Differentiated thyroid cancer: an update
ABSTRACT The incidence of differentiated thyroid cancer (DTC) is increasing. There remains controversy regarding several aspects of its management, including the need for prophylactic central compartment neck dissection and use of recombinant human thyroid stimulating hormone (rhTSH) for ¹³¹I radioactive iodine remnant ablation in patients with low-risk disease.
Central compartment neck dissection entails removal of the prelaryngeal, pretracheal, and paratracheal lymph nodes. Description of the dissection should include the indication (prophylactic vs. therapeutic) and extent of dissection (unilateral vs. bilateral). After 3.7 years, patients who underwent rhTSH-assisted ablation appeared to have similar rates of ablation as patients who underwent thyroid hormone withdrawal using criteria of negative whole body scans (84% of euthyroid and 94% of hypothyroid patients) and stimulated thyroglobulin less than 2 ng/ml (95%, euthyroid; 96%, hypothyroid). In the United States, rhTSH would cost $15,994 per patient, with an incremental societal cost of $1365 per patient and incremental cost-effectiveness ratio of $52,554/quality-adjusted-life-year.
The use of rhTSH in patients with low-risk DTC undergoing thyroid remnant ablation appears to have similar efficacy in remnant ablation and tumoricidal effects and is associated with improved patient quality of life. Cost-effectiveness appears to be above the conventional threshold for cost-effectiveness, but is dependent on cost of rhTSH, patient utility, days off work, and rates of remnant ablation.
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ABSTRACT: The molecular work-up of thyroid nodules on fine needle aspiration (FNA) cytology samples has given clinicians a new level of diagnostic information. We focus this review on the molecular techniques used in the diagnosis of thyroid cancer, especially BRAF, and the resulting management considerations that are raised. BRAF testing offers both diagnostic and prognostic information; it has been used along with the Bethesda Thyroid FNA Classification System to offer preoperative guidance in the management of thyroid nodules. Various authors have successfully utilized molecular panels on cytologic specimens including mutations and rearrangements such as RAS and RET/PTC. Preoperative mutation detection allows initial management decisions to be made with a greater clinical confidence. BRAF molecular testing holds promise as a possible diagnostic tool for indeterminate FNAs, and as a determinant for planning initial clinical management of thyroid nodules. Further developments in the molecular approach to thyroid cancer are expected to allow greater individualization of patient care.Current opinion in oncology 11/2011; 24(1):35-41. DOI:10.1097/CCO.0b013e32834dcfca · 3.76 Impact Factor
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ABSTRACT: To evaluate the relationship between microscopic cancerous involvement of surgical margin and recurrence in patients with differentiated papillary thyroid cancer (PTC) who underwent total thyroidectomy followed by high-dose radioactive iodine ablation (HDRIA). Consecutive 197 PTC patients (184 women; mean age 44.9 years) who underwent total thyroidectomy without gross residual tumor followed by HDRIA were retrospectively reviewed. Resection margin involvement was evaluated and recurrence of the disease was assessed with clinicopathologically. Recurrence detected within 12 months after HDRIA were defined as early recurrence, detected after 12 months were defined as late recurrence. The mean follow-up was 85.9 ± 16.6 months. Twelve patients (6.1%) had microscopic cancerous involvement of surgical margin [margin (+) group], and 185 patients had negative surgical resection margins [margin (-) group]. Three patients (25.0%) in the margin (+) group and 11 patients (5.9%) in the margin (-) group had early recurrence. Margin (+) group showed higher incidence of early recurrence and lower incidence of disease free compared to margin (-) group (25.0 vs. 5.9%, p < 0.01; 66.7 vs. 81.1%, p < 0.01, respectively); however, there was no difference in incidence of late recurrence between the two groups (p = 1.00). There were no significant differences in the disease-free survival between the margin (+) and margin (-) groups after exclusion of early recurrence (p = 0.78). After high-dose radioactive iodine ablation, PTC patients with microscopic cancerous surgical margin involvement had a higher incidence of early recurrence and no different late recurrence rate compared to patients without microscopic cancerous surgical margin involvement.Annals of Nuclear Medicine 02/2012; 26(4):311-8. DOI:10.1007/s12149-012-0574-7 · 1.51 Impact Factor
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ABSTRACT: Objectives Describe trends and outcomes of patients undergoing thyroidectomy.Study Design and SettingRetrospective search of national inpatient database.Subjects and Methods The Nationwide Inpatient Sample 2009 was searched using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for thyroidectomy. Data extraction included patient demographics, hospital characteristics, and associated diagnoses. Subgroup analysis was performed on mortalities; bivariate and multivariate analysis was used to examine predictors of complications.ResultsIn the United States, 59,478 patients were admitted and underwent thyroidectomy in 2009. Their mean (SD) age was 53.0 (16.4) years. Mean (SD) length of stay was 3.0 (6.9) days, and mean (SD) total charges was $39,236 ($73,679). Total thyroidectomy was performed in 53.6% of patients; 33.2% underwent unilateral lobectomy. Most common thyroid disorders included nontoxic nodular goiter (36.0%) and malignant neoplasm (30.3%). There were 363 (0.61%) mortalities, with a mean (SD) age of 65.5 (15.2) years, length of stay of 13.9 (15.2) days, and total charges of $218,855 ($191,977). Of all patients, 6.18% had hypocalcemia and 0.77% had hypoparathyroidism; the incidence of vocal cord paresis was 0.85% unilaterally and 0.34% bilaterally. Multivariate analysis revealed predictors of complications following thyroid surgery were female sex (P = .0001), total thyroidectomy procedure (P < .0001), hospital location and teaching status (P = .0060), hospital bed size (P = .0054), type of thyroid disorder, and underlying patient comorbidities.Conclusion Reporting of normative data for thyroidectomy facilitates comparison. Hospitalizations for patients undergoing thyroidectomy require significant resource utilization. Predictors of complications include female sex, type of thyroid disorder and procedure, hospital location and teaching status, hospital bed size, and patient comorbidities.Otolaryngology Head and Neck Surgery 07/2012; 147(6). DOI:10.1177/0194599812454401 · 1.72 Impact Factor