Evidence-based protocols for the management of well-differentiated carcinomas of the thyroid

OBJECTIVES: In recent years, well-differentiated carcinomas of the thyroid have been stratified into low-risk and high-risk groups. The pattern of thyroid cancer in India is different from that seen in the West. Moreover, patients present with more advanced stages of the disease. Our aim was to develop protocols for the management of well-differentiated thyroid cancer, based on the analysis of our data and our experience. METHODS: Cases of thyroid carcinoma, which were surgically treated at the Tata Memorial Hospital during 1970-5, were studied. The survival curves were plotted according to the Kaplan-Meier method. Univariate analysis was done using the log rank test. The prognostic factors analyzed were age, sex, tumour size, extra-thyroid extension, distant metastases and lymph node metastases. Multivariate analysis using the Cox regression model was performed. Analyses were separate for follicular and papillary carcinomas. RESULTS: Four hundred and seventeen cases were entered in the study, of which 198 were follicular and 219 were papillary. Based on the evidence derived from this study, we stratified our cases into low- and high-risk groups. The low-risk group consisted of patients below 40 years of age, nodules smaller than 5 cm, absence of extra-thyroidal spread and absence of distant metastases. For follicular carcinoma, the low-risk group had 100% survival at 15 years, compared with 40% for the high-risk group. (p < 0.001). For papillary carcinomas, the survival at 15 years was 95% for the low-risk group and 40% for the high-risk group (p < 0.001). CONCLUSIONS: We recommend lobectomy for the low-risk group, and total thyroidectomy for the high-risk group and for cases with lymph node metastases. In the latter, total thyroidectomy facilitates the use of 131I.