ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM.

OBJECTIVE: The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy. METHODS: We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed. RESULTS: Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance. CONCLUSION: With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.

The differential diagnosis of central compartment radioactive iodine uptake after thyroidectomy: anatomic and surgical considerations.

OBJECTIVE: Foci of increased radioactive iodine (RAI) uptake in the thyroid bed following total thyroidectomy (TT) indicate residual thyroid tissue that may be benign or malignant. The use of postoperative RAI therapy in the form of remnant ablation, adjuvant therapy, or therapeutic intervention is often followed by a posttherapy scan. Our objective is to improve the clinician's understanding of the anatomic complexity of this region and to enhance the interpretation of postoperative scans. METHODS: We conducted a comprehensive review of the literature evaluating RAI uptake in the central compartment following thyroid cancer treatment and literature related to anatomic nuances associated with this region. Thirty-eight articles were selected. RESULTS: Through extensive surgical experience and a literature review, we identified the 5 most important anatomic considerations for clinicians to understand in the interpretation of foci of increased RAI uptake in the thyroid bed on a diagnostic scan: 1) residual benign thyroid tissue at the level of the posterior thyroid ligament, 2) residual benign thyroid tissue at the superior portion of the pyramidal lobe and/or superior poles of the lateral thyroid lobes, 3) residual benign thyroid tissue that was left attached to a parathyroid gland in order to preserve its vascularity, 4) ectopic benign thyroid tissue, and 5) malignant thyroid tissue that has metastasized to central compartment nodes or invaded visceral structures. CONCLUSION: By correlating anatomic description, medical illustrations, surgical photos, and scans, we have attempted to clarify the reasons for foci of increased uptake following TT to improve the clinician's understanding of the anatomic complexity of this region.

Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: Report of 8 cases.

BACKGROUND: Our surgical approach describes a bipaddled radial forearm free flap (RFFF) for closure of chronic tracheoesophageal fistulae (TEF) in patients who underwent total laryngectomy. The desired functional results were achieved. METHODS: Eight patients underwent the procedure. The surgical approach includes exposure and resection of the fistula tract, and a bipaddled RFFF transfer. Key surgical maneuvers include: circumferential dissection and mobilization of the trachea; partial sternal resection in select cases; inset of flap's distal paddle into the anterior esophageal wall; and inset of the proximal skin paddle to the posterior tracheal wall and cervical skin. RESULTS: Successful reconstruction of all 8 cases was done to restore a normal diet and a widely patent tracheal opening. One patient developed a delayed esophageal stricture, which was successfully managed with home dilation. CONCLUSION: Several TEF treatment approaches have been reported. Our 87.5% esophageal lumen preservation success rate, reestablishment of adequate airway, and uncomplicated postoperative courses demonstrates the reliability of this surgical approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E172-E178, 2016.

Improving the adoption of thyroid cancer clinical practice guidelines.

OBJECTIVES/HYPOTHESIS: To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system. DATA SOURCES: PubMed. REVIEW METHODS: A review of studies on adherence to CPGs was conducted. RESULTS: Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice. CONCLUSION: Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 126:2640-2645, 2016.

Size distribution of metastatic lymph nodes with extranodal extension in patients with papillary thyroid cancer: a pilot study.

BACKGROUND: Extranodal extension (ENE) is a documented negative prognostic factor in patients with papillary thyroid cancer (PTC). ENE is presumed to manifest in larger lymph nodes. Yet, to date, no study has proven this. This is a pilot study that specifically examines the size distribution of positive lymph nodes manifesting ENE in patients with PTC. METHODS: An Institutional Review Board approved review examined the size of all lymph nodes demonstrating ENE in postoperative PTC patients that underwent surgery for PTC under the care of a single surgeon between 2004 and 2014. All patients in the study had regional metastatic lymph nodes with ENE. Analysis of the size distribution for all lymph nodes with ENE was performed. RESULTS: A total of 47% of lymph nodes with ENE were ≤10 mm. CONCLUSIONS: RESULTS indicate that clinically nonevident, small lymph nodes are at risk of harboring aggressive disease biology reflected in ENE. A total of 47% of all nodes fell within Randolph et al.'s classification of "small" lymph nodes, while 59% of the nodes with ENE were <1.5 cm-the threshold size that was deemed to be prognostically significant by Ito et al. It is apparent that clinically nonevident regional lymph nodes can have adverse histologic features and that the previous presumption that nodes with ENE only appear in clinically evident, macroscopic nodes is flawed.

Intrathyroidal tumors presenting with extranodal extension: what are we missing?

Extranodal extension (ENE) is an indicator of poor prognosis in well-differentiated thyroid cancer (WDTC). We have demonstrated that extrathyroidal extension (ETE) predicts ENE in patients with positive lymph nodes, indicating concordance between primary tumor and lymph node biology. In an effort to determine if there were other histologic features of the primary tumors that indicated an aggressive biology, we examined a subset of patients with intrathyroidal (T1/T2) disease whose lymph nodes had ENE. A review was conducted from January 2004 to March 2013. The histologic features of ETE-negative/ENE-positive tumors (group A, 12 cases) were compared with a random sample of ETE-negative/ENE-negative node-positive patients (group B, 27 cases). Cases were reviewed for size, capsule presence, infiltration, sclerosis, lymphocytic thyroiditis (LT), psammoma bodies, lymphovascular invasion (LVI), perineural invasion (PNI), architecture/cytomorphology, and focality. Size was compared using the Mann-Whitney test, while the remaining features were compared using a Fischer exact test. The breakdown of pathologic features of groups A/B were as follows: 2.28 cm/1.46 cm mean tumor size, 90 %/67 % unencapsulated, 100 %/89 % infiltrative, 100 %/89 % sclerotic, 60 %/52 % LT, 30 %/59 % positive psammoma bodies, 0 %/11 % LVI, 0 %/4 % PNI, 90 %/96 % classic architecture, 50 %/44 % multifocal. Neither size (p = 0.072) nor the other nine histologic features examined reached statistical significance. None of the histologic features appeared to significantly predict ENE. Further examination of intrathyroidal tumors at a molecular level is necessary to determine if there are any identifiable features of intrathyroidal tumors that predict ENE and thus a more aggressive phenotype.

The effect of surgeon experience on the detection of metastatic lymph nodes in the central compartment and the pathologic features of clinically unapparent metastatic lymph nodes: what are we missing when we don't perform a prophylactic dissection of central compartment lymph nodes in papillary thyroid cancer?

BACKGROUND: Prophylactic central neck dissection (PCND) for papillary thyroid cancer (PTC) is controversial. Recent publications suggest that the number and size of nodes and the presence of extranodal extension (ENE) are important features for risk stratification of lymph node metastases. We analyzed these features in clinically unapparent nodes that would not otherwise be removed. We also investigated the impact of surgeon experience on the ability to detect metastatic lymph nodes intraoperatively. METHODS: Forty-seven patients with well-differentiated PTC, with no preoperative evidence of central metastases, were included in this study. Intraoperatively, clinically apparent disease was determined by inspection and palpation by the senior surgeon and a fellow/senior resident, and recorded in a blinded fashion. Rate of occult metastases based on intraoperative evaluation were tabulated for each group of surgeons. Histopathologic features of occult nodes were analyzed to determine what clinicians would be missing by foregoing a PCND, and how that would have impacted the patient management. RESULTS: The rate of occult metastases, based on senior surgeon assessment, was 26%, and did not differ significantly from fellow/senior resident assessment. The level of agreement between these two surgeon groups was moderate (k=0.665). Analysis of the false negative cases revealed that the size of the largest undetected node ranged from 0.1 to 1.3 cm; 36% of patients with occult metastases demonstrated five or more positive nodes, and 27% showed ENE. DISCUSSION: Clinical assessment based on intraoperative inspection and palpation had poor sensitivity and specificity in identifying metastatic central nodes, regardless of the level of experience of the surgeon. There was moderate agreement between surgeons of different experience levels. Sensitivity improved significantly with larger size of positive nodes, but not with the presence of multiple positive nodes or presence of ENE. In foregoing PCND in this patient population, our results suggest that treating clinicians miss potentially virulent disease with a large number of occult positive central nodes and occult nodes with ENE. This is the first report to address the pathologic features of clinically nonevident central nodes showing a high incidence of clinically relevant, adverse histologic features, as well as the impact of surgeon experience in performing the important intraoperative determination of whether there are clinically evident nodes that require removal.

Extrathyroidal extension predicts extranodal extension in patients with positive lymph nodes: an important association that may affect clinical management.

BACKGROUND: While there is consensus that significant extrathyroidal extension (ETE) (T4) should upstage a patient with well-differentiated thyroid cancer, the importance of minimal ETE (T3) remains controversial. Additionally, the importance of nodal metastases on prognosis has come under scrutiny. Recent publications highlight the importance of size, number of positive nodes, and, in particular, the presence of extranodal extension (ENE) as measures of disease aggressiveness. In this study, we examined whether ETE is a predictor of ENE. METHODS: A retrospective review was conducted from January 2004 to March 2013. All node-positive patients who underwent total or completion thyroidectomy were included. Histologic features defined by the College of American Pathologists (CAP) protocol for thyroid carcinoma were recorded. RESULTS: A total of 193 patients qualified for review. Patients who were found to have ETE were 12 times more likely to have lymph nodes in the primary setting with ENE than patients with intrathyroidal primary tumors (p<0.000). After exclusion of all T4 cases (n=6), patients with minimal ETE were 13 times more likely to have ENE than those with no ETE (p<0.000). Twenty percent of microcarcinomas with ETE demonstrated ENE. CONCLUSION: We have found that the biology of the primary tumor is conferred to the lymph node in that the presence of ETE leads to a significantly higher incidence of ENE. Awareness of this relationship should be accounted for in the management of primary and recurrent lymph nodes. This study shows that minimal ETE is a significant predictor of ENE. Although long-term survival and recurrence follow-up is not available for the majority of patients in this series, the presence of ENE as a surrogate for more aggressive disease biology and its strong association with minimal ETE supports the upstaging of patients with minimal ETE.

Striving toward standardization of reporting of ultrasound features of thyroid nodules and lymph nodes: a multidisciplinary consensus statement.

BACKGROUND: The use of high-resolution ultrasound (US) imaging is a mainstay of the initial evaluation and long-term management of thyroid nodules and thyroid cancer. To fully capitalize on the diagnostic capabilities of a US examination in the context of thyroid disease, many clinicians consider it desirable to establish a universal format and standard of US reporting. The goals of this interdisciplinary consensus statement are twofold. First, to create a standardized set of US features to characterize thyroid nodules and cervical lymph nodes accurately, and second, to create a standardized system for tracking sequential changes in the US examination of thyroid nodules and cervical lymph nodes for the purpose of determining risk of malignancy. SUMMARY: The Thyroid, Head and Neck Cancer (THANC) Foundation convened a panel of nine specialists from a variety of medical disciplines that are actively involved in the diagnosis and treatment of thyroid nodules and thyroid cancer. Consensus was achieved on the following topics: US evaluation of the thyroid gland, US evaluation of thyroid nodules, US evaluation of cervical lymph nodes, US-guided fine needle aspiration (FNA) of thyroid nodules, and US-guided FNA of cervical lymph nodes. CONCLUSION: We propose that this statement represents a consensus within a multidisciplinary team on the salient and essential elements of a comprehensive and clinically significant thyroid and neck US report with regards to content, terminology, and organization. This reporting protocol supplements previous US performance guidelines by not only capturing categories of findings that may have important clinical implications, but also delineating findings that are clinically relevant within those categories as specifically as possible. Additionally, we have included the specific features of diagnostic and therapeutic interventions that have not been previously addressed.

What is the gold standard for comprehensive interinstitutional communication of perioperative information for thyroid cancer patients? A comparison of existing electronic health records with the current American Thyroid Association recommendations.

BACKGROUND: Appropriate management of well-differentiated thyroid cancer requires treating clinicians to have access to critical elements of the patient's presentation, surgical management, postoperative course, and pathologic assessment. Electronic health records (EHRs) provide an effective method for the storage and transmission of patient information, although most commercially available EHRs are not intended to be disease-specific. In addition, there are significant challenges for the sharing of relevant clinical information when providers involved in the care of a patient with thyroid cancer are not connected by a common EHR. In 2012, the American Thyroid Association (ATA) defined the critical elements for optimal interclinician communication in a position paper entitled, "The Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery." SUMMARY: We present a field-by-field comparison of the ATA's essential elements as applied to three contemporary electronic reporting systems: the Thyroid Surgery e-Form from Memorial Sloan-Kettering Cancer Center (MSKCC), the Alberta WebSMR from the University of Calgary, and the Thyroid Cancer Care Collaborative (TCCC). The MSKCC e-form fulfills 21 of 32 intraoperative fields and includes an additional 14 fields not specifically mentioned in the ATA's report. The Alberta WebSMR fulfills 45 of 82 preoperative and intraoperative fields outlined by the ATA and includes 13 additional fields. The TCCC fulfills 117 of 120 fields outlined by the ATA and includes 23 additional fields. CONCLUSIONS: Effective management of thyroid cancer is a highly collaborative, multidisciplinary effort. The patient information that factors into clinical decisions about thyroid cancer is complex. For these reasons, EHRs are particularly favorable for the management of patients with thyroid cancer. The MSKCC Thyroid Surgery e-Form, the Alberta WebSMR, and the TCCC each meet all of the general recommendations for effective reporting of the specific domains that they cover in the management of thyroid cancer, as recommended by the ATA. However, the TCCC format is the most comprehensive. The TCCC is a new Web-based disease-specific database to enhance communication of patient information between clinicians in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner. We believe the easy-to-use TCCC format will enhance clinician communication while providing portability of thyroid cancer information for patients.

Improving the quality of thyroid cancer care: how does the Thyroid Cancer Care Collaborative cross the Institute of Medicine's Quality Chasm?

BACKGROUND: The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery. SUMMARY: The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management. CONCLUSION: The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.