This original study suggests thyroidectomy for low-risk cancers measuring >1.5 cm rather >1.0 cm as currently recommended by ATA; to avoid unnecessary surgeries, cost and complications.
In stead, authors propose “active surveillance” in carcinomas <1.5 cm. About 700 thyroid cancer patients were observed and analyzed over a 10 year period.
The 2015 ATA guidelines acknowledged that “an active surveillance management approach can be considered as an alternative to immediate surgery” in patients with low risk papillary thyroid carcinoma (PTC).
The aim of this study is to determine the proportion of PTC that would meet criteria for active surveillance and the surgeries and complications that could have been avoided.
We retrospectively reviewed 681 patients with thyroid cancer who underwent thyroid surgery from 2003-2012. A decision-making framework for active surveillance was applied to patients with PTC in nodules measuring ≤1.5 cm on ultrasound. Patients were identified as suitable for active surveillance based on imaging and patient characteristics. We reviewed these patients for management and outcomes.
243 patients had PTC diagnosed based on FNA histology of Bethesda V or VI in thyroid nodules. 77 of these patients had nodules measuring ≤1.5 cm on ultrasound and 56/77 (23%) patients met criteria for surveillance. 15/243 (6%) patients met criteria with a ≤1 cm size threshold and 41/243 (17%) met criteria with a 1.1–1.5 cm threshold.
Of the 56 patients that met criteria for active surveillance, 52 underwent total thyroidectomy and 4 had lobectomy. 45 (80%) of patients had elective central nodal dissection and 14 had nodal metastases on pathology (all <4 mm). Three patients had permanent complications from surgery including vocal cord paralysis, hypoparathyroidism, and a chipped tooth from intubation. No patients died or had recurrent disease.
Future programs in the United States should consider increasing the size threshold for active surveillance of PTC to 1.5 cm since this will allow up to 25% of patients to be eligible instead of only 6% with a 1 cm size threshold. Without an active surveillance program, the majority of patients with low risk cancers have thyroidectomy and carry a small risk of permanent complications.