Is surgery recommended for a 1.4 cm papillary thyroid carcinoma (PTC) tumor?

From the Guidelines

Surgery is typically recommended for a 1.4 cm papillary thyroid carcinoma (PTC) tumor. The standard approach would be a total thyroidectomy (complete removal of the thyroid gland) or, in select cases, a thyroid lobectomy (removal of the affected lobe). The specific surgical approach depends on factors such as the tumor's location, whether it has spread to lymph nodes, patient age, and overall health status. Following surgery, patients may require thyroid hormone replacement therapy, typically levothyroxine at a dose individualized to the patient's weight and other factors, taken daily for life. Radioactive iodine treatment might be recommended after surgery depending on risk stratification. This recommendation aligns with most treatment guidelines because papillary thyroid carcinomas larger than 1 cm generally warrant surgical intervention due to their potential for growth and spread, as supported by the 2019 ESMO clinical practice guidelines for diagnosis, treatment, and follow-up of thyroid cancer 1. While PTC is typically slow-growing with an excellent prognosis, tumors of this size have a higher risk of local invasion or lymph node metastasis compared to smaller tumors, making surgical management the standard of care for optimal outcomes.

Some key points to consider in the management of PTC include:

• The initial treatment for DTC is total or near-total thyroidectomy whenever the diagnosis is made before surgery and the nodule is ≥1 cm, or regardless of the size and histology if there is metastatic, multifocal, or familial DTC, as stated in the 2010 ESMO guidelines 1.
• Active surveillance may be considered for low-risk papillary microcarcinoma, but this approach is generally recommended for tumors ≤10 mm, as discussed in the 2019 Annual Review of Medicine 1.
• Risk stratification is crucial in determining the best course of treatment, with factors such as tumor size, histology, and presence of lymph node metastases influencing the decision, as outlined in the 2019 ESMO guidelines 1.

Overall, the management of a 1.4 cm PTC tumor should be individualized based on the patient's specific characteristics and risk factors, with surgery being the primary treatment option for most cases.

From the Research

Surgical Recommendations for 1.4 cm Papillary Thyroid Carcinoma (PTC)

• The management of PTC has evolved, with a shift in emphasis from disease survival to recurrence, due to the highly curable nature of the disease in 85% of cases 2.
• For PTC >1 cm, bilateral thyroid resection, either total or near-total thyroidectomy, remains the standard, although recent data has re-emphasized the value of unilateral lobectomy in treating some PTC measuring 1-4 cm 2.
• A moderate surgical approach of bilateral thyroid resection, with usual central neck nodal clearance, and lateral internal jugular lymphadenectomy for node-positive disease can be performed safely, with about a 5% recurrence rate 2.
• Initial treatment for low-risk papillary cancers, which represent the vast majority of thyroid cancers diagnosed today, consists of a total thyroidectomy without prophylactic lymph node dissection, or a hemithyroidectomy in some patients with an intrathyroidal tumor and a normal contralateral lobe at pre-operative neck ultrasonography 3.

Considerations for Surgery

• The use of post-operative radioiodine should be restricted to selected patients, and follow-up at 6-18 months is based on serum thyroglobulin (Tg), Tg-antibody determination, and neck ultrasonography 3.
• In patients with detectable serum Tg or detectable Tg antibodies, the trend over time of these markers on levothyroxine treatment will dictate subsequent follow-up 3.
• Select low- and intermediate-risk group patients who have undetectable Tg after total thyroidectomy for PTC can be managed safely without adjuvant radioactive iodine therapy with no increase in risk of recurrence 4.

Diagnosis and Surveillance

• Fine needle aspiration (FNA) is recommended as the initial diagnostic test, and whole body iodine scans are done every 12 months for follow-up until one negative scan 5.
• Thyroglobulin measurements (with antithyroglobulin antibodies) and ultrasound neck are suggested at 6 and 12 months and then annually if disease-free 5.
• US-guided FNA is the "gold-standard" for diagnosis, and an enhanced prognostic classification could better guide initial surgical therapy, standardize surveillance, and reduce the risk of recurrent and persistent disease 6.