Not All Enlarging Papillary Microcarcinomas Under Active Surveillance Require Immediate Surgery

Papillary thyroid microcarcinoma (PMC) is defined as papillary thyroid carcinoma ≤10 mm. Active surveillance of PMC without high-risk features, such as clinical node metastasis, distant metastasis, and clinical evidence of significant extrathyroid extension, was initiated in two Japanese hospitals in the mid-1990s. This strategy was incorporated into guidelines in Japan in 2010 and in the United States in 2015. In studies conducted by the two hospitals, most PMCs grew very slowly or did not grow, and none of the patients during active surveillance showed distant metastasis or died of thyroid carcinoma. Furthermore, none of the patients who underwent surgery after progression signs were detected showed significant recurrence. Therefore, we conclude that active surveillance should be the first line in management of low-risk PMC, because it is safer and less costly than immediate surgery. Active surveillance helps in avoiding adverse events of surgery and is an economical strategy.

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17-Gene Genomic Prostate Score Test Results in the Canary Prostate Active Surveillance Study (PASS) Cohort

Journal of Clinical Oncology ◽

10.1200/jco.19.02267 ◽

2020 ◽

Vol 38 (14) ◽

pp. 1549-1557 ◽

Cited By ~ 7

Author(s):

Daniel W. Lin ◽

Yingye Zheng ◽

Jesse K. McKenney ◽

Marshall D. Brown ◽

Ruixiao Lu ◽

...

Keyword(s):

Active Surveillance ◽

Proportional Hazards ◽

Specific Antigen ◽

Score Test ◽

Cox Proportional Hazards ◽

Surveillance Study ◽

Gleason Grade ◽

Grade Group ◽

Cox Proportional Hazards Models ◽

Immediate Surgery

PURPOSE The 17-gene Onco type DX Genomic Prostate Score (GPS) test predicts adverse pathology (AP) in patients with low-risk prostate cancer treated with immediate surgery. We evaluated the GPS test as a predictor of outcomes in a multicenter active surveillance cohort. MATERIALS AND METHODS Diagnostic biopsy tissue was obtained from men enrolled at 8 sites in the Canary Prostate Active Surveillance Study. The primary endpoint was AP (Gleason Grade Group [GG] ≥ 3, ≥ pT3a) in men who underwent radical prostatectomy (RP) after initial surveillance. Multivariable regression models for interval-censored data were used to evaluate the association between AP and GPS. Inverse probability of censoring weighting was applied to adjust for informative censoring. Predictiveness curves were used to evaluate how models stratified risk of AP. Association between GPS and time to upgrade on surveillance biopsy was evaluated using Cox proportional hazards models. RESULTS GPS results were obtained for 432 men (median follow-up, 4.6 years); 101 underwent RP after a median 2.1 years of surveillance, and 52 had AP. A total of 167 men (39%) upgraded at a subsequent biopsy. GPS was significantly associated with AP when adjusted for diagnostic GG (hazards ratio [HR]/5 GPS units, 1.18; 95% CI, 1.04 to 1.44; P = .030), but not when also adjusted for prostate-specific antigen density (PSAD; HR, 1.85; 95% CI, 0.99 to 4.19; P = .066). Models containing PSAD and GG, or PSAD, GG, and GPS may stratify risk better than a model with GPS and GG. No association was observed between GPS and subsequent biopsy upgrade ( P = .48). CONCLUSION In our study, the independent association of GPS with AP after initial active surveillance was not statistically significant, and there was no association with upgrading in surveillance biopsy. Adding GPS to a model containing PSAD and diagnostic GG did not significantly improve stratification of risk for AP over the clinical variables alone.

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QUALITY OF LIFE IN PATIENTS WITH LOW-RISK PAPILLARY THYROID MICROCARCINOMA: ACTIVE SURVEILLANCE VERSUS IMMEDIATE SURGERY

Endocrine Practice ◽

10.4158/ep-2020-0201 ◽

2020 ◽

Vol 26 (12) ◽

pp. 1451-1457 ◽

Cited By ~ 1

Author(s):

Tomohiko Nakamura ◽

Akira Miyauchi ◽

Yasuhiro Ito ◽

Mitsuru Ito ◽

Takumi Kudo ◽

...

Keyword(s):

Quality Of Life ◽

Active Surveillance ◽

Depression Scale ◽

Low Risk ◽

Papillary Thyroid ◽

Thyroid Microcarcinoma ◽

Health Related ◽

Immediate Surgery ◽

Specific Health

Objective: This study aimed to compare the quality of life (QoL) and psychological issues of patients with papillary thyroid microcarcinoma (PMC) who were under active surveillance (AS) and those who underwent immediate surgery (OP). Methods: This was a cross-sectional study conducted on 347 patients with low-risk PMC who were under AS (n = 298) or who underwent OP (n = 49). They were asked to complete two questionnaires (thyroid cancer–specific health-related QoL [THYCA-QoL] and the Hospital Anxiety and Depression Scale [HADS]). The results between the AS and OP groups were compared. Results: The mean ages of patients in the AS and OP groups were 58.6 ± 12.5 and 58.4 ± 13.1 years ( P = .94), respectively, and the male ratios were 34/298 (11%) and 2/49 (4.1%) ( P = .14), respectively. The median follow-up periods from diagnosis in the AS and OP groups were 56.5 months (interquartile range [IQR], 32 to 88 months) and 84 months (IQR, 64 to 130 months) ( P<.001), respectively. In the THYCA-QoL questionnaire, the OP group had more complaints about “voice” ( P<.001), “psychological” ( P = .025), “problems with scar” ( P<.001), and “gained weight” ( P = .047) than the AS group. Other scales of the THYCA-QoL were comparable in the two groups. In the HADS questionnaire, the AS group had significantly better anxiety ( P = .020), depression ( P = .027), and total scores ( P = .014) than the OP group. Conclusion: PMC patients in the OP group had more complaints and were more anxious and depressed than the AS group. These findings suggest that AS is a reasonable alternative to surgery for patients with low-risk PMC from the point of view of QoL and psychology. Abbreviations: AS = active surveillance; CI = confidence interval; HADS = Hospital Anxiety and Depression Scale; LT4 = levothyroxine; OP = immediate surgery; PMC = papillary microcarcinoma; PTC = papillary thyroid carcinoma; QoL = quality of life; STAI = State-Trait Anxiety Inventory; THYCA-QoL = thyroid cancer–specific health-related quality of life; TSH = thyrotropin

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Active Surveillance of Papillary Thyroid Microcarcinoma: Where Do We Stand?

European Thyroid Journal ◽

10.1159/000503064 ◽

2019 ◽

Vol 8 (6) ◽

pp. 298-306 ◽

Cited By ~ 4

Author(s):

Min Ji Jeon ◽

Won Gu Kim ◽

Ki-Wook Chung ◽

Jung Hwan Baek ◽

Won Bae Kim ◽

...

Keyword(s):

Active Surveillance ◽

Surgical Intervention ◽

Three Dimensional ◽

Volume Measurement ◽

Papillary Thyroid Microcarcinoma ◽

Papillary Thyroid ◽

Major Drawback ◽

Thyroid Microcarcinoma ◽

Immediate Surgery

The recent sharp increase in thyroid cancer incidence is mainly due to increased detection of small papillary thyroid microcarcinoma (PTMC). Due to the indolent nature of the disease, active surveillance (AS) of low-risk PTMCs is suggested as an alternative to immediate surgery to reduce morbidity from surgery. For appropriately selected PTMC patients, AS can be a good management option and surgical intervention can be safely delayed until progression occurs. Many considerations must be taken into account at the time of initiation of AS, including radiological tumor characteristics and clinical characteristics of the patient. A specialized medical team should be assembled to monitor patients during AS with an appropriate follow-up protocol. The fact that some patients require surgery for disease progression after long-term follow-up is a major drawback of the current AS protocol. Evaluation of tumor kinetics by three-dimensional tumor volume measurement during the initial 2–3 years of AS may be helpful for discrimination of PTMCs that need early surgical intervention. In this review, we will discuss the clinical outcomes of surgical intervention and AS, considerations during AS, and unresolved questions about AS.

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Active Surveillance Versus Immediate Surgery: Questionnaire Survey on the Current Treatment Strategy for Adult Patients with Low-Risk Papillary Thyroid Microcarcinoma in Japan

Thyroid ◽

10.1089/thy.2019.0211 ◽

2019 ◽

Vol 29 (11) ◽

pp. 1563-1571 ◽

Cited By ~ 9

Author(s):

Iwao Sugitani ◽

Yasuhiro Ito ◽

Akira Miyauchi ◽

Tsuneo Imai ◽

Shinichi Suzuki

Keyword(s):

Active Surveillance ◽

Treatment Strategy ◽

Questionnaire Survey ◽

Current Treatment ◽

Low Risk ◽

Adult Patients ◽

Papillary Thyroid ◽

Thyroid Microcarcinoma ◽

Current Treatment Strategy ◽

Immediate Surgery

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Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery

Thyroid ◽

10.1089/thy.2015.0313 ◽

2016 ◽

Vol 26 (1) ◽

pp. 150-155 ◽

Cited By ~ 141

Author(s):

Hitomi Oda ◽

Akira Miyauchi ◽

Yasuhiro Ito ◽

Kana Yoshioka ◽

Ayako Nakayama ◽

...

Keyword(s):

Active Surveillance ◽

Low Risk ◽

Papillary Microcarcinoma ◽

Immediate Surgery

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Low-risk papillary thyroid carcinoma

Revista de Medicina ◽

10.11606/issn.1679-9836.v98i6p403-407 ◽

2019 ◽

Vol 98 (6) ◽

pp. 403-407

Author(s):

Caio Nassuo Furukawa ◽

Leonardo André Hage Fabri ◽

Flávio Carneiro Hojaij

Keyword(s):

Papillary Thyroid Carcinoma ◽

Thyroid Carcinoma ◽

Active Surveillance ◽

Hormone Replacement ◽

Good Alternative ◽

Low Risk ◽

Papillary Thyroid ◽

Risk Patients ◽

Immediate Surgery

Introduction: A epidemic increase in the incidence of papillary thyroid carcinoma (PTC) has been happening within the last 25 years. The majority of those tumors are low-risk, and some studies reported low progression rates of low-risk PTC. It suggests that immediate surgery may not be the best option, specially when considering the intrinsic risk to a thyroidectomy and inconvenience of lifelong hormone replacement. In this systematic review we compare the outcomes of active surveillance for the primary management of low-risk PTC. Methods: The review was conducted based on three studies selected from specific databases. These studies followed up low-risk patients nonoperatively and surgery was performed if needed. Results: All studies reported low percentages of tumor growth and metastatic disease during active surveillance. Furthermore, no significant differences between immediate surgery and late rescue surgery were reported, and active surveillance appears to be cheaper than the tradicional conduct. Conclusions: Active surveillance seems to be a good alternative for low-risk PTC management, yet, more long-term and bigger research is still needed, specially outside of a japanese population.

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Cost-Effectiveness Analysis of Active Surveillance for Small Asymptomatic Intracranial Aneurysms

Neurosurgery ◽

10.1093/neuros/nyz310_302 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

David M Panczykowski ◽

Clark Veet ◽

Natasha Parekh ◽

Spiros L Blackburn

Keyword(s):

Cost Effectiveness ◽

Active Surveillance ◽

Watchful Waiting ◽

Surgical Complication ◽

Cost Effective ◽

Sensitivity Analyses ◽

Rupture Rate ◽

Effectiveness Analysis ◽

Immediate Surgery ◽

The Cost

Abstract INTRODUCTION The current recommended management strategy for small, asymptomatic unruptured anterior circulation aneurysms (UIAs) is active surveillance utilizing serial magnetic resonance angiography (MRA). Our objective was to determine the cost-effectiveness of active surveillance via MRA, immediate surgery, and watchful waiting for small UIAs. METHODS We developed a Markov cost-effectiveness model simulating a cohort of patients with small (<7 mm) UIAs diagnosed at age 50-yr who were treated with active surveillance via MRA, immediate surgery, or watchful waiting. Model inputs (eg risk of aneurysm growth, rupture rate, treatment complications, etc) were abstracted from peer-reviewed literature. Outcomes were quality-adjusted life-years (QALY), lifetime medical costs (2015 US$), and incremental cost-effectiveness ratios (ICER). Cost-effectiveness analysis as well as deterministic and probabilistic sensitivity analyses were performed. Willingness to pay (WTP) threshold was $100,000/QALY. RESULTS At a WTP of $100,000/QALY, immediate surgical treatment was the most cost-effective management strategy for small UIAs; ICER of $43,880 relative to active surveillance. Sensitivity analyses demonstrated immediate surgery was the preferred strategy if rupture rate was >0.1%/yr and if diagnosis age was <70 yr. Active surveillance became the preferred strategy if surgical complication risk was >11% and if diagnosis age was >70-yr. MRA surveillance interval did not significantly impact cost-effectiveness (surveillance frequency range 6 mo-10 yr). Probabilistic sensitivity analysis demonstrated that at a WTP of $100,000/QALY immediate surgery was the most cost-effective strategy in 64% of iterations (compared to active surveillance in 34%, and watchful waiting in 1.4%). CONCLUSION Immediate surgical treatment is a reasonable and cost-effective strategy for initial management of small UIAs. The cost-effectiveness of immediate surgery is highly sensitive to age at diagnosis, rupture rate, and probability of surgical complication. As there are wide published ranges for rates of rupture and surgical complications, individual lesion characteristics and surgeon-specific complication metrics should be considered in counseling patients.

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