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The role of surgery in small differentiated thyroid cancer

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Abstract

Introduction

The incidence of small, differentiated thyroid cancer (DTC) cases has been increasing in the United States and the world mainly due to incidental detection because of widespread use of diagnostic modalities. While the option of active surveillance instead of surgical resection is getting more popular, there is still an open discussion about the best approach in these cases.

Materials and methods

The National Cancer Database was queried for patients diagnosed with non-metastatic small T1/N0 DTC between 2004 and 2016, who have known surgical status and Charlson comorbidity index of two or less. We evaluated the overall survival (OS) based on the surgery status using Kaplan–Meier estimates and multivariable cox regression analyses.

Results

A total of 98,501 patients with non-metastatic small DTC were included, within which 96,612 (98.1%) were treated with surgery, and 1889 (1.9%) were not treated with surgery or other ablative modalities. We found that patients who were treated with surgery had better OS compared to patients who were not treated with surgery (mean OS 171 months vs 134.1 months, P < 0.001, median OS was not reached). This difference was still statistically significant even after we used propensity score matching for age, gender, race, Charlson-Deyo score, tumor size, and histology. On multivariate analysis, surgery was associated with better OS (HR 0.218; 95% CI: 0.196–0.244; P < 0.001). Same trend was found in subgroup analysis when we split the cohort according to tumor size (<1 and ≥1 cm), histology (follicular, papillary and Hurthle cell carcinoma), and age (<55 years vs ≥55 years).

Conclusion

Patients with non-metastatic small DTC who were treated with surgery had significant improvement in OS compared to patients who were not treated with surgery. Notwithstanding the limitations of the current analysis, these results call for caution prior to recommending routine surveillance for all patients with small DTC.

Highlights

  • Thyroid cancer is the most common endocrine malignancy.

  • Thyroid cancer incidence rate is increasing, especially small thyroid tumors.

  • The oncologic safety of active surveillance versus surgical resection in small, differentiated thyroid cancer is still controversial.

  • Surgical resection improves the OS in small DTC.

  • The survival benefit of surgical treatment is seen in all histologic types of DTC.

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Data availability

The data we used in this study is available from the National Cancer Database.

Abbreviations

AJCC:

American Joint Committee on Cancer

AS:

active surveillance

CI:

confidence intervals

CoC:

commission on cancer

DTC:

differentiated thyroid cancer

FNA:

fine-needle aspiration

HR:

Hazard Ratio

NCDB:

National Cancer Database

OS:

overall survival

PMC:

papillary microcarcinoma

PTC:

papillary thyroid cancer

US:

United States

References

  1. International Agency for Research on Cancer. (2020). https://gco.iarc.fr/today/data/factsheets/cancers/32-Thyroid-fact-sheet.pdf

  2. American Cancer Society. Key statistics for thyroid cancer: how common is thyroid cancer? Am Cancer Soc. (2022). https://www.cancer.org/cancer/thyroid-cancer/about/key-statistics.html

  3. F. Baidoun, A.M. Saad, O. Abdel-Rahman, New paradigms in the treatment of low-risk thyroid cancer. Expert Rev. Endocrinol. Metab. 15(4), 251–260 (2020). https://doi.org/10.1080/17446651.2020.1773802

    Article  CAS  PubMed  Google Scholar 

  4. National Cancer Institute Surveillance. Epidemiology, and end results program. cancer stat facts: thyroid cancer. (2022). https://seer.cancer.gov/statfacts/html/thyro.html

  5. J.J. Wiltshire, T.M. Drake, L. Uttley, S.P. Balasubramanian, Systematic review of trends in the incidence rates of thyroid cancer. Thyroid 26(11), 1541–1552 (2016). https://doi.org/10.1089/thy.2016.0100

    Article  PubMed  Google Scholar 

  6. J.A. Sosa, J.W. Hanna, K.A. Robinson, R.B. Lanman, Increases in thyroid nodule fine-needle aspirations, operations, and diagnoses of thyroid cancer in the United States. Surgery 154(6), 1420–1427 (2013). https://linkinghub.elsevier.com/retrieve/pii/S0039606013003954

  7. L. Davies, H.G. Welch, Current thyroid cancer trends in the United States. JAMA Otolaryngol. Neck Surg. 140(4), 317 (2014). https://doi.org/10.1001/jamaoto.2014.1

    Article  Google Scholar 

  8. S.M. Mousavi, A. Brandt, J. Sundquist, K. Hemminki, Risks of papillary and follicular thyroid cancer among immigrants to Sweden. Int. J. Cancer 129(9), 2248–55 (2011). http://www.ncbi.nlm.nih.gov/pubmed/21170937

  9. J.D. Mathews, A.V. Forsythe, Z. Brady et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 346, f2360 (2013). http://www.ncbi.nlm.nih.gov/pubmed/23694687

  10. C. Zhu, T. Zheng, B.A. Kilfoy et al. A birth cohort analysis of the incidence of papillary thyroid cancer in the United States, 1973–2004. Thyroid 19(10), 1061–1066 (2009). https://doi.org/10.1089/thy.2008.0342

    Article  PubMed  PubMed Central  Google Scholar 

  11. C.M. Kitahara, M.L. McCullough, S. Franceschi et al. Anthropometric factors and thyroid cancer risk by histological subtype: pooled analysis of 22 prospective studies. Thyroid 26(2), 306–18 (2016). http://www.ncbi.nlm.nih.gov/pubmed/26756356

  12. D. Schmid, C. Ricci, G. Behrens, M.F. Leitzmann, Adiposity and risk of thyroid cancer: a systematic review and meta-analysis. Obes. Rev. 16(12), 1042–54 (2015). http://www.ncbi.nlm.nih.gov/pubmed/26365757

  13. R. Vigneri, P. Malandrino, F. Gianì, M. Russo, P. Vigneri, Heavy metals in the volcanic environment and thyroid cancer. Mol. Cell. Endocrinol. 457, 73–80 (2017). http://www.ncbi.nlm.nih.gov/pubmed/27794445

  14. NCCN Clinical Practice Guidlines in Oncology. Thyroid Carcinoma. (2022). https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf

  15. S. Lohia, M. Hanson, R.M. Tuttle, L.G.T. Morris, Active surveillance for patients with very low-risk thyroid cancer. Laryngoscope Investig. Otolaryngol. 5(1), 175–182 (2020). https://doi.org/10.1002/lio2.356

    Article  PubMed  PubMed Central  Google Scholar 

  16. L. Davies, H.G. Welch, Thyroid cancer survival in the United States. Arch. Otolaryngol. Neck Surg. 136(5), 440 (2010). https://doi.org/10.1001/archoto.2010.55

    Article  Google Scholar 

  17. Y. Ito, C. Tomoda, T. Uruno et al. Papillary microcarcinoma of the thyroid: how should it be treated? World J. Surg. 28(11), 1115–21 (2004). http://www.ncbi.nlm.nih.gov/pubmed/15490053

    Article  Google Scholar 

  18. I. Sugitani, K. Toda, K. Yamada, N. Yamamoto, M. Ikenaga, Y. Fujimoto, Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes. World J. Surg. 34(6), 1222–1231 (2010)

    Article  Google Scholar 

  19. Y. Ito, A. Miyauchi, H. Inoue et al. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J. Surg. 34(1), 28–35 (2010)

    Article  Google Scholar 

  20. A. Miyauchi, Clinical Trials of Active Surveillance of Papillary Microcarcinoma of the Thyroid. World J. Surg. 40(3), 516–522 (2016)

    Article  Google Scholar 

  21. National Cancer Database ‐ About the National Cancer Database, (2020). https://www.facs.org/quality-programs/cancer/ncdb/about

  22. World Health Organization. International classification of diseases for oncology (ICD-O), 1st revision, 3rd ed. (2013). https://apps.who.int/iris/handle/10665/96612

  23. Y. Ito, A. Miyauchi, Nonoperative management of low-risk differentiated thyroid carcinoma. Curr. Opin. Oncol. 27(1), 15–20 (2015)

    Article  Google Scholar 

  24. A. Miyauchi, Y. Ito, Conservative Surveillance Management of Low-Risk Papillary Thyroid Microcarcinoma. Endocrinol. Metab. Clin. North Am. 48(1), 215–226 (2019). https://doi.org/10.1016/j.ecl.2018.10.007

    Article  PubMed  Google Scholar 

  25. Y. Ito, K. Kuma, A. Miyauchi et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid 13(4), 381–387 (2003)

    Article  Google Scholar 

  26. Y. Ito, A. Miyauchi, M. Kihara, T. Higashiyama, K. Kobayashi, A. Miya, Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation. Thyroid 24(1), 27–34 (2014). http://www.ncbi.nlm.nih.gov/pubmed/24001104

  27. H. Oda, A. Miyauchi, Y. Ito et al. Incidences of unfavorable events in the management of low-risk papillary microcarcinoma of the thyroid by active surveillance versus immediate surgery. Thyroid 26(1), 150–155 (2016)

    Article  Google Scholar 

  28. H. Oda, A. Miyauchi, Y. Ito et al. Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid. Endocr. J. 64(1), 59–64 (2017)

    Article  Google Scholar 

  29. B.H.H. Lang, C.K.H. Wong, A cost-effectiveness comparison between early surgery and non-surgical approach for incidental papillary thyroid microcarcinoma. Eur. J. Endocrinol. 173(3), 367–375 (2015)

    Article  CAS  Google Scholar 

  30. A. Yoshida, Guidelines for the management of thyroid tumors. Nihon Geka Gakkai Zasshi 113(6), 507–11 (2012). http://www.ncbi.nlm.nih.gov/pubmed/23330459

  31. H. Takami, Y. Ito, T. Okamoto, A. Yoshida, Therapeutic strategy for differentiated thyroid carcinoma in Japan based on a newly established guideline managed by Japanese Society of Thyroid Surgeons and Japanese Association of Endocrine Surgeons. World J. Surg. 35(1), 111–121 (2011). https://doi.org/10.1007/s00268-010-0832-6

    Article  PubMed  Google Scholar 

  32. R.M. Tuttle, J.A. Fagin, G. Minkowitz et al. Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol. Head. Neck Surg. 143(10), 1015–1020 (2017)

    Article  Google Scholar 

  33. T.S. Wang, P. Goffredo, J.A. Sosa, S.A. Roman, Papillary thyroid microcarcinoma: an over-treated malignancy? World J. Surg. 38(9), 2297–303 (2014). https://doi.org/10.1007/s00268-014-2602-3

    Article  PubMed  Google Scholar 

  34. P. Miccoli, S. Bakkar, Surgical management of papillary thyroid carcinoma: an overview. Updates Surg. 69(2), 145–150 (2017)

    Article  Google Scholar 

  35. V.D. Tarasova, R.M. Tuttle, Current Management of Low Risk Differentiated Thyroid Cancer and Papillary Microcarcinoma. Clin. Oncol. 29(5), 290–297 (2017). https://doi.org/10.1016/j.clon.2016.12.009

    Article  CAS  Google Scholar 

  36. K.J. Kovatch, C.W. Hoban, A.G. Shuman, Thyroid cancer surgery guidelines in an era of de-escalation. Eur. J. Surg. Oncol. 44(3), 297–306 (2018)

    Article  CAS  Google Scholar 

  37. A.D. McDow, S.C. Pitt, Extent of surgery for low-risk differentiated thyroid cancer. Surg. Clin. North Am. 99(4), 599–610 (2019). https://doi.org/10.1016/j.suc.2019.04.003

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA

    Firas Baidoun

  2. Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, Canada

    Omar Abdel-Rahman

Authors
  1. Firas Baidoun
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  2. Omar Abdel-Rahman
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Contributions

FB: data analysis, data interpretation, manuscript writing. OA-R: study concept, manuscript editing, critical revision.

Corresponding author

Correspondence to Firas Baidoun.

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Conflict of interest

FB: declares no competing interests. OA-R: Advisory board/ honoraria with Roche; Lilly; Ipsen; Eisai; and Bayer.

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Baidoun, F., Abdel-Rahman, O. The role of surgery in small differentiated thyroid cancer. Endocrine 77, 469–479 (2022). https://doi.org/10.1007/s12020-022-03097-6

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