Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus <span class="so-article-trans-title" dir="auto"> Translated title: Nódulo tireoidiano e câncer diferenciado de tireoide: atualização do consenso brasileiro </span>

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Abstract

Thyroid nodules are frequent findings, especially when sensitive imaging methods are used. Although thyroid cancer is relatively rare, its incidence is increasing, particularly in terms of small tumors, which have an uncertain clinical relevance. Most patients with differentiated thyroid cancer exhibit satisfactory clinical outcomes when treatment is appropriate, and their mortality rate is similar to that of the overall population. However, relapse occurs in a considerable fraction of these patients, and some patients stop responding to conventional treatment and eventually die from their disease. Therefore, the challenge is how to identify the individuals who require more aggressive disease management while sparing the majority of patients from unnecessary treatments and procedures. We have updated the Brazilian Consensus that was published in 2007, emphasizing the diagnostic and therapeutic advances that the participants, representing several Brazilian university centers, consider most relevant in clinical practice. The formulation of the present guidelines was based on the participants' experience and a review of the relevant literature.

Translated abstract

Nódulos tireoidianos são muito frequentes, sobretudo quando se empregam métodos sensíveis de imagem. Embora o câncer seja proporcionalmente raro, sua incidência vem aumentando, especialmente de tumores pequenos, cuja evolução clínica é incerta. A maioria dos pacientes com carcinoma diferenciado de tireoide evolui bem quando adequadamente tratada, com índices de mortalidade similares à população geral. Por outro lado, um percentual não desprezível apresenta recidivas e alguns eventualmente não respondem às terapias convencionais, evoluindo para óbito. Assim, o desafio é distinguir os pacientes merecedores de condutas mais agressivas e, ao mesmo tempo e não menos importante, poupar a maioria de tratamentos e procedimentos desnecessários. Atualizamos o Consenso Brasileiro publicado em 2007, ressaltando os avanços diagnósticos e terapêuticos que os participantes, de diferentes Centros Universitários do Brasil, consideram mais relevantes para prática clínica. A elaboração dessas diretrizes foi baseada na experiência dos participantes e revisão da literatura pertinente.

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Most cited references 190

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The clinical significance of subclinical thyroid dysfunction.

Bernadette Biondi, David S Cooper (2008)

Subclinical thyroid disease (SCTD) is defined as serum free T(4) and free T(3) levels within their respective reference ranges in the presence of abnormal serum TSH levels. SCTD is being diagnosed more frequently in clinical practice in young and middle-aged people as well as in the elderly. However, the clinical significance of subclinical thyroid dysfunction is much debated. Subclinical hyper- and hypothyroidism can have repercussions on the cardiovascular system and bone, as well as on other organs and systems. However, the treatment and management of SCTD and population screening are controversial despite the potential risk of progression to overt disease, and there is no consensus on the thyroid hormone and thyrotropin cutoff values at which treatment should be contemplated. Opinions differ regarding tissue effects, symptoms, signs, and cardiovascular risk. Here, we critically review the data on the prevalence and progression of SCTD, its tissue effects, and its prognostic implications. We also examine the mechanisms underlying tissue alterations in SCTD and the effects of replacement therapy on progression and tissue parameters. Lastly, we address the issue of the need to treat slight thyroid hormone deficiency or excess in relation to the patient's age.

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Increasing incidence of thyroid cancer in the United States, 1973-2002.

Louise Davies, H Gilbert Welch (2006)

Increasing cancer incidence is typically interpreted as an increase in the true occurrence of disease but may also reflect changing pathological criteria or increased diagnostic scrutiny. Changes in the diagnostic approach to thyroid nodules may have resulted in an increase in the apparent incidence of thyroid cancer. To examine trends in thyroid cancer incidence, histology, size distribution, and mortality in the United States. Retrospective cohort evaluation of patients with thyroid cancer, 1973-2002, using the Surveillance, Epidemiology, and End Results (SEER) program and data on thyroid cancer mortality from the National Vital Statistics System. Thyroid cancer incidence, histology, size distribution, and mortality. The incidence of thyroid cancer increased from 3.6 per 100,000 in 1973 to 8.7 per 100,000 in 2002-a 2.4-fold increase (95% confidence interval [CI], 2.2-2.6; P .20 for trend). Virtually the entire increase is attributable to an increase in incidence of papillary thyroid cancer, which increased from 2.7 to 7.7 per 100,000-a 2.9-fold increase (95% CI, 2.6-3.2; P<.001 for trend). Between 1988 (the first year SEER collected data on tumor size) and 2002, 49% (95% CI, 47%-51%) of the increase consisted of cancers measuring 1 cm or smaller; 87% (95% CI, 85%-89%) consisted of cancers measuring 2 cm or smaller. Mortality from thyroid cancer was stable between 1973 and 2002 (approximately 0.5 deaths per 100,000). The increasing incidence of thyroid cancer in the United States is predominantly due to the increased detection of small papillary cancers. These trends, combined with the known existence of a substantial reservoir of subclinical cancer and stable overall mortality, suggest that increasing incidence reflects increased detection of subclinical disease, not an increase in the true occurrence of thyroid cancer.

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Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy.

E Baudin, J D Lumbroso, N Haddy … (2006)

The goal of this study was to estimate the cumulative activity of (131)I to be administered to patients with distant metastases from thyroid carcinoma. A total of 444 patients were treated from 1953-1994 for distant metastases from papillary and follicular thyroid carcinoma: 223 had lung metastases only, 115 had bone metastases only, 82 had both lung and bone metastases, and 24 had metastases at other sites. Treatment consisted of the administration of 3.7 GBq (100 mCi) (131)I after withdrawal of thyroid hormone treatment, every 3-9 months during the first 2 yr and then once a year until the disappearance of any metastatic uptake. Thyroxine treatment was given at suppressive doses between (131)I treatment courses. Negative imaging studies (negative total body (131)I scans and conventional radiographs) were attained in 43% of the 295 patients with (131)I uptake; more frequently in those who were younger, had well-differentiated tumors, and had a limited extent of disease. Most negative studies (96%) were obtained after the administration of 3.7-22 GBq (100-600 mCi). Almost half of negative studies were obtained more than 5 yr after the initiation of the treatment of metastases. Among patients who achieved a negative study, only 7% experienced a subsequent tumor recurrence. Overall survival at 10 yr after initiation of (131)I treatment was 92% in patients who achieved a negative study and 19% in those who did not. (131)I treatment is highly effective in younger patients with (131)I uptake and with small metastases. They should be treated until the disappearance of any uptake or until a cumulative activity of 22 GBq has been administered. In the other patients, other treatment modalities should be used when tumor progression has been documented.

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Author and article information

Journal

Journal ID (publisher-id): abem

Title: Arquivos Brasileiros de Endocrinologia & Metabologia

Abbreviated Title: Arq Bras Endocrinol Metab

Publisher: Sociedade Brasileira de Endocrinologia e Metabologia (São Paulo, SP, Brazil )

ISSN (Electronic): 1677-9487

Publication date (Print and electronic): June 2013

Volume: 57

Issue: 4

Pages: 240-264

Affiliations

[01] Belo Horizonte MG orgnameInstituto de Ensino e Pesquisa orgdiv1Serviço de Endocrinologia Brazil

[02] Campinas SP orgnameUniversidade Estadual de Campinas orgdiv1Faculdade de Ciências Médicas orgdiv2Departamento de Clínica Médica Brazil

[07] Rio de Janeiro RJ orgnameUniversidade Federal do Rio de Janeiro orgdiv1Faculdade de Medicina orgdiv2Hospital Universitário Clementino Fraga Filho Brazil

[03] Curitiba PR orgnameUniversidade Federal do Paraná orgdiv1Serviço de Endocrinologia e Metabologia Brazil

[04] orgnameUniversidade Federal de São Paulo orgdiv1Escola Paulista de Medicina orgdiv2Departamento de Medicina

[05] Ribeirão Preto SP orgnameUniversidade de São Paulo orgdiv1Faculdade de Medicina de Ribeirão Preto orgdiv2Departamento de Clínica Médica Brazil

[06] Porto Alegre RS orgnameUniversidade Federal do Rio Grande do Sul orgdiv1Hospital de Clínicas de Porto Alegre orgdiv2Serviço de Endocrinologia Brazil