically adjusted for confounders and crude rates).FindingsA total of 1658 unique citations were screened, and 62 full-text articles were reviewed, including 5 studies. Three studies included exclusively microcarcinomas and 2 included tumors up to 2 cm in maximal diameter. The mean age of participants was 51.0 to 55.2 years in 4 studies reporting this value. The mean or median follow-up was 5 years or more in 3 studies and approximately 2 years in 2 studies. The pooled risk ratio for tumor growth of 3 mm or more in maximal diameter in individuals aged 40 to 50 years compared with younger individuals was 0.51 when adjusted for confounders (95% CI, 0.29-0.89; 1619 patients, 2 studies), and the unadjusted risk ratio of this outcome for individuals 40 years or older was 0.55 (95% CI, 0.36-0.82; 2097 patients, 4 studies). In adults aged 40 to 45 years, the unadjusted risk ratio for any tumor volume increase compared with younger individuals was 0.65 (95% CI, 0.51-0.83; 1232 patients, 4 studies). The pooled risk ratio for incident nodal metastases in individuals 40 years or older was 0.22 (95% CI, 0.10-0.47; 1806 patients, 3 studies); however, in a secondary analysis, the risk difference was not significantly different. There was no statistically significant heterogeneity in any of the meta-analyses. There were no thyroid cancer-related deaths nor incident distant metastases.Conclusions and relevanceThis study suggests that older age may be associated with a reduced risk of primary papillary thyroid carcinoma tumor growth under active surveillance. Incident metastatic disease is uncommon during active surveillance.

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Effectiveness of routine ultrasonographic surveillance of patients with low-risk papillary carcinoma of the thyroid.

Publications

Effectiveness of routine ultrasonographic surveillance of patients with low-risk papillary carcinoma of the thyroid.

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