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腫瘤大小作為甲狀腺癌手術範圍的決定因子 Tumor size as a determinant of the extent of surgery in thyroid cancer
郭其毓 劉建良 劉滄柏 林鉷彬 柯文清 鄭世平 蔡家騏 何恭誠 Chi-Yu Kuo, Chien-Liang Liu, Tsang-Pai Liu, Hung-Bun Lam, Wen-Ching Ko, Shih-Ping Cheng, Chia-Chi Tsai, Kung-Chen Ho 馬偕紀念醫院及馬偕醫學院 一般外科 Department of Surgery, Mackay Memorial Hospital and Mackay Medical College, Taipei, Taiwan
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Earlier Guideline NCDB: total thyroidectomy for PTC ≥ 1 cm
Lower recurrence rates Improved survival ATA Guideline (2009) For thyroid cancer >1 cm: Near-total or total thyroidectomy
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Updated Guideline SEER and updated NCDB
Total thyroidectomy was NOT associated with a survival benefit for tumors of 1-4 cm, particularly among young patients ATA Guideline (2015) Thyroid cancer >1 cm and <4 cm: Bilateral procedure (near-total or total thyroidectomy) or a unilateral procedure (lobectomy)
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Whether there is a tumor size “threshold” for total thyroidectomy
which may minimize the rate of completion thyroidectomy?
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Patients and Methods From 2008 to 2017 Mackay Memorial Hospital
All patients undergoing curative-intent thyroidectomy for differentiated thyroid cancer
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Total Thyroidectomy 1. Maximum tumor size greater than 4 cm
2. Preoperative evidence of extrathyroidal extension 3. Clinically apparent lymph node metastasis 4. Presence of distant metastasis The remaining patients were treated with either lobectomy or total thyroidectomy
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The Need for Completion Thyroidectomy
Aggressive histology Extrathyroidal extension Lymphovascular invasion Non-low risk nodal metastasis
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Results 771 patients (from 2008 to 2017) Age: 47 ± 13 years
Gender: 630 (82%) were female Tumor size: 1.9 ± 1.3 cm (median, 1.6 cm) Papillary thyroid cancer: 737 (96%) BRAF V600E mutation: 74% cases of PTC
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Results 155 (20%) patients definitely indicated for total thyroidectomy 616 (80%) patients initially eligible for lobectomy 170 (28%) lobectomy 446 (72%) total thyroidectomy
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616 patients initially eligible for lobectomy
206 (33%) lymph node metastasis 161 (78%) non-low risk metastasis
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273 (44%) patients were considered to have the need for completion thyroidectomy
18% 57%
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Cumulative Risk of Requiring Completion Thyroidectomy
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Optimal Cut-off Point Estimation (ROC curve analysis)
tumor size ≥ 1.1 cm
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Risk of Requiring Completion Thyroidectomy
Microcarcinoma: 18% → 31% Tumor size > 1cm and ≤ 4 cm: 57% → 65%
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Summary The Risk of Requiring Completion Thyroidectomy
Tumor Size ≥ 1.1 cm The presence of BRAF V600E mutation
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Thank you for your attention
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