Meet the expert: discussion of common but difficult thyroid cancer cases
Endocrinologists today face an ever increasing variety of presentations of thyroid cancer related to the well documented increasing frequency of thyroid cancer patients worldwide. The overwhelming majority of these tumors are small microcarcinomas with excellent prognosis for which management is quite straightforward. But many patients are seen for whom optimal steps for management are unclear, constituting therapeutic dilemmas that are typically not well addressed in current guidelines of our professional societies. This session will discuss several patient scenarios, ranging from the misleadingly innocent microcarcinoma to the more aggressive thyroid cancer that requires more innovative management. For the microcarcinoma, because there are potential adverse effects of overly aggressive management, questions arise such as whether more conservative approaches are sufficient such as: (i) subtotal rather than total thyroidectomy; (ii) if central compartment dissection is really necessary; (iii) if radioiodine ablation can be avoided; and (iv) how much TSH suppression is required? Yet, management cannot be overly cavalier because a significant percent of patients with microcarcinomata already have lymph node metastases at presentation that imply future recurrences, and a small number may have, or will develop, distant metastases. Other cases will be discussed that require more aggressive surgery, local or regional ablation interventions, and higher dose radioiodine therapy such as that given by dosimetry. It will be proposed that these varied potential clinical presentations call for a risk-stratified approach to management that would minimize harm to the patient and yet optimize outcomes. Clinical parameters such as age, sex, tumor size, multifocality, vascular or capsular invasion, extrathyroidal extension, lymph node metastases, histologic variants of PTC, or the presence of mutational markers that might require more aggressive management will be discussed, to place them into a risk-adapted algorithmic approach intended to achieve minimal morbidity and optimal outcomes at less cost to the patient and society.
Declaration of interest: The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.