Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

Abstract

Increasingly sensitive diagnostic methods, better understanding of molecular pathophysiology, and well-conducted prospective studies have changed the current approach to patients with thyroid cancer, requiring the implementation of individualized management. Most patients with papillary thyroid carcinoma (PTC) are currently considered to have a low risk of mortality and disease persistence/recurrence. Consequently, current treatment recommendations for these patients include less invasive or intensive therapies. We used the most recent evidence to prepare a position statement providing guidance for decisions regarding the management of patients with low-risk PTC (LRPTC). This document summarizes the criteria defining LRPTC (including considerations regarding changes in the TNM staging system), indications and contraindications for active surveillance, and recommendations for follow-up and surgery. Active surveillance may be an appropriate initial choice in selected patients, and the criteria to recommend this approach are detailed. A section is dedicated to the current evidence regarding lobectomy versus total thyroidectomy and the potential pitfalls of each approach, considering the challenges during long-term follow-up. Indications for radioiodine (RAI) therapy are also addressed, along with the benefits and risks associated with this treatment, patient preparation, and dosage. Finally, this statement presents the best follow-up strategies for LRPTC after lobectomy and total thyroidectomy with or without RAI.

Active Surveillance for Low-Risk Thyroid Cancers: A Review of Current Practice Guidelines

“…In the observational study conducted at Japan’s Kuma Hospital, PTMCs located adjacent to the trachea or on the dorsal surface of the thyroid were excluded from AS due to their high risk of tracheal or RLN invasion [ 15 ]. Following these criteria, some guidelines recommend against selecting such cases for AS, even in the absence of clear evidence of invasion into the trachea or RLN, if the tumor is in close proximity [ 47 , 53 , 60 ]. However, JAES consensus statements (2021) suggests that tumors smaller than 0.7 cm, those merely touching the trachea, or those located away from the RLN’s course may be eligible for AS [ 50 ].…”

“…However, prospective studies that included patients with multiple lesions have reported that the multiplicity is not a risk factor for disease progression [ 11 , 15 ]. Therefore, JAES (2021) and the Brazilian Society of Endocrinology and Metabolism (SBEM) (2022) guidelines state that patients with multiple PTMC can be candidates for AS [ 50 , 53 ].…”

“…Miyauchi et al [ 18 ] reported that the 10-year disease progression rates during AS were 36% for patients in their 20s, 13%–14% for those in their 30s–40s, and 5%–6% for those in their 50s–60s. Therefore, most guidelines recommend AS for older patients and generally advise against it for patients under the age of 18 to 20 [ 50 , 53 , 60 ]. While most guidelines do not provide specific age recommendations, the French Society of Endocrinology, French Association of Endocrine Surgery, and French Society of Nuclear Medicine (SFE/AFCE/SFMN) guidelines (2022) suggest that patients aged 45 and older are more suitable for AS [ 51 ].…”

“…While most guidelines do not provide specific age recommendations, the French Society of Endocrinology, French Association of Endocrine Surgery, and French Society of Nuclear Medicine (SFE/AFCE/SFMN) guidelines (2022) suggest that patients aged 45 and older are more suitable for AS [ 51 ]. The SBEM (2022) and Korean Thyroid Association (KTA) (2023) guidelines state that AS is ideal for patients aged 60 and above and can be considered appropriate for those between 18 and 59 [ 53 , 55 ].…”

Cervical lymph node metastases in patients with differentiated thyroid cancer: A new (and more relevant) indication of active surveillance?

“…The efficacy and safety of this treatment strategy for low-risk PTC is already demonstrated in several countries, with the most extended experience from Japan (30 years) with more than 3,000 patients followed ( 9 ). This mounting evidence led to guidelines and societies (including the Brazilian Society of Endocrinology and Metabolism) recommending AS as the initial approach in selected patients with microPTC ( 10 ). Moreover, a systematic review of the cost-effectiveness of AS compared to immediate surgery found that most studies favored AS ( 11 ).…”