www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Review
of
survival
rates
20-years
after
conservative
surgery
for
papillary
thyroid
carcinoma
夽
,
夽夽
Abrão
Rapoport
a,b,
Otávio
Alberto
Curioni
c,d,
Ali
Amar
c,d,
Rogério
Aparecido
Dedivitis
e,∗aDepartmentofSurgery,MedicineSchool,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil bDepartmentofHealth,HospitalHeliópolis,SãoPaulo,SP,Brazil
cLusíadaFoundation(UNILUS),SãoPaulo,SP,Brazil
dDepartmentofHeadandNeckSurgeryandOtorhinolaryngology,HospitalHeliópolis,SãoPaulo,SP,Brazil
eLarynxGroup,DepartmentofHeadandNeckSurgery,HospitaldasClínicas,MedicineSchool,UniversidadedeSãoPaulo(USP),
SãoPaulo,SP,Brazil
Received6March2014;accepted24August2014 Availableonline9June2015
KEYWORDS
Thyroidectomy; Thyroidneoplasms; Thyroidgland; Papillarycarcinoma
Abstract
Introduction:Alessextensivethyroidectomycouldbeusedforpatientsinthelowriskgroup.
Objective: Toperformacriticalfollow-upafterlobectomywithisthmusectomyforthe treat-mentofpapillarythyroidcarcinomainpatientswithasinglenodulelimitedtotheperiphery ofthelobe.
Methods:Thirty-one patients with thyroid papillary carcinoma operated on till 1993 were selected.Theyhadundergonelobectomywithisthmusectomy.Thisisaretrospectivecohort studyinwhichtheoncologicaloutcome(contralateralandregionalrecurrence)andthe reopera-tioncomplications(recurrentnerveparalysis/paresisandhypoparathyroidism)wereevaluated. Descriptiveanalysiswasemployed.
Results:Inthelastdecade(2003---2013),6(20%)contralateralrecurrenceswereobservedinthe remaininglobeandin1ofthesecases(3%),contralaterallymphnodemetastaseswerenoted. A completionthyroidectomypluslymphadenectomywas performed,withoutmodificationof globalsurvival.
Conclusion: Becauseoftherateof20%ofcontralateralrecurrenceaftera20-yearfollow-up, wesuggestmodificationofthesurgicalparadigmfortotalthyroidectomyasaninitialtherapy. © 2015 Publishedby Elsevier Editora Ltda. onbehalf of Associação Brasileira de Otorrino-laringologiaeCirurgiaCérvico-Facial.
夽
Pleasecitethisarticleas:RapoportA,CurioniOA,AmarA,DedivitisRA.Reviewofsurvivalrates20-yearsafterconservativesurgeryfor papillarythyroidcarcinoma.BrazJOtorhinolaryngol.2015;81:389---93.
夽夽Institution:DepartmentofHeadandNeckSurgeryandOtorhinolaryngology,HospitalHeliópolis,SãoPaulo,SP,Brazil.
∗Correspondingauthor.
E-mail:dedivitis@usp.br(R.A.Dedivitis).
http://dx.doi.org/10.1016/j.bjorl.2014.08.020
PALAVRAS-CHAVE
Tireoidectomia; Neoplasiasda glândulatireoide; Glândulatireoide; Carcinomapapilar
Revisãodosresultadosdesobrevidaa20anosdacirurgiaconservadoranocarcinoma papilíferodatireoide
Resumo
Introduc¸ão:Umacirurgiamenosextensadaglândulatireoidepoderiaserutilizadaempacientes dogrupodebaixorisco.
Objetivo:Realizarseguimentocríticoapóshemitireoidectomiaparatratamentodocarcinoma papilíferodetireoideemcasosdenóduloúnicolimitadoàperiferiadolobo.
Método: Foramselecionados31pacientesportadoresdecarcinomapapilíferodetireoide oper-ados,até1993,porlobectomiamaisistmectomia.Trata-sedeumestudoretrospectivodecoorte sendoavaliadosoresultadooncológico(recidivacontralateraleregional)ecomplicac¸õesde reoperac¸ão(paralisia/paresiadenervorecorrenteehipoparatireoidismo).Utilizou-seanálise descritiva.
Resultados: Naúltimadécada,foramobservados6(20%)casosderecidivascontralaterais(lobo remanescente)sendoque,emumcaso,estavaacompanhadodemetástaseslinfonodais con-tralaterais(3%),semimpactonasobrevidadospacientesreoperados.
Conclusão:Aocorrênciade20%derecidivacontralateralapósumamédiaevolutivade20anos sugererevisãodoparadigmaconservadorparaatotalizac¸ãoimediatadatireoidectomia. ©2015Publicado porElsevier EditoraLtda. emnome daAssociaçãoBrasileira de Otorrino-laringologiaeCirurgiaCérvico-Facial.
Introduction
The definitionof the therapeutic paradigmfor differenti-atedthyroidcancersstillremains achallengeforexperts. Historically,thelowaggressivenessoftheselesions,which presentslowgrowth,hasledclinicianstoadoptamore con-servativeapproachinpatientswithasinglenodulelocated ontheperipheryofthethyroidlobe,oncologically justify-ingtheconservationoftheremaininglobe;thisusuallywas sufficienttissuetomaintainfunction,withouttheneedfor hormonereplacement and alsohelp maintain the regula-tionofthyroid-stimulatinghormone(TSH).Alongwiththese facts,inprinciple,theclinical andhistologicalabsenceof metastaticregionallymphnodesdidnotjustifyelective pro-cedures,sincelymphnodemetastasesarestagingfindings, but are not prognosticin the shortand medium term.1---4
Anotherconsiderationisthatapartialresectiondecreases thepotentialforiatrogeniccomplications(especially recur-rentnerveinjuryandhypoparathyroidism),which,although uncommon,dooccur.
The literature revealsthat patients withpapillary car-cinomaundergoingtotallobectomyandisthmectomyhave equivalentoverallsurvivalcomparedtopatientstreatedby totalthyroidectomy.5Currently,over 70% ofpatients with
papillarycarcinoma ofthyroid aretreated withtotal thy-roidectomy.However,manypatientsareinitiallytreatedby lobectomy. In these patients, most clinicians would favor a total thyroidectomy, in face of risk of disease in the contralaterallobe.6 The survival of patients withlow-risk
tumorsisexcellent, regardlessof theextent of their thy-roidectomy. Thus, it is suggested that a less extensive surgical approach, such as a lobectomy plus isthmec-tomy, could be used in patients at low risk, rather than the systematic recommendation for total thyroidectomy. Unfortunately,norandomizedclinicaltrialscomparingthe
effectivenessofthesetwoformsofsurgicalapproacheshave beenpublished;thus,surgeonsmustselectwhichprocedure touse,basedontheirownopinion andfromtheevidence ofretrospectivestudies.7
Inthissense,duringtheperiodfrom1977to1997,witha 10---15-yearfollow-up,therewerenoincidentsof contralat-eral or lymph node recurrence until2003.8 However, the
facts observed in ourstudy indicate aneed for reflection ontheindicationtoadoptamoreaggressiveinitialtherapy. The questionthatremains relatestothepossibilitythata secondresection,performeddecadesafterthefirst,maybe necessary inadverseclinical conditions,asaresultofany comorbidconditionthatwouldbeaffectingthesepatients, alongwithpossibleiatrogeniccomplicationsresultingfrom thehandlingofthepreviouslytreatedoperativefield.9
Thisstudyaimedtoevaluatethesurvivalresults20years afterlobectomyplusisthmectomyforpatientswithpapillary thyroidcarcinoma.
Methods
This study was approved by the Ethics Committee on Researchoftheinstitutioninwhichitwasconducted,under No.222.
Table1 Patientdistributionaccordingtogenderandage.
Male Female Total
≥45years 3(21%) 11(79%) 14(45%)
<45years 4(23%) 13(77%) 17(55%)
Total 7(22%) 24(78%) 31(100%)
Table2 Patientdistributionaccordingtotumorsize.
Diameter(cm) Number(%)
<1 3(9)
1---2 15(48)
>2 13(41)
thosecasesofreoperation,potentialcomplications (paral-ysis/paresisof recurrentnerveandclinicalandlaboratory hypoparathyroidism)wereevaluated.Descriptivestatistics wereapplied.
Results
Of the 31 patients, seven (22%) were male and 24 (78%) female, ranging between 16 and 79 years. Seventeen patients(55%) belongedtoagroupunder45yearsand 14 (45%)wereover45years(Table1).
The nodes had a size between 1cm and 5cm in their longestaxis.Nodeswithameandiameterof2.2cm(Table2) prevailed.Sixpatients(19%)ofthisseriesshowedmetastatic cervical lymph node enlargement, and underwent func-tionalneckdissectioninassociationwiththyroidectomy.All patientsarealive;insix(20%)relapseoccurredinthe resid-uallobe,followedbysurgicalrescue,with100%survival.
Regardingcomplications,onepatient(3%)hadtransient dysphonia,withunilateralvocalfoldparesis,whichresolved spontaneously.Therewerenocasesoftransientor perma-nenthypoparathyroidism.
Mean follow-up was 20 years.Ten patients (32%) were monitoredbetween 10and15 years,10(32%)had follow-upsover15years,and11(37%)over20years.Therewereno casesoflocalorregionalrecurrenceorofdistantmetastasis, withallpatientsasymptomaticandwithoutthedisease.
Discussion
Becauseof the differenceof opinion, thehypothesis that treatmentoutcomesarecomparablewithbothmethods,but withfewercomplicationsforpartialthyroidectomy (lobec-tomy plus isthmectomy),10 for many years the authors’
clinical reasoning spoke in favor of the latter conduct in thisservice.However,itwasdecidedtoreviewthisseries of papillary thyroid carcinoma limited to only one lobe and treated by partial thyroidectomy, with a minimum evolutionoffiveyears,andtochecktheincidenceand loca-tionof recurrences anddistantmetastases, postoperative complications,andsurvivalresultsafterfive,10,15,and20 years.
Disagreementsdonotoccurwhenfacinglocallyadvanced tumors with infiltration of adjacent tissues and/or with regionalordistantmetastases.11Theproblemoccursinthat
groupofpatientsconsideredaslowriskcases.Noobjection hasbeenfoundtothestatementthatthetreatmentof dif-ferentiatedthyroid carcinomais primarily surgical---what is underdiscussion is the extent of the surgical approach tothisglandandlymphnodes,andhencetheramifications relatedtothemonitoringofthesepatients.12
In the initial cases, each node measured 1---5cm in its longestaxis,withameandiameterof2.2cm.Sixpatients (19%)hadmetastaticcervicallymphnodeenlargementand underwent functional neck dissection plus a partial thy-roidectomy. Even though therewere nodes up to 5cm in size observed at the time of the procedure, in cases of papillarycarcinoma theincidence ofdistant metastasis is minimal,allowingtheselectionofthepartialprocedureas firstchoice.TheuseofiodineI131isquestionablebecause,in thesepatients,distantdisseminationusuallydoesnotoccur; therefore,thispracticeisstillconsideredcontroversial.13,14
The fact that six patients (19%) had cervical metasta-sis without capsular rupture makes the functional neck dissectionaperfectlyacceptableprocedure.Butthe empha-sis of this study was in the assessment of long-term results.
Thisseriesdemonstratedthat80%ofpatientshadnodes largerthan 1cm, and 22% had histologically positive cer-vical metastases,treated by neck dissection. All patients werefollowedforoverfiveyears,andmorethan60%ofthe caseswerefollowedforovertenyears.Therewasnolocal orregionalrecurrence.
Tumorsizeisconsideredanimportantindicatorofriskfor recurrenceinthecontralaterallobe,aswellasthe involve-ment of a regional lymph node and distant metastasis. However, microcarcinomata with clinical manifestations, thatis,thepresenceofregionalordistantmetastasis, are moreaggressivecomparedtoasymptomatic microcarcino-mata,whichtendtohaveagoodoutcomewithconservative treatment.15
Over thepast ten years,the presence ofcontralateral recurrencewasfoundinsixpatients(allwithmorethan20 yearsoffollow-up),whichrepresents20%(6/31).Although the survival rate was 100% (thanks to surgical rescue), a 20%recurrenceratesuggestsarethinkingoftheprocedures adoptedinthefirstperiodofthisstudy.Thus,inviewofthe need for a complete thyroidectomy,we wantedto revisit theinitialplanofperformingthehemithyroidectomyasthe firsttherapeuticapproachandhavecometoconsidertotal resectionofthethyroidglandfromthebeginning.We com-binethiswithhormonetherapyinyoungpatientswho,due totheirexpectedlongsurvival,mightneedasecondsurgery becauseoflocalrecurrenceintheeventofalessthan com-pletethyroidectomy.
Lymphnodemetastases,canbedetectedearlywiththe imagingmethodsnowavailable,morerecentlybypositron emissiontomography/computedtomographyattheregional leveland,morerarely,fordistantmanifestations.However, intheinitialcasesofthesixpatientswithrecurrenceinthe contralaterallobe (the emphasis of the authors’ previous study),8onlyinonewerecontralaterallymphnodesinlevels
IV---Vdetected.Thedevelopmentoftheserecurrenceswas accompaniedbyaslightincreaseinthyroglobulin,despite being usually valued asthe marker of recurrence.16---19 In
havegoodsurvivalresults,withsomeexceptions,regardless oftheapproachperformed.
Epidemiological data suggest the existence of regional andinternationaldifferenceswithrespecttotumorbiology. WhileU.S. studies could not demonstrate the advantages ofatotalthyroidectomyandofneckdissection,compared toless extensive procedures,especially in T2/T3cases,20
European studies showan increase in survival rates when lymphadenectomy wasperformed in additionto thetotal thyroidectomy.21 Regarding multicentric foci, it is known
thatthepotentialforexistenceoftumorfociinaremaining contralaterallobeisvariable.Autopsystudieshavedetected microscopicfociofpapillarythyroidcarcinomaas inciden-tal findings in more than 25% of patients killed by other diseases,reachingupto90%ofcasesindifferentcenters. However,the authors of this study have always reported bilateralrates lowerthanthosefor localrecurrence.This means that the presence of a contralateral microscopic tumorisnotan indicationthattherewillnecessarilybea clinicalmanifestation of thisresidual tumorthroughlocal recurrence;and ifthis does happen, that therewill bea higherrateofdeathfromcancer.
Nonetheless, the fear of multicentric foci should be included among the reasons for routinely performing a totalthyroidectomyinpatients withpapillarythyroid car-cinoma, since it could cause recurrence and death; the risk of a transformation of a non-resected microscopic tumor toan anaplastic malignant form;and the opportu-nitytomonitorthyroglobulin,amarkerofrecurrenceofthis disease.22
The rates of thyroidectomy complications have been reduced by improvements in surgical technique and the experience of specialized centers. Nevertheless, tempo-raryparesisoftherecurrentnerveandhypoparathyroidism arethe main complications inpatients treated withtotal thyroidectomy. Thus, when comparing complications in the groups who underwent primary total thyroidectomy versus total thyroidectomy as a secondary procedure for a well-differentiated thyroid carcinoma, no significant difference was noted, except for a transient recurrent paresis,whichoccurredmoreofteninthesecondgroup.23
Thus, this does not seem to be a criterion for decision making.
Previously,thisservice’ssurgicalpreferencewas lobec-tomyplusisthmectomyinpatientswithpapillarycarcinomas limited to a glandular lobe, with a virtually nonexistent complication rate. However, the long term contralateral recurrence rate of 20% of led us to revise this, in favor of a initial total thyroidectomy. For the specialist who treatspatientswiththyroidcancer,itiscriticaltotakeinto accounttheexperienceofspecializedcenters,thusbuilding his/herownexperience,sincethecompletionof random-izedprospectivestudiesalthoughadesirablepractice,has questionablefeasibility.
Conclusion
The occurrence of 20% contralateral recurrence after an average of 20 years of evolution suggests review of the conservative paradigm for immediate completion of thy-roidectomy.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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