LETTER TO THE EDITOR

Practice Patterns in the Surgical Treatmentof Papillary Thyroid Microcarcinoma

Chau Nguyen1 and Marilene Wang2,3

Dear Editor:

We read with great interest the article by Goffredo et al.(1). As the authors correctly point out, ‘‘There is a widevariability in the degree of adherence to guideline recom-mendations among caregivers.’’ They sought to determinethe impact of the 2006 American Thyroid Association(ATA) guidelines on the management of differentiated thy-roid cancer (DTC) in the United States. They utilized theSurveillance, Epidemiology and End Results (SEER) data-base (2004–2009) to assess compliance with specific rec-ommendations of the 2006 ATA guidelines, includingRecommendation 26, which states that total or near-totalthyroidectomy should be the initial surgical procedure formost patients with thyroid cancer and that thyroid lobectomyalone may be considered for small ( < 1 cm), low risk, iso-lated, intrathyroidal papillary tumors in the absence of cer-vical nodal metastases (2). Examining papillary thyroidcancer (PTC) tumors larger than 1 cm, they found that overallcompliance with Recommendation 26 tended to increaseslightly in the 2007–2009 time period to 83.2% versus 82.2%in the 2004–2006 time period. Patients with smaller tumorsreceived treatment more adherent to the guidelines; 85.5% oftumors 2 cm or less in size underwent total thyroidectomy.Factors associated with discordant practice to guidelineswere older patient age, treatment in the northeast, havingmore than one primary cancer, tumor size larger than 4 cm,and follicular thyroid cancer and Hurthle cell thyroid cancerhistologies. They stated that, ‘‘To our knowledge, the currentstudy is the first to analyze practice patterns and potentialchanges in clinical practice associated with the publication ofthe 2006 ATA guidelines for the management of patientswith thyroid nodules and DTC.’’

We would like to highlight our experience studying prac-tice patterns in the treatment of papillary thyroid micro-carcinoma (PTMC) published in 2010 (3). We utilized asurvey methodology including members of the AmericanAssociation of Endocrine Surgeons, American Academy ofOtolaryngology-Head & Neck Surgery, and general surgeonson the online physician forum Sermo.com. We had 438 re-sponses distributed fairly evenly across the geographic Uni-ted States and encompassing an estimated 14.5% of surgeons

performing thyroidectomies annually. We queried physiciandecision-making for, among other scenarios, the finding of a3 mm focus of PTMC on final pathology after hemi-thyroidectomy. We sought to compare this with recommen-dation 26 of the 2006 ATA guidelines, which had beenrestated in the 2009 guidelines, for which ‘‘lobectomy alonemay be sufficient treatment for small ( < 1 cm), low-risk,unifocal, intrathyroidal papillary carcinomas (4).’’ We foundthat 70.3% of responders agreed no further treatment to benecessary, in keeping with the current guidelines, while 29.7%felt completion thyroidectomy to be necessary. Interestingly,when asked about what motivations were behind these choices,the ease of patient follow-up and multifocality of disease werejudged to be very significant by most responders. Notably, in-fluence from national published guidelines and current litera-ture or from nationally or internationally recognized authoritieswas rated as only somewhat or minimally significant by mostresponders. Surgeons from the south and west, otolaryngolo-gists, and low volume surgeons were more likely to recommendcompletion thyroidectomy.

In summary, we found through a different study techniquevery similar issues to that of Goffredo et al. (1). There is awide variety of practice patterns in the current treatment ofthyroid cancer in the United States. We commend theircareful study and agree with their conclusion that ‘‘Ongoingefforts should be undertaken to propagate guidelines to re-duce variation in care and improve overall quality of care.’’

Author Disclosure Statement

The authors declare no competing financial interests.

References

1. Goffredo P, Roman SA, Sosa, JA 2014 Have 2006 ATApractice guidelines affected the treatment of differentiatedthyroid cancer in the United States? Thyroid 24:463–471.

2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL,Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, TuttleRM 2006 American Thyroid Association Guidelines Task-force, Management guidelines for patients with thyroidnodules and differentiated thyroid cancer. Thyroid 16:109–142.

1Division of Otolaryngology-Head & Neck Surgery, Ventura County Medical Center, Ventura, California.2Department of Head and Neck Surgery, UCLA David Geffen School of Medicine; 3VA Greater Los Angeles Healthcare System,

Los Angeles, California.

THYROIDVolume X, Number X, 2014ª Mary Ann Liebert, Inc.DOI: 10.1089/thy.2014.0388

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3. Wu AW, Wang MB, Nguyen CT 2010 Surgical practicepatterns in the treatment of papillary thyroid micro-carcinoma. Arch Otolaryngol Head Neck Surg 136:1182–1190. Erratum in: Arch Otolaryngol Head Neck Surg2011;137:123.

4. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL,Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlum-berger M, Sherman SI, Steward DL, Tuttle RM. 2009American Thyroid Association (ATA) Guidelines Taskforceon Thyroid Nodules and Differentiated Thyroid Cancer,Revised American Thyroid Association management guide-lines for patients with thyroid nodules and differentiated

thyroid cancer [published correction appears in Thyroid2010;20:942]. Thyroid 19:1167–1214.

Address correspondence to:Chau Nguyen, MD, FACS

Division of Otolaryngology-Head & Neck SurgeryVentura County Medical Center

3291 Loma Vista Rd Ste 401Ventura, CA 93003

E-mail: chau.nguyen@ventura.org

2 LETTER TO THE EDITOR