Predictors of recurrence after total thyroidectomy in 1,611 patients with papillary thyroid carcinoma: postoperative stimulated serum thyroglobulin and ATA initial and dynamic risk assessment.

Objective: Despite a favorable prognosis, some patients with papillary thyroid carcinoma (PTC) develop recurrence. The objective of this study was to examine the impact of the combination of initial American Thyroid Association (ATA) risk stratification with serum level of postoperative stimulated thyroglobulin (s-Tg) in predicting recurrence in patients with PTC and compare the results with an assessment of response to initial therapy (dynamic risk stratification). Subjects and methods: We retrospectively analyzed 1,611 patients who had undergone total thyroidectomy for PTC, followed in most cases (87.3%) by radioactive iodine (RAI) administration. Clinicopathological features and s-Tg levels obtained 3 months postoperatively were evaluated. The patients were stratified according to ATA risk categories. Nonstimulated thyroglobulin levels and imaging studies obtained during the first year of follow-up were used to restage the patients based on response to initial therapy. Results: After a mean follow-up of 61.5 months (range 12-246 months), tumor recurrence was diagnosed in 99 (6.1%) patients. According to ATA risk, recurrence was identified in 2.3% of the low-risk, 9% of the intermediate-risk, and 25% of the high-risk patients (p < 0.001). Using a receiver operating characteristic curve approach, a postoperative s-Tg level of 10 ng/mL emerged as the ideal cutoff value, with positive and negative predictive values of 24% and 97.8%, respectively (p < 0.001). Patients with low to intermediate ATA risk with postoperative s-Tg levels < 10 ng/mL and excellent response to treatment had a very low recurrence rate (<0.8%). In contrast, higher recurrence rates were observed in intermediate-riskto high-risk patients with postoperative s-Tg > 10 ng/mL and indeterminate response (25%) and in those with incomplete response regardless of ATA category or postoperative s-Tg value (38.5-87.5%). Using proportion of variance explained (PVE), the predicted recurrence using the ATA initial risk assessment alone was 12.7% and increased to 29.9% when postoperative s-Tg was added to the logistic regression model and 49.1% with dynamic risk stratification. Conclusion: The combination of ATA staging system and postoperative s-Tg can better predict the risk of PTC recurrence. Initial risk estimates can be refined based ondynamic risk assessment following response to therapy, thus providing a useful guide for follow-up recommendations.

Predictive factors for recurrence of papillary thyroid carcinoma: analysis of 4,085 patients.

OBJECTIVE: The incidence of papillary thyroid carcinoma (PTC) has increased in recent years and its treatment remains controversial. The objective of this study is to identify clinicopathological predictive factors of tumour recurrence. METHODS: We retrospectively analysed 4,085 patients who underwent thyroidectomy for PTC from 1996 to 2015. Patients were stratified according to American Thyroid Association (ATA) risk categories and clinicopathological features were evaluated to identify independent factors for recurrence. RESULTS: After a mean follow-up of 58.7 (range 3-256.5) months, tumour recurrence was diagnosed in 176 (4.3%) patients, mostly in lymph nodes. Distant metastasis occurred in 18 patients (0.4%). There were 3 (0.1%) cancer-related deaths. Multivariate analysis showed that tumour size >10 mm, multifocality, extrathyroidal extension and lymph node metastasis (all, P < 0.001) were independent risk factors for recurrence. Further, recurrence was identified in 1.6% of the ATA low-risk, 7.4% of the intermediate-risk and 22.7% of the high-risk patients (P < 0.001). CONCLUSIONS: In PTC patients, tumour size >10 mm, multifocality, extrathyroidal extension and presence of lymph node metastasis as well as the ATA recurrence staging system effectively predict recurrence.

Long-term Results of Observation vs Prophylactic Selective Level VI Neck Dissection for Papillary Thyroid Carcinoma at a Cancer Center.

IMPORTANCE: The indication for prophylactic central neck dissection in papillary thyroid cancer (PTC) is controversial. OBJECTIVE: To compare long-term results of observation vs prophylactic selective level VI neck dissection for PTC. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of 812 patients with PTC who were treated from January 1, 1996, through January 1, 2007, at the Department of Head and Neck Surgery and Otorhinolaryngology of A. C. Camargo Cancer Center. A group of 580 consecutive patients with previously untreated PTCs and without lymph node metastasis were eligible for the study. We collected and analyzed retrospective data from February 1, 2012, through August 31, 2013. INTERVENTIONS: One hundred two patients (group A) underwent total thyroidectomy with elective central neck dissection; 478 patients (group B) underwent total thyroidectomy alone. MAIN OUTCOMES AND MEASURES: Absence of difference in rates of locoregional control and rates of major complications in group A. RESULTS: In group A, the rate of occult metastatic disease was 67.2%. Patients in group A exhibited higher rates of temporary hypocalcemia (46.1% vs 32.2%; P = .004) and permanent hypoparathyroidism (11.8% vs 2.3%; P < .001). We also found a significantly higher incidence of temporary (11.8% vs 6.1%; P = .04) and permanent (5.9% vs 1.5%; P = .02) recurrent laryngeal nerve dysfunction in group A. The overall recurrence rate at level VI was 1.9%. CONCLUSIONS AND RELEVANCE: Although the risk for occult lymph node metastasis reached 67.2% in a selected group of patients, elective central neck dissection for patients with PTC increased the risk for complications and did not contribute to a decrease in local recurrence rates.

Mudanças no perfil de atendimento do departamento de cirurgia de cabeça e pescoço em um hospital de referência para câncer / Changes in the attending profile of the department of head and neck surgery in a reference hospital to cancer

Introdução: Serviços especializados em Cirurgia de Cabeça ePescoço até o fim do século passado era praticamente exclusividadede hospitais terciários localizados em grandes centros. Nos anosmais recentes eles vêm se difundindo não só nos grandes centros,mas também em cidades menores, acompanhando o fenômenoda interiorização da medicina especializada. Em hospitais dereferência para câncer, o perfil de atendimento tem se modificadodrasticamente nos últimos anos. Objetivo: Analisar de formadescritiva o perfil atual de atendimento de um departamento decirurgia de cabeça e pescoço e otorrinolaringologia de um hospitalde referência no tratamento do câncer e comparar os números atuaiscom os dos anos de 1990 e 2000. Material: Foram analisados 23910atendimentos ambulatoriais e 1285 cirurgias consecutivas realizadaspelos médicos do Departamento de Cirurgia de Cabeça e Pescoçoe Otorrinolaringologia de um hospital oncológico no período de 1 deJaneiro a 31 de Dezembro de 2010. Método: Revisão do prontuárioeletrônico de todos os pacientes atendidos através do sistema MV2000. Análise descritiva de dados hospitalares e de atendimentoambulatorial do departamento. Resultados: Em 2010, foramrealizados 23910 atendimentos ambulatoriais no departamento, comuma média mensal de 1993 atendimentos, sendo 1692 pacientesatendidos pela primeira vez na instituição. No mesmo período, 1285cirurgias foram realizadas, sendo 1115 (86,8%) delas por cirurgiõesde cabeça e pescoço, 91 (7%) por cirurgiões plásticos e 79 (6,2%)por otorrinolaringologistas. 138 cirurgias foram indicadas comotratamento de resgate. As doenças da tireoide foram responsáveispela indicação 38% das cirurgias. Em divisão por porte cirúrgico217 cirurgias foram consideradas de grande porte, 703 de médioporte e 365 de pequeno porte. Em relação às complicações, asmais frequentes foram: infecção de ferida operatória (57 casos)e o hipocalcemia (81 casos). No período houve nove óbitos pósoperatórios, dos quais 8 após cirurgias de grande porte. Conclusão:Esta análise do ano de 2010, mostra que em um mesmo hospitalde referência para câncer, vêm crescendo a parcela de pacientestireoideopatias tratadas, o que provavelmente reflete o aumento daincidência do câncer de tireoide detectado nas últimas décadas. Domesmo modo, observou-se um aumento no número de pacientessubmetidos a cirurgias de resgate.