1. CHLC – H. Curry Cabral Centro Hospitalar Lisboa Central Departamento de Cirurgia – Diretor Prof. Dr. Eduardo Barroso Unidade de Cirurgia Endócrina José Mário Coutinho jmariocoutinho@gmail.com

2. Hospital Dona Estefânia Maternidade Alfredo da Costa Hospital Santo António dos Capuchos Hospital Curry Cabral Hosptal São José Hospital Santa Marta

3. Protocolo de actuación en el Microcarcinoma Papilar de Tireoide. ¿Estamos tratando en exceso?

4. According to World Health Organization, Papillary thyroid microcarcinomas (PTMCs) are papillary thyroid cancers (PTCs) measuring 1cm or less

5. Incidence of PTMC US (Eco) FNA PET, CT, …

6. Incidence of PTMC Cramer JD, et al. Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry. Surgery 2010;148(6):1147–52 [discussion: 1152–3]. Hughes DT, et al. The most commonly occurring papillary thyroid cancer in the United States is now a microcarcinoma in a patient older than 45 years. Thyroid 2011;21(3):231–6) Ries LAG, et al. SEER Cancer Statistics Review, 1975-2004, National Cancer Institute. [cited May 5, 2014] Bethesda, MD: http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007

7. Survival of PTMC Yu XM, et al. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann Surg 2011;254(4):653–60. which means that 0.5% of the patients died of PTMC.

8. Risk factors in PTMC Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

9. Risk factors in PTMC A meta-analysis identified the following risk factors: clinical (rather than incidental) presentation (P < 0.0001), multifocality (P < 0.0001) lymph node involvement at diagnosis (P < 0.0001). The data on age as a risk factor are contradictory. Gulben, K., Berberoglu, U., Celen, O. et al. (2008) Incidental papillary microcarcinoma of the thyroid–factors affecting lymph node metastasis. Langenbeck’s Archives of Surgery, 393,25. Yu, X.M., Wan, Y., Sippel, R.S. et al. (2011) Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Annals of Surgery, 254, 653–660. Roti, E., degli Uberti, E.C., Bondanelli, M. et al. (2008) Thyroid papillary microcarcinoma: a descriptive and meta-analysis study. European Journal of Endocrinology, 159, 659–673.

10. Risk factors in PTMC Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

11. Risk factors in PTMC PTMC > 6mm and extrathyroidal extension PTMC > 6mm and extrathyroidal extension More frequently Multifocal tumors More frequently Multifocal tumors distant metastases loco- regional disease Lymph node involvement persistent disease Malandrino P, Pellegriti G, Attard M, Violi MA, Giordano C, Sciacca L, et al. Papillary thyroid microcarcinomas: a comparative study of the characteristics and risk factors at presentation in two cancer registries. J Clin Endocrinol Metab 2013; 98(4):1427-34

12. Treatment of PTMC Haymart MR, et al. Papillary thyroid microcarcinomas: big decisions for a small tumor. Ann Surg Oncol 2009;16(11):3132–9

13. Treatment of PTMC Surgery – Total Thyroidectomy / Near Total – Lobectomy (Hemithyroidectomy) – Completion thyroidectomy – Lymphadenectomy Observation without surgery Given that long-term survival is nearly 100%, the objective of any treatment is to reduce the risk of loco-regional recurrence (2.5%) and distant metastases (0.4%), while minimizing iatrogenic morbidity.

14. Total/near total thyroidectomy

15. Lobectomy

16. Total Thyroidectomy or Lobectomy? Young Don Lee. Surgical Strategy for Papillary Thyroid Microcarcinoma. J Korean Thyroid Assoc. 2014; 7(1):48-56

17. Prophylactic central neck lymph node dissection? authorCentral node involvement Attie JN – 198821 – 82% Wada N – 200364% Ito Y – 200740.5% Attie JN. Modified neck dissection in treatment of thyroid cancer: a safe procedure. Eur J Cancer Clin Oncol 1988; 24: 315–24. Wada N, Duh QY, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003;237(3):399-407 Ito Y, et al. Risk factors for recurrence to the lymph node in papillary thyroid carcinoma patients without preoperatively detectable lateral node metastasis: validity of prophylactic modified radical neck dissection. World J Surg 2007;31(11):2085-91. So YK, et al. Prophylactic central lymph node dissection for clinically node-negative papillary thyroid microcarcinoma: influence on serum thyroglobulin level, recurrence rate, and postoperative complications. Surgery 2012; 151: 192-8. So YK, et al. Subclinical lymph node metastasis in papillary thyroid microcarcinoma: a study of 551 resections. Surgery 2010; 148: 526-31

18. Prophylactic central neck lymph node dissection?

20. Completion thyroidectomy Londero SC, Krogdahl A, Bastholt L, Overgaard J, Trolle W, Pedersen HB, et al. Papillary thyroid microcarcinoma in Denmark 1996-2008: a national study of epidemiology and clinical significance. Thyroid 2013;23(9):1159-64. Lee J, Park JH, Lee CR, Chung WY, Park CS. Long-term outcomes of total thyroidectomy versus thyroid lobectomy for papillary thyroid microcarcinoma: comparative analysis after propensity score matching. Thyroid2013;23(11):1408-15

21. Revised ATA Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer

22. Incidental microcarcinomas Ito Y, Tomoda C, Uruno T, et al. Papillary microcarcinoma of the thyroid: how should it be treated? World J Surg 2004; 28: 1115-21. Neuhold, N., et al. (2011) Incidental papillary microcarcinoma of the thyroid – further evidence of a very low malignant potential: a retrospective clinicopathological study with up to 30 years of follow-up. Annals of Surgical Oncology, 18, 3430–3436. Erratum in: Ann Surg Oncol. 2011;18:3528.. Dunki-Jacobs, E., Grannan, K., McDonough, S. et al. (2012) Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology? American Journal of Surgery, 203, 140–144.

23. Observation without surgery Ito Y, Tomoda C, Uruno T, et al. Papillary microcarcinoma of the thyroid: how should it be treated? World J Surg 2004; 28: 1115-21. de Matos PS, Ferreira AP, Ward LS. Prevalence of papillary microcarcinoma of the thyroid in Brazilian autopsy and surgical series. Endocr Pathol 2006; 17: 165-73. Ito Y, Miyauchi A. A therapeutic strategy for incidentally detected papillary microcarcinoma of the thyroid. Nat Clin Pract Endocrinol Metab 2007; 3: 240-8

24. Guideline Extent of surgery Prophylactic central neck dissection (PCND) USA (ATA, 2009) TT for diameter >1 cm, or if any high risk features, or multifocal tumours <1 cm in diameter Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases. Near-total or total thyroidectomy without prophylactic central neck dissection may be appropriate for small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer. Recommendation rating: C USA (NCCN, 2014) TT or lobectomy plus isthmusectomy (category 2B for both) and no radiation history, Tumor < 4cm, no cervical lymphnode metastases, no aggressive histological variant, no extrathyroidal extension, no macroscopic multifocality, no distant metastases Radiation hystory Tumor > 4 cm, Poorly differentiated bilateral nodularity, extrathyroidal extension, distant metastases

25. Guideline Extent of surgeryProphylactic central neck dissection (PCND) Europe (ETA, 2006) TT, except for unifocal tumours <1 cm diameter with no nodal or distant metastases, and no radiation history Not recommended (could change staging and approach to management) UK (BTA/RCP, 2014) Lobectomy for patients with unifocal tumours ≤1 cm diameter with no nodal or distant metastases, and no radiation history TT for most other patients, multifocal microscopic tumours involving both lobes familial non-medullary thyroid cancer (FNMTC) Other risk factors Patients with papillary microcarcinoma who present with cervical node metastases require total thyroidectomy and therapeutic lymph node dissection of the involved nodal compartment/s as with PTC >T1a PCCND should be considered in patients with tumours that are multifocal, pT3 and with extra-thyroidal spread Personalised Decision Making Japan (JSTS/ JAES, 2011) Lobectomy when unifocal tumour diameter ≤2 cm with no nodal or distant metastases. Observation without immediate surgery for microcarcinoma in absence of lymph-node metastases might be considered an option TT moderately recommended when tumour diameter >4 cm Routinely recommended

26. Obrigado