Thermal Ablation for Small Papillary Thyroid Cancer: A Potential Game Changer
2021; Radiological Society of North America; Volume: 300; Issue: 1 Linguagem: Inglês
10.1148/radiol.2021210424
ISSN1527-1315
Autores Tópico(s)Radiomics and Machine Learning in Medical Imaging
ResumoHomeRadiologyVol. 300, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialThermal Ablation for Small Papillary Thyroid Cancer: A Potential Game ChangerJung Hwan Baek , Se Jin ChoJung Hwan Baek , Se Jin ChoAuthor AffiliationsFrom the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, Republic of Korea (J.H.B.); and Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea (S.J.C.).Address correspondence to J.H.B. (e-mail: [email protected]).Jung Hwan Baek Se Jin ChoPublished Online:Apr 27 2021https://doi.org/10.1148/radiol.2021210424MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Cao et al in this issue.Dr Baek is professor of radiology at the Asan Medical Center and president of the Korean Society of Thyroid Radiology. He is dedicated to thyroid and head and neck imaging and intervention. He has established advanced diagnostic and interventional techniques, including core-needle biopsy and ethanol and radiofrequency ablation of thyroid and neck diseases. He has published more than 300 scientific articles and nine book chapters and has served on multiple national and international committees.Download as PowerPointOpen in Image Viewer Dr Cho is assistant professor in the radiology department at Seoul National University Bundang Hospital, Korea. He is dedicated to brain and head and neck imaging. He actively publishes on the topic of treatment options for papillary thyroid microcarcioma. He has published about 35 scientific papers.Download as PowerPointOpen in Image Viewer The increase in the incidental detection of small low-risk papillary thyroid carcinoma (PTC) has sparked active discussion about treatment options (1) and made it imperative to consider nonsurgical treatment, such as active surveillance (AS) and thermal ablations. This was reflected in the 2015 guidelines by the American Thyroid Association, which endorsed AS as an alternative to immediate surgery for low-risk PTC measuring up to 1 cm (papillary thyroid microcarcinoma, T1a) (2). In a recent meta-analysis, pooled 5-year follow-up data for AS showed an acceptable tumor progression rate (5.3% with size enlargement, 1.6% with lymph node metastasis) among patients undergoing AS (3). There are ongoing clinical trials to extend the size threshold for AS to 2 cm (T1b) (4).The main concern of AS lies with the anxiety experienced by both patients and physicians due to indwelling cancer. A recent meta-analysis showed that a substantial proportion (range, 8.7%–32%) of patients underwent delayed surgery during AS despite absence of tumor progression (size enlargement or lymph node metastasis) (3). In a large population study evaluating the outcome of AS, a substantial number of patients were lost to follow-up, which may overestimate the outcome of AS, and it may be speculated that patients’ anxiety contributed to follow-up loss. Moreover, a national survey conducted in the United States showed that less than 50% of physicians adopted AS, and those who are anxious or who have reservations about AS themselves were less likely to recommend AS to their patients (5). In addition, young age (less than 40 years) and male sex were associated with poor clinical outcomes, and individuals in these categories were considered part of a high-risk group with relatively rapid progression during AS (6). Therefore, immediate surgery rather than AS should be recommended for these patients.While dealing with anxiety and patients with high risk (ie, patients younger than 40 years) remain unsolved in AS, US-guided thermal ablations may be considered as another alternative to AS or immediate surgery in patients with small low-risk PTC. A recent systematic review of 503 papillary thyroid microcarcinomas in 470 patients who underwent thermal ablation showed no local tumor recurrence or distant metastasis, while two patients developed lymph node metastasis and one patient developed new cancer (7). There was no major complication or procedure-related death. Most notably, no patients underwent delayed surgery due to anxiety during the follow-up period after they underwent thermal ablations. This suggests that thermal ablations may be considered as an alternative treatment option while avoiding anxiety to patients and physicians. Furthermore, there was no disease progression in patients considered to have high risk for AS when they underwent thermal ablation.The evolution in the management of thyroid cancer mirrors that of prostate cancer due to similarities in biologic indolence between low-risk prostate cancer and low-risk small thyroid cancer, with a well-behaved subclinical reservoir, a long natural history, and superlative outcomes (8). Such parallels between low-risk prostate and small thyroid cancer have enabled AS to be incorporated into the respective guidelines, and treatment options have matured from medical and sociocultural resistance to the broad acceptance of AS. Ultimately, patients with thyroid cancer may require more reassurances to choose AS than their counterparts with prostate cancer, with more strict selection criteria and earlier triggers for intervention. Nonsurgical intervention, such as thermal ablation, also might play an important role.However, there are few short-term follow-up data available for patients who underwent thermal ablation, and a direct comparison of outcome between those who underwent AS and those who underwent thermal ablation is not feasible. There are several recently published long-term studies reinforcing the excellent short-term outcome of thermal ablations at 5-year follow-up with no local tumor recurrence, lymph node metastasis, or distant metastasis and confirming that no patients underwent delayed surgery due to anxiety (9).We appreciate the study by Cao et al in this issue of Radiology (10). Considering the clinical impact of thermal ablations for small low-risk PTC, the results of this large-population multicenter study are relevant, timely, and meaningful. The study enrolled 847 patients from 14 hospitals in China who underwent radiofrequency ablation (n = 202) or microwave ablation (n = 645) for solitary small PTC encompassing both T1a (n = 673) and T1b (n = 174) groups. The results of thermal ablations are promising, and the authors report a technical success rate of 100%, a tumor disappearance rate of 68%, a disease progression rate of 1%, and an overall complication rate of 3%. When the results of T1a and T1b groups were compared, disease progression rates were comparable (0.9% vs 1.7%, P = .54). However, considering the indolent nature of thyroid cancer, a relatively short follow-up period (mean follow-up period, 22 months) is a major limitation of this study. Therefore, long-term follow-up data in these patients will be invaluable in further substantiating the efficacy and safety of thermal ablations. In addition, despite comparable disease progression rates, the T1b group showed a higher complication rate than the T1a group (6.3% vs 2.7%, P = .02), and it would be worth introducing measures to ensure safety of thermal ablations in the future.For thermal ablations to be performed effectively and safely, we propose the following prerequisites: First, accurate radiologic evaluation of tumor and lymph nodes before and after conducting thermal ablations is essential. In particular, US evaluation of primary cancer and lymph node metastasis is a basic examination. However, US is highly dependent on the experience of the physician, and appropriate training is required (7). In addition, a thyroid-dedicated contrast-enhanced CT protocol has an added value to US alone in the detection of lymph node metastasis by demonstrating early strong enhancement of metastatic lymph nodes and enables visualization of lymph nodes not accessible on US images, such as those in the retropharyngeal, retrosternal, and mediastinal areas. Second, physicians should be adequately trained to safely perform thermal ablations. It is fundamental to understand the anatomic relationship of tumor with critical structures, such as nerves, the esophagus, and the trachea. Hydrodissection should be performed, whenever necessary, to prevent thermal damage to the adjacent structures. Third, proper choice of device (ie, the size of active tip according to tumor size) is recommended. Finally, for the decision to perform thermal ablations, we recommend a multidisciplinary approach and shared decision making with patients based on the imaging characteristics and clinical situations.In summary, we discussed nonsurgical treatment options for small low-risk PTC to counter the recent changing epidemiologic landscape in the incidence of thyroid cancer. While the 2015 American Thyroid Association guidelines acknowledged active surveillance as an alternative to immediate surgery, dealing with anxiety and patients at high risk remains unsolved, leading to follow-up loss and delayed surgery. Thermal ablations proved to be an effective and safe treatment option in small low-risk PTCs supported by recent long-term follow-up data and the results of a multicenter study. For safe and effective thermal ablations, accurate radiologic evaluation with US and a thyroid-dedicated CT protocol and adequate training of physicians equipped with relevant anatomic knowledge and techniques are essential. We believe that thermal ablations can be a potential game changer in the management of small low-risk PTCs.Disclosures of Conflicts of Interest: J.H.B. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: holds a patent for a unidirectional ablation electrode; has served as a consultant to STARmed and RF Medical since 2017. Other relationships: disclosed no relevant relationships. S.J.C. disclosed no relevant relationships.References1. Vaccarella S, Franceschi S, Bray F, Wild CP, Plummer M, Dal Maso L. Worldwide Thyroid-Cancer Epidemic? The Increasing Impact of Overdiagnosis. N Engl J Med 2016;375(7):614–617. Crossref, Medline, Google Scholar2. Tufano RP, Clayman G, Heller KS, et al. Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance. Thyroid 2015;25(1):15–27. Crossref, Medline, Google Scholar3. Cho SJ, Suh CH, Baek JH, et al. Active Surveillance for Small Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis. Thyroid 2019;29(10):1399–1408. Crossref, Medline, Google Scholar4. Sakai T, Sugitani I, Ebina A, et al. Active Surveillance for T1bN0M0 Papillary Thyroid Carcinoma. Thyroid 2019;29(1):59–63. Crossref, Medline, Google Scholar5. Pitt SC, Yang N, Saucke MC, et al. Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey. J Clin Endocrinol Metab 2020. https://doi.org/10.1210/clinem/dgaa942. Published online December 29, 2020. Google Scholar6. Oh HS, Park S, Kim M, et al. Young Age and Male Sex Are Predictors of Large-Volume Central Neck Lymph Node Metastasis in Clinical N0 Papillary Thyroid Microcarcinomas. Thyroid 2017;27(10):1285–1290. Crossref, Medline, Google Scholar7. Cho SJ, Baek JH, Chung SR, Choi YJ, Lee JH. Thermal Ablation for Small Papillary Thyroid Cancer: A Systematic Review. Thyroid 2019;29(12):1774–1783. Crossref, Medline, Google Scholar8. Ho AS, Daskivich TJ, Sacks WL, Zumsteg ZS. Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review. JAMA Oncol 2019;5(4):556–564. Crossref, Medline, Google Scholar9. Cho SJ, Baek SM, Lim HK, Lee KD, Son JM, Baek JH. Long-Term Follow-Up Results of Ultrasound-Guided Radiofrequency Ablation for Low-Risk Papillary Thyroid Microcarcinoma: More Than 5-Year Follow-Up for 84 Tumors. Thyroid 2020;30(12):1745–1751. Crossref, Medline, Google Scholar10. Cao XJ, Wang SR, Che Y, et al. Efficacy and Safety of Thermal Ablation for Treatment of Solitary T1N0M0 Papillary Thyroid Carcinoma: A Multicenter Retrospective Study. Radiology 2021. https://doi.org/10.1148/radiol.2021202735. Published online April 27, 2021. Google ScholarArticle HistoryReceived: Feb 15 2021Revision requested: Feb 26 2021Revision received: Feb 26 2021Accepted: Mar 02 2021Published online: Apr 27 2021Published in print: July 2021 FiguresReferencesRelatedDetailsCited ByComparison of ultrasound-guided radiofrequency ablation versus thyroid lobectomy for T1bN0M0 papillary thyroid carcinomaLinYan, XinyangLi, YingyingLi, JingXiao, MingboZhang, YukunLuo2022 | European Radiology, Vol. 33, No. 1Efficacy of Modified Nonpneumatic Transaxillary Approach in the Treatment of Thyroid Cancer and Its Effect on Immune Function and Parathyroid FunctionTaoHuang, YimingSang, JizongZhang, WeiguoLi2022 | Emergency Medicine International, Vol. 2022Accompanying This ArticleEfficacy and Safety of Thermal Ablation for Treatment of Solitary T1N0M0 Papillary Thyroid Carcinoma: A Multicenter Retrospective StudyApr 27 2021RadiologyIssue Summary: July 2021Jun 29 2021Default Digital Object SeriesRecommended Articles Microwave Ablation versus Surgery for Papillary Thyroid Carcinoma: More Therapeutic Options, More ControversiesRadiology2022Volume: 304Issue: 3pp. 714-715Microwave Ablation versus Surgical Resection for Solitary T1N0M0 Papillary Thyroid CarcinomaRadiology2022Volume: 304Issue: 3pp. 704-713Is There a Place for Lymphatic Contrast-enhanced US in Thyroid Cancer?Radiology2023Volume: 307Issue: 4Revisiting Prostate Cancer Recurrence with PSMA PET: Atlas of Typical and Atypical Patterns of SpreadRadioGraphics2019Volume: 39Issue: 1pp. 186-212Efficacy and Safety of Thermal Ablation for Treatment of Solitary T1N0M0 Papillary Thyroid Carcinoma: A Multicenter Retrospective StudyRadiology2021Volume: 300Issue: 1pp. 209-216See More RSNA Education Exhibits Radiofrequency Ablation for Recurrent Thyroid CancerDigital Posters2020Ultrasound-guided Minimally Invasive Treatments Of Thyroid Cancer: Current PossibilitiesDigital Posters2021Practical Strategies to Improve the Use of PET CT in Thyroid CancerDigital Posters2019 RSNA Case Collection Dedifferentiated Thyroid CancerRSNA Case Collection2020Papillary Thyroid CarcinomaRSNA Case Collection2022Radioembolization of Liver Metastasis RSNA Case Collection2020 Vol. 300, No. 1 PodcastMetrics Altmetric Score PDF download
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