A 2022 UCSF study found that, since publication of the 2015 American Thyroid Association (ATA) guidelines, surgeons nationwide are performing more thyroid lobectomies for low-risk differentiated thyroid cancer (DTC) proportional to other thyroid surgeries for the condition. The guidelines recommend either total thyroidectomy or lobectomy for surgical treatment of low-risk DTC, with the decision on management course nuanced, such that the strategy selected is based on patient preferences, values and other considerations.
“Up to half of Americans have a thyroid nodule, and the overwhelming majority of them are benign,” said study co-author Julie Ann Sosa, MD, MA, FACS, endocrine surgeon and chair of the UCSF Department of Surgery. She is president of the ATA and co-chair of the committee writing the next set of guidelines for the management of DTC. “Until recently – in the past six to 10 years – most patients with thyroid cancer were advised to undergo a total thyroidectomy, usually with radioactive iodine as an adjunct. The new guidelines de-escalated overtreatment for low-risk tumors.”
Sosa also co-wrote a recent review article focused on balancing treatment risks with the likelihood of disease progression for patients with low-risk DTC. “If there is evidential equipoise, listen to the patient and have a nuanced conversation about personal preferences,” she said. “Then drive treatment decision-making so that the patient is at the epicenter.”
At UCSF, patients are seen in a multidisciplinary clinic and have access to six high-volume endocrine surgeons. “We do imaging and testing – ultrasound, neck mapping, genetic testing – and preoperative staging,” Sosa said. “We conduct the due diligence so there’s greater likelihood that nuances will be communicated.”
Cases for which preoperative decision-making is more challenging are discussed at a multidisciplinary tumor board. Care teams can include endocrinologists, surgeons, oncologists, radiologists, pathologists and other specialists as needed to provide each patient with the most comprehensive care possible.
The following cases illustrate patient-centered approaches to treating low-risk DTC.
Family history of PTC informs treatment decision-making
A 40-year-old woman had a 2-cm right thyroid nodule shown by biopsy to be papillary thyroid cancer (PTC) and two 7-mm left thyroid nodules. Following a recommendation for right thyroid lobectomy, she was referred to the UCSF Endocrine Surgery and Oncology Clinic for a second opinion.
A detailed medical history taken by the UCSF team revealed that the patient’s mother and sister had PTC at ages 45 and 35 years, respectively, and her 42-year-old brother had a multinodular goiter. Ultrasound showed two left thyroid nodules measuring 6 and 7 mm, both category 4 on the Thyroid Imaging Reporting and Data System (TI-RADS). A 6-mm TI-RADS 5 right thyroid nodule was also detected. No suspicious lymphadenopathy was observed in her neck.
The patient expressed concern about the risk of recurrence, and her care team explained the implications of her family history and the chance of multifocal PTC in an inherited setting. Together, they decided that a total thyroidectomy was the most appropriate treatment. She felt reassured that a high-volume endocrine surgeon would perform the procedure, as this is associated with a low risk of complications.
After the procedure, pathology showed bilateral multifocal PTC with two positive central lymph nodes. Each lymph node deposit was less than 2 mm, and the largest tumor was 2 cm, with vascular invasion present. The patient began planning for radioactive iodine therapy.
This case illustrates the importance of discussing family medical history and listening to the patient’s concerns. “Inherited forms of the disease are more aggressive and more often multifocal,” Sosa said.
Neck mapping unmasks advanced disease
A 40-year-old woman with a 2-cm right thyroid nodule and two 7-mm left thyroid nodules came to UCSF after another provider recommended a right thyroid lobectomy based on ultrasound. She had no family history of thyroid cancer.
The UCSF radiology team performed a neck mapping ultrasound to evaluate her lymph nodes, which unmasked a 1.5-cm TI-RADS 4 right lymph node with microcalcifications. A biopsy was positive for metastatic PTC. After discussing these findings with the patient, the surgical team performed a total thyroidectomy, central neck dissection, and right modified radical neck dissection to remove lymph nodes in the region of the metastatic node.
This case highlights the importance of preoperative lateral compartment lymph node imaging.
Molecular testing helps professional singer avoid surgery
A 40-year-old man had an incidentally found, asymptomatic 2-cm TI-RADS 4 right thyroid nodule. A fine-needle aspiration cytology was performed, and the nodule was classified as Bethesda category III, cytologically indeterminate. The patient came to UCSF after another provider recommended a thyroid lobectomy. As a professional opera singer, he wanted to avoid surgery out of concern for complications that may affect his voice. “It’s important to have conversations with patients about what matters most to them,” Sosa said.
The UCSF team repeated the biopsy and confirmed the Bethesda III categorization. They then performed molecular testing and found that the nodule’s mutational profile had a less than 3% risk for malignancy. The patient and his care team agreed on active surveillance rather than lobectomy. He returned to the clinic a year later for a neck exam and neck ultrasound, which revealed a stable nodule.
This case demonstrates the value of molecular testing as a risk stratification tool that can inform treatment decision-making for cytologically indeterminate thyroid nodules.
No disease progression in PTC patient on active surveillance
After experiencing symptoms consistent with a transient ischemic attack while on antiplatelet therapy, a 65-year-old man underwent a carotid ultrasound that revealed a 1-cm TI-RADS 5 right thyroid nodule. A dedicated thyroid ultrasound confirmed this finding and showed no obvious extrathyroidal extension, abutment of other structures, contralateral thyroid nodules or suspicious lymph nodes. A biopsy of the nodule resulted in a Bethesda VI classification, diagnostic of PTC.
The patient came to UCSF for surgical consultation. His medical history included COPD, hypertension, type 2 diabetes mellitus, coronary artery disease and peripheral vascular disease. Patients with a papillary thyroid microcarcinoma have a disease-specific survival of 99% overall at 30 years and a less than 2 to 3% risk of recurrence. Because of the patient’s age and comorbidities, the UCSF team recommended active surveillance, and he concurred. He returned for routine ultrasound every six months for two years and then annually. No disease progression has been detected.
This case highlights a successful individualized management strategy based on the patient’s age, comorbidities, risk stratification and preference.
High-volume surgeons improve patient outcomes
A 2017 study led by Sosa found that a surgeon volume threshold of at least 25 total thyroidectomies per year was associated with the lowest risk of complications. UCSF’s six high-volume endocrine surgeons each perform more than 25 thyroid surgeries a year, resulting in greater likelihood that their patients will experience excellent outcomes.
UCSF’s Endocrine Surgery and Oncology Program delivers state-of-the-art surgical and endocrinologic care pertaining to the thyroid, parathyroid and adrenal glands, complemented by a strong clinical research enterprise geared toward discovering effective therapies for thyroid and other endocrine cancers.
Cancer research and treatment take place within the UCSF Helen Diller Family Comprehensive Cancer Center.
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UCSF Endocrine Surgery and Oncology Clinic
Phone: (415) 353-7687 | Fax: (415) 353-7781
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