- Email: [email protected]
Papillary thyroid microcarcinoma and active surveillance
Correspondence
MJB and WMD have received grants from the UK National Institute for Health Research and Barts and the London Charity to measure outcomes of adrenalectomy in patients who have undergone adrenal vein sampling and 11C-metomidate PET CT and from the British Heart Foundation to assess endoscopic radiofrequency ablation of adrenal adenomas. MJB and Queen Mary University of London hold a fast-track award from GlaxoSmithKline to identify new compounds for the treatment of primary aldosteronism. MJB is a UK National Institute for Health Research senior investigator. Research cited in this Comment was funded by project and special project research grants to MJB from the British Heart Foundation and the Wellcome Trust.
*Morris J Brown, William M Drake [email protected] Barts Heart Centre, William Harvey Research Institute, Barts and the London Medical School, Queen Mary University London, WCIM 6BQ, UK (MJB, WMD) 1
2
Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 1889–916. Brown MJ, Drake WM. Splitting atoms: the Endocrine Society guideline for the management of primary aldosteronism. Lancet Diabetes Endocrinol 2016; 4: 805–07.
Papillary thyroid microcarcinoma and active surveillance Sophie Leboulleux and colleagues1 provide an excellent review of papillary thyroid microcarcinoma, concluding that “an active surveillance approach in which active treatment is delayed until the cancer shows signs of substantial progression should be considered in selected patients.” The wording, “should be considered”, is substantially different from the 2015 American Thyroid Association guideline’s framing, which states in recommendation 12 that an active surveillance management approach “can be considered as an alternative to immediate surgery” in papillary thyroid microcarcinoma.2 Either this apparent change from reasonably possible to imperative action is simply an innocent conflation of auxiliary verbs by Leboulleux and colleagues,1 or the authors have decided to depart from the guideline. 974
Clarification from the authors would be useful, particularly because the Review mentioned not a single institution or a specialist in Europe or the USA (where the authors are based) who have implemented active surveillance for papillary thyroid microcarcinoma in practice. We are told that only two centres, both in Japan, are currently employing active surveillance in management of papillary thyroid microcarcinoma. The Review gives the impression that the authors feel very positively about using active surveillance, but they do not clearly state if they have indeed introduced the appraoch into their clinical practices. It was also unclear how to interpret the term “substantial progression”. It would help readers if the authors could clearly state their position on active surveillance, as well as clarify two practical points, by answering three important questions. First, do the authors currently employ active surveillance in their personal practice for the “selected patients” with papillary thyroid microcarcinoma?, Second, if they do employ active surveillance, do they obtain informed written or just a verbal consent from these patients? Third, what do the authors specifically consider as “signs of substantial progression” of papillary thyroid microcarcinoma? It is time for the authors to shift from academic ambiguity to practicable clarity. I declare no competing interests.
Mark Tulchinsky [email protected] Department of Radiology, Penn State Milton S Hershey Medical Center, Hershey, PA 17033, USA 1
2
Leboulleux S, Tuttle RM, Pacini F, Schlumberger M. Papillary thyroid microcarcinoma: time to shift from surgery to active surveillance? Lancet Diabetes Endocrinol 2016; 4: 933–42. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid 2016; 26: 1–133.
We read with great interest the Review by Sophie Leboulleux and colleagues,1 in which the authors suggest that active surveillance with curative intent should be considered in properly selected patients with papillary thyroid microcarcinoma. However, several questions remain. The main evidence in support of active surveillance comes from a study by Ito and colleagues,2 who reported that 22·1% (162/732) of patients chose observation. Among these patients, 56 eventually underwent surgery due to tumour enlargement and other unfavourable events. This means that only 14·9% of patients ultimately underwent continued observation. Such a low proportion of patients cannot represent the overall treatment trend. Furthermore, excluding the factor of selection bias, the 626 patients in the surgical treatment group had pathologically multifocal tumours (42·8%) and lymph node metastasis (50·5%) at high incidences.2 In studies by Xiang and colleagues3 and Zhang and colleagues, 4 the investigators reported that 40·6% and 38% patients with clinical lateral cervical lymph node-negative (cN0) papillary thyroid microcarcinoma had central lymph node metastases by the final pathological examination, respectively. Therefore, active surveillance might not be appropriate for patients who are at low risk preoperatively. In Miyauchi and colleagues’ study,5 the investigators reported that the incidence of unfavourable events, including temporary vocal cord paralysis and hypoparathyroidism, was higher in the immediate surgery group than in the observation group. However, whether the incidence of unfavourable events was higher in patients who underwent surgery after a period of follow-up than in those who underwent immediate surgery remains unknown. We cannot exclude the possibility that the complication rate of patients showing signs of progression was higher than that of those immediately undergoing surgery.
www.thelancet.com/diabetes-endocrinology Vol 4 December 2016
MJB and WMD have received grants from the UK National Institute for Health Research and Barts and the London Charity to measure outcomes of adrenalectomy in patients who have undergone adrenal vein sampling and 11C-metomidate PET CT and from the British Heart Foundation to assess endoscopic radiofrequency ablation of adrenal adenomas. MJB and Queen Mary University of London hold a fast-track award from GlaxoSmithKline to identify new compounds for the treatment of primary aldosteronism. MJB is a UK National Institute for Health Research senior investigator. Research cited in this Comment was funded by project and special project research grants to MJB from the British Heart Foundation and the Wellcome Trust.
*Morris J Brown, William M Drake [email protected] Barts Heart Centre, William Harvey Research Institute, Barts and the London Medical School, Queen Mary University London, WCIM 6BQ, UK (MJB, WMD) 1
2
Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 1889–916. Brown MJ, Drake WM. Splitting atoms: the Endocrine Society guideline for the management of primary aldosteronism. Lancet Diabetes Endocrinol 2016; 4: 805–07.
Papillary thyroid microcarcinoma and active surveillance Sophie Leboulleux and colleagues1 provide an excellent review of papillary thyroid microcarcinoma, concluding that “an active surveillance approach in which active treatment is delayed until the cancer shows signs of substantial progression should be considered in selected patients.” The wording, “should be considered”, is substantially different from the 2015 American Thyroid Association guideline’s framing, which states in recommendation 12 that an active surveillance management approach “can be considered as an alternative to immediate surgery” in papillary thyroid microcarcinoma.2 Either this apparent change from reasonably possible to imperative action is simply an innocent conflation of auxiliary verbs by Leboulleux and colleagues,1 or the authors have decided to depart from the guideline. 974
Clarification from the authors would be useful, particularly because the Review mentioned not a single institution or a specialist in Europe or the USA (where the authors are based) who have implemented active surveillance for papillary thyroid microcarcinoma in practice. We are told that only two centres, both in Japan, are currently employing active surveillance in management of papillary thyroid microcarcinoma. The Review gives the impression that the authors feel very positively about using active surveillance, but they do not clearly state if they have indeed introduced the appraoch into their clinical practices. It was also unclear how to interpret the term “substantial progression”. It would help readers if the authors could clearly state their position on active surveillance, as well as clarify two practical points, by answering three important questions. First, do the authors currently employ active surveillance in their personal practice for the “selected patients” with papillary thyroid microcarcinoma?, Second, if they do employ active surveillance, do they obtain informed written or just a verbal consent from these patients? Third, what do the authors specifically consider as “signs of substantial progression” of papillary thyroid microcarcinoma? It is time for the authors to shift from academic ambiguity to practicable clarity. I declare no competing interests.
Mark Tulchinsky [email protected] Department of Radiology, Penn State Milton S Hershey Medical Center, Hershey, PA 17033, USA 1
2
Leboulleux S, Tuttle RM, Pacini F, Schlumberger M. Papillary thyroid microcarcinoma: time to shift from surgery to active surveillance? Lancet Diabetes Endocrinol 2016; 4: 933–42. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid 2016; 26: 1–133.
We read with great interest the Review by Sophie Leboulleux and colleagues,1 in which the authors suggest that active surveillance with curative intent should be considered in properly selected patients with papillary thyroid microcarcinoma. However, several questions remain. The main evidence in support of active surveillance comes from a study by Ito and colleagues,2 who reported that 22·1% (162/732) of patients chose observation. Among these patients, 56 eventually underwent surgery due to tumour enlargement and other unfavourable events. This means that only 14·9% of patients ultimately underwent continued observation. Such a low proportion of patients cannot represent the overall treatment trend. Furthermore, excluding the factor of selection bias, the 626 patients in the surgical treatment group had pathologically multifocal tumours (42·8%) and lymph node metastasis (50·5%) at high incidences.2 In studies by Xiang and colleagues3 and Zhang and colleagues, 4 the investigators reported that 40·6% and 38% patients with clinical lateral cervical lymph node-negative (cN0) papillary thyroid microcarcinoma had central lymph node metastases by the final pathological examination, respectively. Therefore, active surveillance might not be appropriate for patients who are at low risk preoperatively. In Miyauchi and colleagues’ study,5 the investigators reported that the incidence of unfavourable events, including temporary vocal cord paralysis and hypoparathyroidism, was higher in the immediate surgery group than in the observation group. However, whether the incidence of unfavourable events was higher in patients who underwent surgery after a period of follow-up than in those who underwent immediate surgery remains unknown. We cannot exclude the possibility that the complication rate of patients showing signs of progression was higher than that of those immediately undergoing surgery.
www.thelancet.com/diabetes-endocrinology Vol 4 December 2016