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Thirty years of active surveillance for low-risk thyroid cancer, lessons learned and future directions

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Abstract

Active Surveillance is a non-invasive strategy designed to identify a minority of patients with low-risk papillary thyroid carcinoma who might experience clinical progression and benefit from additional definitive treatments. Global experience suggests that these tumors typically show minimal changes in size during active surveillance, often demonstrating very slow growth or even size reduction. Moreover, the rate of lymph node metastases is low and can be effectively managed through rescue surgery, without impacting cancer-related mortality. However, despite 30 years of experience demonstrating the safety and feasibility of active surveillance for appropriately selected patients, this approach seems to have limited adoption in specific contexts. This limitation can be attributed to various barriers, including disparities in access to accurate information about the indolent nature of this disease and the prevalence of a maximalist mindset among certain patients and medical settings. This review aims to revisit the experience from the last three decades, provide current insights into the clinical outcomes of active surveillance trials, and propose a systematic approach for its implementation. Furthermore, it intends to emphasize the importance of precise patient selection and provides new perspectives in the field.

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Abbreviations

AS:

Active surveillance

ATA:

American Thyroid Association

CI:

Confidence interval

DTC:

Differentiated thyroid carcinoma

FNAB:

Fine-needle aspiration biopsy

FN/SFN:

Follicular neoplasm or suspicious for a follicular neoplasm

HIFU:

High intensity focused ultrasound

IS:

Immediate surgery

JAES:

Japan Association of Endocrine Surgery Task Force

L-T4:

Levothyroxine

LA:

Laser ablation

MWA:

Microwave ablation

NIFTP:

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features

NR:

Not reported

NS:

Non-significant

RFA:

Radiofrequency ablation

RLN:

Recurrent laryngeal nerve

RR:

Relative risk

Tg:

Thyroglobulin

TgAB:

Anti-thyroglobulin antibodies

TSH:

Thyroid stimulating hormone

TV-DR:

Tumor volume doubling rate

PMC:

Papillary microcarcinoma

PTC:

Papillary thyroid carcinoma

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Authors and Affiliations

  1. Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Córdoba, Buenos Aires, 2351, Argentina

    Anabella Smulever & Fabian Pitoia

  2. Division of Endocrinology, Instituto de Investigaciones Médicas A. Lanari, University of Buenos Aires, Buenos Aires, Argentina

    Anabella Smulever

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  1. Anabella Smulever
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AS y FP contributed to the conception and design of the article. Both authors drafted, revised, and approved the final manuscript.

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Correspondence to Anabella Smulever.

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Smulever, A., Pitoia, F. Thirty years of active surveillance for low-risk thyroid cancer, lessons learned and future directions. Rev Endocr Metab Disord (2023). https://doi.org/10.1007/s11154-023-09844-y

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