Differentiated thyroid carcinoma - Follow-up of 264 patients from one institution for up to 25 years

The optimum treatment for differentiated thyroid carcinoma (DTC) is still d ebated. Results obtained using a selective treatment strategy for papillary (PTC) and follicular (FTC) thyroid carcinoma over 25 years in one institut ion are reported. 149 patients (mean age 46 yrs) had PTC in TNM stages I-IV in 58%, 26%, 15% and 1% respectively Total thyroidectomy and remnant I-131 ablation (43 %)were carried out in TNM high-risk patients (stages III and IV) and in loa-risk patients (I and II) at risk for a (curable) recurrence (stages pN(1) and/or pT(4)). Hemi- or total thyroidectomy; without radioiod ine, was used in 76% of pT(1-3) No tumours (68%). Central and/or lateral ly mphadenectomy was performed in 42% of patients (electively in the last 4 ye ars). The mean follow-up was 7 years. Results: 6 patients died of PTC and 8 /143 patients treated for cure had a recurrence (6 nodal, 1 contralateral, 1 local). In lon-risk patients -including 68% of patients aged greater than or equal to 45 yrs - the cause specitic 25-year survival rate nas 100%, ws . 62 % (at 15 years) (p <0.0001) in high-risk patients. In stage I and stag e II the recurrence-free survival rates at 25 years were 95% and 100% respe ctively Risk factors for recurrence were macroscopic (p <0.0001) but not mi croscopic local invasion (pT(4)); stage pN(1) (p = 0.0004). Only 1/107 pati ents initially judged node-negative had a nodal recurrence. FTC (n = 115; m ean age 56 yrs; mean follow-up 8 yrs): Cause-related death (n = 8) or serio us recurrence (n = 3) occurred in 10/53 grossly invasive FTC, in 1/45 minim ally invasive FTC with vascular invasion, and in none of 17 FTC with capsul ar invasion (CT) alone, under radical treatment(I-131) in 75%, 33%, and 12% respectively 20 year disease-free survival in grossly and in minimally inv asive FTC was 78% and 95.5% respectively (p = 0.0007). Patients aged <45 4 rs and patients with minimally invasive FTC with CI alone (all ages) had 10 0% 20-year disease-fret: survival vs. 80% (p = 0.013) in the remainder. The re was no curable recurrence in FTC. The ratio of grossly invasive FTC decr eased (p <0.0001) during the study period. Conclusions: Risk-0 groups may be defined and selected for a reduced extent of treatment (PTC pT(1-3) N-0; FTC <45 yrs, or CI alone). Older (<greater than or equal to>45 yrs) patients with PTC in stages I and II have an excellent prognosis (risk 0). With selective (therapeutic) lymphadenectomy the risk of nodal recurrence m ay be very lon in node negative tumours, without use of radioiodine. Meticu lous lymphadenectomy is indicated in pN(1) tumours with nodal recurrences d espite I-131(5/36 patients). The technique of capsular dissection for extracapsular total uni- or bilate ral thyroidectomy provides excellent oncological and surgical results. A decrease in the incidence of FTC parallels a decrease in endemic goitre: in Switzerland.