RE: Papillary Microcarcinoma/Multifocal

[Guest guest]

Barbara --

I found the following research while looking for research related to my

wifes condiction that you might want to pick up at the med libarary. Most

discuss multifocality, although I agree there is no great research limited

to papillary microcarcinoma (or small carcinoma) and multifocality. There

is a diversity of opinion on treatment as you will see from reading the

research ..

Jeff

****

1: In Vivo 2000 Mar-Apr;14(2):367-76

Papillary microcarcinoma of the thyroid: a clinico-pathologic and prognostic

review.

Nasir A, Chaudhry AZ, Gillespie J, Kaiser HE.

Department of Pathology, Washington University, School of Medicine &

Health Sciences, Washington DC 20037, USA.

Papillary microcarcinoma (PMC) of the thyroid is the most common form of

thyroid

cancer, which usually remains clinically silent until its incidental

histologic

diagnosis in autopsy or surgical material. Autopsy incidence varies from

3%-36%.

PMC may, however, present with clinical symptoms, the commonest of which is

cervical lymphadenopathy with or without palpable thyroid nodules. Other

reported presentations include cystic neck mass, pulmonary mass (es),

metastases

in the skull or vertebral column. The upper limit of size to define PMC is

10 mm

in most studies but many studies include lesions up to 15 mm in diameter.

Histologic variants include encapsulated and partially encapsulated

papillary

carcinoma, circumscribed microcarcinoma and occult sclerosing carcinoma.

Younger

age and size less than 10 mm (< 15 mm in other studies) are considered to be

favorable prognostic factors. Size alone, however, cannot be regarded as a

determinant of prognosis. Older age, larger tumor size, distant metastases,

capsular invasion and multifocality indicate unfavorable prognosis. Loss of

heterozygosity (LOH) is an infrequent finding, since small deletions may be

missed by southern blot analysis. Activation of oncogenes ret and trk have

been

reported in papillary carcinoma. Some authors advocate conservative while

others

favor aggressive therapy including total thyroidectomy with or without

Iodine

131ablation. Additional investigative techniques are needed to identify the

subset of PMC cases with a potential for aggressive clinical course, thereby

targeting more aggressive therapy to an appropriate subset of tumors.

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1: Presse Med 1998 Oct 3;27(29):1467-9

[Papillary microcarcinoma of the thyroid. 179 cases reported since 1973].

[Article in French]

Tourniaire J, Bernard MH, Bizollon-Roblin MH, Bertholon-Gregoire M,

Berger-Dutrieux N.

Clinique Endocrinologique, Hopital de l'Antiquaille, Lyon.

OBJECTIVES: Defined as a tumor measuring < or = 1 cm, the prognosis and

treatment of occult papillary thyroid carcinoma has been the topic of some

controversy. The aim of this study was to report experience with a series of

179

cases observed since 1973. PATIENTS AND METHODS: Occult papillary thyroid

carcinoma was discovered in 179 patients aged 12 to 81 years (151 women and

28

men) at cervicotomy prescribed for Graves' disease (n = 9), toxic adenoma (n

=

16), isolated nodule (n = 71), multinodular goiter (n = 74) or cervical node

enlargement (n = 9). The surgical procedures were lobo-isthmectomy (n = 79),

subtotal thyroidectomy (n = 74), or total thyroidectomy (n = 26) with node

dissection in case of enlargement. Thyroxin was prescribed in all cases and

annual follow-up was programmed. Five patients were lost to follow-up.

RESULTS:

Two cervical recurrences were observed warranting reoperation. None of the

patients died from cancer-related causes. CONCLUSION: Minute papillary

carcinomas of the thyroid are frequently discovered, but prognosis is

generally

excellent. Systematic total thyroidectomy and node dissection are not

warranted.

Only those lesions with an extrathyroid extension, associated node

enlargement

or inaugural metastasis require wide resection. These results are in

agreement

with a critical analysis of data reported in the literature demonstrating

the

exceptional nature, and in half of the cases, cure of metastatic occult

papillary thyroid carcinoma.

PMID: 9798460 [PubMed - indexed for MEDLINE]

******************

1: Minerva Chir 1997 Jul-Aug;52(7-8):891-900

[Clinico-pathological study of microcarcinoma of the thyroid].

[Article in Italian]

Russo F, Barone Adesi TL, Arturi A, Stolfi VM, Spina C, Savio A, De Majo A,

Uccioli L, Gentileschi P.

Dipartimento di Chirurgia, Universita di Roma Tor Vergata.

We have analysed the results of surgical treatment for microcarcinoma of the

thyroid (MCT). In sixteen patient clinical and follow-up data were

retrospectively evaluated during a 35.1-month follow-up. Thyroid

hyperfunctional

state us was present in two subjects. A single nodule was detected by

echotomography in 11 patients, while multinodular diffuse goitre was

revealed in

3 patients. In the last two subjects, thyroid gland appeared completely

normal

at ultrasonography, despite laterocervical lymph node metastases.

Fine-needle

aspiration biopsy was performed in 6 patients and its diagnostic accuracy

was

high (83,3%). MCT was classified as " incidental " in 12 patients and " occult "

in

the remaining 4 patients. Eight subjects underwent total thyroidectomy and 8

hemithyroidectomy plus isthmectomy. No postoperative complications were

recorded. In 10 patients MCT histotype was papillar adenocarcinoma, in 5 was

follicular adenocarcinoma and in the remaining case it was medullary

carcinoma.

Goitre was associated in 75% of the cases. Only in a patient disease

progressed

to death because of hematogenous metastases. In conclusion, we believe that

incidental MCT is a low-grade malignancy with a benign biological behaviour.

Occult MCT is a potentially lethal disease. We did not observe differences

in

the long-term results between different surgical treatments of MCT.

PMID: 9411290 [PubMed - indexed for MEDLINE]

***********

1: Surgery 1992 Dec;112(6):1139-46; discussion 1146-7

Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year

period.

Hay ID, Grant CS, van Heerden JA, Goellner JR, Ebersold JR, Bergstralh EJ.

Department of Surgery, Mayo Clinic, Rochester, MN 55905.

BACKGROUND. The study aims were to characterize patients with papillary

thyroid

microcarcinoma and to provide data on outcome after surgical therapy.

METHODS.

Five hundred thirty-five patients with papillary microcarcinoma had initial

treatment at Mayo Clinic from 1940 to 1989. Follow-up extended to 48 years.

Median follow-up time for 400 survivors was 16 years. Recurrence and

mortality

details were derived from a computerized cancer database. RESULTS. Median

tumor

size was 8 mm. Ninety-nine percent of tumors were histologic grade 1; 98%

were

not locally invasive. Thirty-two percent of patients had nodal metastases at

examination. TNM stages were I in 485 patients (91%), III in 49 patients

(9%),

and IV in one patient (0.2%). Ninety-one percent of patients underwent

bilateral

lobar resection. Tumor resection was incomplete in three cases (0.6%).

Radioiodine remnant ablation was performed in 55 patients (10%). All-causes

survival did not differ from expected; two patients (0.4%) died of papillary

microcarcinoma. Twenty-year tumor recurrence rate was 6%. Higher recurrence

rates were seen either with node-positive patients (p < 0.0001) or after

unilateral lobectomy (p < 0.0001). Recurrence rates did not appear to be

significantly altered by total thyroidectomy (p = 0.44) or radioiodine

remnant

ablation in node-positive patients (p = 0.99). CONCLUSIONS. These results

reaffirm that papillary microcarcinoma has an excellent prognosis if managed

initially by bilateral lobar resection. Routine radioiodine remnant ablation

is

not indicated.

PMID: 1455316 [PubMed - indexed for MEDLINE]

******************

1: J Endocrinol Invest 1998 Jul-Aug;21(7):445-8

Papillary microcarcinoma of the thyroid.

Sugino K, Ito K Jr, Ozaki O, Mimura T, Iwasaki H, Ito K.

Ito Hospital, Tokyo, Japan.

Papillary microcarcinoma of the thyroid has been often detected by

aspiration

biopsy cytology performed with ultrasonographic guidance. Autopsy studies

also

have often revealed small thyroid carcinomas, and it was concluded that most

small thyroid carcinomas should not be regarded as a clinical matter. In

this

study, 112 patients with papillary microcarcinoma 10 mm or less in size

treated

between 1992 and 1995 were analyzed. There were 104 females and 8 males,

with a

mean age of 46.0 years. Diagnosis of papillary carcinoma was made

preoperatively

in 100 of these patients (89.3%), and 77 patients underwent aspiration

biopsy

cytology under ultrasound guidance. Seventy of these patients underwent

modified

neck dissection, and 63.8% of these patients had lymph node metastases. The

number of lymph node metastasis increased as primary tumor size increased.

There

was no clear border or clinical differences between primary tumors 10 mm or

less

and tumors more than 10 mm. One patient had lymph node recurrence after

surgery

and another patient had recurrent nerve palsy at the first visit. Based on

these

findings, papillary microcarcinoma should be treated surgically.

Publication Types:

Clinical trial

PMID: 9766259 [PubMed - indexed for MEDLINE]

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1: Cancer 1998 Aug 1;83(3):553-9

Comment in:

Cancer. 1998 Aug 1;83(3):401-2; discussion 403-1

Microcarcinoma of the thyroid gland: the Gustave-Roussy Institute

experience.

Baudin E, Travagli JP, Ropers J, Mancusi F, Bruno-Bossio G, Caillou B,

Cailleux

AF, Lumbroso JD, Parmentier C, Schlumberger M.

Service de Medecine Nucleaire, Institut Gustave-Roussy, Villejuif, France.

BACKGROUND: Patients with thyroid microcarcinoma (TMC) have favorable long

term

prognoses. However, recurrences in the neck and distant metastases have been

reported. The authors investigated independent factors associated with

recurrence in an effort to define therapeutic guidelines. METHODS: Two

hundred

eighty-one patients (207 females, 74 males; mean age, 41.9 years) with a

differentiated thyroid carcinoma < or = 1 cm in greatest dimension (mean

size

+/- standard deviation, 5.9+/-3.3 mm) were analyzed. The median follow-up

time

was 7.3 years. RESULTS: TMC diagnosis was incidental in 189 patients, and

metastases were the first manifestation of the disease in the other 92

patients.

Therapy included near-total thyroidectomy for 195 patients, lymph node

dissection for 195, and therapeutic administration of radioiodine for 124.

Eleven recurrences (3.9%) were observed 4.3+/-2.7 years (mean +/- standard

deviation) after initial treatment: all had locoregional recurrence (4 in

the

thyroid bed and 7 in the lymph nodes), and in one of these the local

recurrence

was associated with lung metastases. Multivariate analysis showed that two

parameters significantly influenced TMC recurrence, namely, the number of

histologic foci (P < 0.002) and the extent of initial thyroid surgery (P <

0.01). Only 3.3% of patients with unifocal TMC treated with

loboisthmusectomy

had tumor recurrence. CONCLUSIONS: The recurrence rate for TMC appears to be

low

(3.9%). In the authors' view, loboisthmusectomy is the treatment of choice

for

patients with TMC when only one focus of cancer is found histologically, and

total thyroidectomy is the optimal treatment for patients with multiple

foci.

PMID: 9690549 [PubMed - indexed for MEDLINE]

*********************

1: Ann Endocrinol (Paris) 1997;58(3):211-5

[Treatment of differentiated thyroid cancers of nodular type].

[Article in French]

Tourniaire J, Bernard MH, Bertholon-Gregoire M, Adeleine P, Berger-Dutrieux

N.

Clinique Endocrinologique de l'Universite Claude Bernard, Hopital de

l'Antiquaille, Lyon.

Papillary and follicular carcinomas are the most frequent thyroid cancers.

The

choice of the treatment is dependent on the prognostic scoring systems. A

good

prognosis is linked to the small size of the nodule (especially)

microcarcinoma)

the age of the patient (less than 40), the lack of extra-thyroid (for

papillary

cancer) or extra capsular (for follicular carcinoma) extension. Total

thyroidectomy decreases the number of recurrences but does not modify the

mortality. The risk of laryngeal nerve palsy and hypoparathyroidism is not

negligible. Lobo-isthmectomy thus can be used in the low risk tumors.

Radioactive iodine administration is rational after total thyroidectomy but

its

efficacy is questioned. Thyroxine treatment is always prescribed. Taking

into

account the risk of osteopenia and cardiovascular disturbances induced by

iatrogenic thyrotoxicosis, the desirable serum TSH level is debated.

Publication Types:

Review

Review, tutorial

PMID: 9239243 [PubMed - indexed for MEDLINE]

******************

: Endocr Pract 2001 Mar-Apr;7(2):139-42

Histologic variants of papillary thyroid carcinoma.

Mazzaferri EL.

Emeritus Professor and Chairman of Internal Medicine, The Ohio State

University,

Current address: 4020 Southwest 93rd Drive, Gainesville FL, 32608-4653.

PMID: 11421559 [PubMed - in process]

************************

1: J Clin Endocrinol Metab 2001 Apr;86(4):1447-63

Clinical review 128: Current approaches to primary therapy for papillary and

follicular thyroid cancer.

Mazzaferri EL, Kloos RT.

The Center for Health Outcome Policy and Evaluation Studies, The Ohio State

University, Columbus, Ohio 43210-1228, USA. mazz01@...

Publication Types:

Review

Review, tutorial

PMID: 11297567 [PubMed - indexed for MEDLINE]

**********************

1: Endocr Pract 2000 Nov-Dec;6(6):469-76

Long-term outcome of patients with differentiated thyroid carcinoma: effect

of

therapy.

Mazzaferri EL.

Department of Internal Medicine, The Ohio State University, Columbus, Ohio,

USA.

OBJECTIVE: To present an overview of current therapeutic practices and

results

in patients with differentiated thyroid carcinoma. METHODS: Personal series

of

patients and selected studies reported in the literature are reviewed

relative

to outcome (tumor recurrence and cancer-related mortality) after treatment

of

differentiated thyroid cancer. RESULTS: In the United States, thyroid

carcinoma

ranks 14th in incidence among the major malignant tumors. Although many

factors

influence the long-term outcome with papillary and follicular thyroid

carcinoma,

the patient's age at the time of diagnosis, tumor stage, and initial

treatment

are the most important. The risk of death from thyroid cancer becomes

substantially greater after age 40 years and increases dramatically after 60

years of age. Tumor recurrence is more prevalent before age 20 and after age

60

years. Delay in therapy for more than a year after initial manifestation

also

has been shown to have an adverse effect on outcome. The optimal initial

treatment is usually near-total thyroidectomy and surgical excision of

extrathyroidal tumor, when possible. For complete ablation of residual

thyroid

tissue, radioactive iodine therapy is usually necessary and should be

followed

by thyroid hormone suppression of serum thyrotropin concentrations. A

schedule

of 6-month follow-up intervals is recommended, until the serum thyroglobulin

is

undetectable and 131I whole-body scanning shows no uptake in the neck or

extrathyroidal sites. CONCLUSION: An aggressive approach to management of

differentiated thyroid carcinoma is likely to render about 90% of patients

permanently free of disease.

Publication Types:

Review

Review, tutorial

PMID: 11155222 [PubMed - indexed for MEDLINE]