Low-risk papillary thyroid cancer: times are changing

Abstract

The prevalence of papillary thyroid cancer (PTC), particularly of low-risk PTC (MACIS <6), is rising due to the increasingly use of neck imaging techniques, fine-needle aspiration and whole body PET scans. Observational cohort studies carried out in the last two decades suggest that low-risk PTC are being overtreated due to the current management paradigm being built on studies done in the 70s and 80s that still echo in some influential guidelines. With the progressive adoption of total thyroidectomy and central neck dissection as the mainstay of treatment for PTC, and suppressed basal thyroglobulin and neck ultrasound once a year as the essential tools for follow-up, the use of radioiodine ablation, body scans and stimulated thyroglobulin concentrations has become obsolete for the vast majority of patients with low-risk PTC. Future guidelines on the management of differentiated thyroid cancer should discuss separately three different diseases: low-risk PTC, high-risk PTC and follicular cancer.

Keywords::

• de-escalating
• management
• new paradigm
• papillary
• thyroid cancer

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Low-risk papillary thyroid cancer (PTC) (MACIS <6) now represents over 80% of all PTCs and is on the rise due to the increasing use of imaging techniques.

• Current management paradigm and guidelines for differentiated thyroid cancer treatment are based on Mazzaferri's initial studies that mixed papillary (low- and high-risk) with follicular cancer and included patients with inappropriate surgical treatment.

• Most of the current algorithms for PTC management propose an unnecessarily aggressive follow-up with routine radioiodine ablation, repeated body scans and TSH stimulation.

• Comprehensive surgery (total thyroidectomy plus central neck dissection) performed by dedicated teams, has shown to be more than enough for most patients with low-risk PTC.

• Medical treatment has limited role in the postoperative management of low-risk PTC.

• A radical change of paradigm for managing low-risk papillary cancer is urgently needed to avoid morbidity, overtreatment and increased follow-up costs.

• In future guidelines, PTC and follicular cancer should de discussed separately and they should not be sponsored by the pharmaceutical industry.