Risk Stratification in Active Surveillance of Papillary Microcarcinoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • 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 < 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 microcarcinomas:
        • 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
  • References:
    • Ito Y, Miyauchi A. Active surveillance as first-line management of papillary microcarcinoma. Annu Rev Med. 2019;70:369–379.
    • Ito Y, Miyauchi A, Kudo T, Oda H, Yamamoto M, Sasai H, Masuoka H, Fukushima M, Higashiyama T, Kihara M, Miya A.. Trends in the implementation of active surveillance for low-risk papillary thyroid microcarcinomas at Kuma Hospital: gradual increase and heterogeneity in the acceptance of this new management option. Thyroid. 2018;28(4):488–495.
    • Tuttle RM, Zhang L, Shaha A. A clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management. Expert Rev Endocrinol Metab. 2018;13(2):77–85. 
    • Tuttle RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S, Untch B, Ganly I, Shaha AR, Shah JP, Pace M, Li D, Bach A, Lin O, Whiting A, Ghossein R, Landa I, Sabra M, Boucai L, Fish S, Morris LGT. Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1015–1020. 
    • Tuttle RM, Zhang L, Shaha A. A clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management. Expert Rev Endocrinol Metab. 2018;13(2):77–85.
    • D’Agostino TA, Shuk E, Maloney EK, Zeuren R, Tuttle RM, Bylund CL. Treatment decision making in early-stage papillary thyroid cancer. Psychooncology. 2018;27(1):61–68.
    • Groopman J, Hartzband P.. Your Medical Mind. How to Decide What Is Right for You. New York, NY: Penguin Books.
    • Ito Y, Miyauchi A. Prognostic factors and therapeutic strategies for differentiated carcinomas of the thyroid. Endocr J. 2009;56(2):177–192.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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