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Journal of Postgraduate Medicine, Vol. 53, No. 1, January-March, 2007, pp. 6-7 Guest Editorials Management of occult papillary thyroid cancer found incidentally during surgery for benign disease Solares CA Head and Neck Institute, Cleveland Clinic Health System, Cleveland, OH, USA; Department of Otolaryngology Head and Neck Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia Code Number: jp07008 Thyroid carcinoma is, in many cases, an incidental finding in thyroid glands that are removed for other benign conditions or in postmortem examinations.[1],[2] This subgroup has been classified as occult papillary thyroid cancer (OPTC). The proper terminology for these tumors is controversial, but most agree that this type of tumor should not be more than 1.5 cm in diameter. In this issue of JPGM, the manuscript entitled "Microscopic papillary thyroid cancer as an incidental finding in patients treated surgically for presumably benign thyroid disease"[3] reports a series of 380 patients treated for benign thyroid disease among which 27 were found to have OPTC. The authors treated these patients with a total or near-total thyroidectomy, plus/minus radioactive iodine and propose that this should be the treatment of choice for any patient in which OPTC is found during surgery for benign disease. Postmortem studies have reported that the incidence of OPTC may be as high as 36%. In fact, as cited in this paper, some consider this to be a "normal" occurrence.[4] No one has been able to determine which patients with this entity progress to clinical thyroid cancer. Recommending total thyroidectomy as the procedure of choice may have serious implications and, in my opinion, the data presented by the authors does not support this approach. The number of patients with OPTC treated with total thyroidectomy is not sufficient to draw this conclusion. In addition, there was no control group in which patients with OPTC were treated with less aggressive surgery (i.e., hemithyroidectomy). I have no doubt that if one treats all patients of OPTC with a total thyroidectomy plus radioactive iodine, the recurrence rate will be low. The question is whether these patients needed treatment at all and unfortunately this study does not answer this question. It is acknowledged that this question may be difficult to answer. Dewil et al . reported that it is their preference to perform completion thyroidectomy to remove potential occult malignancy and to allow for postoperative 131sub I-treatment in all patients with an incidental diagnosis of malignancy in their thyroid lobectomy specimen. The exception was tumors less than 1 cm.[5] Thus, these authors treated patients with OPTC less aggressively. In my opinion, it is best to individualize which patients may require a total thyroidectomy based on other risk factors for aggressive disease such as male gender, history of total body radiation, women over 45, etc.[6] In these patients, I would probably recommend a total thyroidectomy. Not simply because papillary thyroid cancer was found incidentally, but because they have risk factors for aggressive disease. Although in experienced hands the incidence of recurrent laryngeal nerve injury and postoperative hypoparathyroidism are low, these are still true surgical risks that should be weighed against the potential added benefit of a total thyroidectomy. This is a difficult clinical scenario and, ultimately, it is the patient who has to make the decision. References
Copyright 2007 - Journal of Postgraduate Medicine |
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