Risk stratification in active surveillance of papillary microcarcinoma

  • Asymptomatic, small thyroid nodules (usually ≤ 1 cm maximal diameter, 1 cm3, or 1 mL volume) confined to the thyroid and surrounded by normal thyroid parenchyma:
    • Can be followed with active surveillance:
      • With or without cytologic confirmation:
      • In patients who value their normal thyroid function and who desire avoidance of thyroid surgery
  • Patients who demonstrate tumors larger than 1.5 to 2.0 cm; tumors in subcapsular locations adjacent to important structures, such as the trachea and recurrent laryngeal nerve; or tumors with documented growth rate doubling times of less than 2 years:
    • Are generally considered inappropriate for observation and would be considered to have actionable disease
  • If the tumor growth rate is unknown at the time of nodule detection:
    • Then this can be established with serial ultrasound evaluations:
      • Done approximately every 6 months for 1 to 2 years
  • The frequency of ultrasound evaluations and long-term follow-up depends on the tumor size, location, and established growth rate
  • With the use of this paradigm, active surveillance continues until there is a:
    • 3-mm increase in tumor diameter:
      • Which corresponds to a 100% increase in tumor volume
    • Identification of metastatic disease
    • Direct invasion into surrounding structures of the thyroid
    • A decision to discontinue active surveillance based on patient preference
  • This risk-stratified, minimalistic management approach to very low-risk thyroid cancers:
    • Has been shown to be safe and effective over 5 to 10 years of follow-up in studies from Japan, Korea, and the United States
  • In the first 10 years of active surveillance follow-up:
    • Only 2% to 8% of papillary micro-carcinomas increase ≥ 3 mm in maximum diameter
    • 12% to 14% demonstrate an increase in tumor volume of > 50% (the smallest change in nodule volume that can be reproducibly measured)
    • Novel lymph node metastases are detected in 2% to 4%
  • The likelihood of disease progression is higher in younger patients than in older patients
  • Importantly, at the time of disease progression:
    • Deferred surgical intervention is quite effective with excellent outcomes and no disease-specific mortality

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #CancerSurgeon #SurgicalOncologist #HeadandNeckSurgeon #ThyroidCancer

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