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Follicular variant of papillary thyroid carcinoma

International panel of doctors renames a type of tumor initially classified as cancer as Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features (NIFTP), leading to a reduction in overtreatment of indolent tumors.

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Follicular variant of papillary thyroid carcinoma

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  1. It’s Not Cancer: Follicular variant of papillary thyroid carcinoma Winchester Kwok, Princess Margaret Hospital

  2. “An international panel of doctors has decided that a type of tumor that was classified as a cancer is not a cancer at all.” Encapsulated follicular variant of papillary thyroid carcinoma was rename as  noninvasive follicular thyroid neoplasm with papillary-like nuclear features, or Niftp, which pronounced as “Nift-P”

  3. Background • On March 8–9, 2012, the National Cancer Institute convened a conference • Problem of cancer overdiagnosis • When tumors that would otherwise not become symptomatic are identified and treated. • When this overdiagnosis is not recognized, it can lead to overtreatment. Esserman, L. J. (2014). Lancet Oncol.. Addressing overdiagnosis and overtreatment in cancer: a prescription for change, 15 .

  4. Ca thyroid • Yearly incidence has nearly tripled from 1975 to 2009 • Yet death rate remained constant • 25%of the new thyroid cancers diagnosed in 1988–1989 were <=1cm compared with 39% of the new thyroid cancer diagnoses in 2008–2009 • Prevalence of palpable thyroid nodule 1-5% vs. USG 19-68% • Increase in incidence attributed to the rapid growth of ultrasound and fine-needle aspiration use Haugen, B. R. (2015). THYROID. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer, 26 (1).

  5. Differentiated Ca Thyroid • Papillary thyroid tumor (75-85%) • - arise from follicular cells with papillary architecture- more than 10 microscopic variants • Follicular thyroid tumor (10-20%)

  6. Follicular variant of papillary Ca thyroid • 2nd most common subtype variant • ~4.9-41.2% of PTC • Encapsulated or non encapsulated; invasive or non invasive • Diagnosis could have interobserver difference Jug, R. (2016). Papillary carcinoma Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Retrieved October 1, 2016 from http://www.pathologyoutlines.com/topic/thyroidglandNIFTP.html

  7. 36 studies published from 2003-2014 was reviewed • Comparing FVPTC and classical PTC • FVPTC was associated with statistically significant less • extrathyroid extension • lymph node metastasis • recurrence • BRAF mutation FVPTC had more indolent behavior and likely a genetically distinct entity from classical papillary Ca thyroid

  8. A study published in 2006 69 patient with FVPTC Median follow up: 10.8 years recurrence:1 distant metastasis: 0 In a subgroup of patient (n=31) with non invasive encapsulated FVPTC treated with lobectomy only without RAI recurrence/ lymph node metastasis: 0 Liu, J. (2006). Follicular Variant of Papillary Thyroid Carcinoma A Clinicopathologic Study of a Problematic Entity. CANCER, 107(6).

  9. - Published in 4/2016 • Retrospective study by The Endocrine Pathology Society working group including 28 pathologists/ endocrinologists/ surgeons from 7 countries and 4 continents • Total 268 encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) from 13 institutions • Divided into 2 groups: group 1: non invasive EFVPTC treated with surgery only without RAIgroup 2: EFVPTC with vascular invasion +- tumor capsule invasion

  10. 109 patient with non invasive EFVPTC treated without RAI • median 13.0 (10-26) years of follow up • Adverse events: 0

  11. Scanned slides were reviewed and new diagnostic criteria was published

  12. Revision of nomenclature Encapsulated follicular variant of papillary thyroid carcinoma  Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features (NIFTP)

  13. What are the clinical implications?

  14. Due to a great degree of cytological difficulty in interpretation, >90% of EFVPTC was put into Bethesda Categories III/ IV/ V during initial FNAC cytology report

  15. In the Past… By BTA guidelines: NIFTP with size >=4cm or size 1-4cm By ATA guidelines NIFTP with size >=4cm  RAI +- Completion thyroidectomy X RAI No longer indicated

  16. In the Present… • Decrease the use of RAI +- completion thyroidectomy and related complications • Decrease psychological impact to patient with diagnosis of cancer • Decrease need for long term surveillance • Decrease overall cost of health care surveillance(Based on US cost, no RAI alone would save ~$5000-$8500/ patient) • ~45000 patient per year worldwide Nikiforov, Y. E. (2016). Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma A Paradigm Shift to Reduce Overtreatment of Indolent Tumors. JAMA Oncology, 2 (8). Perros, P. (2014). British Thyroid Association Guidelines for the Management of Thyroid Cancer. CLINICAL ENDOCRINOLOGY, 81 .

  17. In the future… • Training and update of pathologists • More updated guidelines will be needed for clinicians • Increase global awareness of cancer overdiagnosis and efforts in reviewing current clinicopathology diagnosis in lesions with indolent behaviors

  18. Take Home Message • Encapsulated follicular variant of papillary thyroid carcinoma no longer considered as malignant lesionsRenamed as noninvasive follicular thyroid neoplasm with papillary-like nuclear features • Problem of nowadays worldwide medical care: overdiagnosis of cancer and over treatment“First - do - harm”

  19. Questions are welcome

  20. Reference • Esserman, L. J. (2014). Lancet Oncol.. Addressing overdiagnosis and overtreatment in cancer: a prescription for change, 15 . • Haugen, B. R. (2015). THYROID. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer, 26 (1). • Jug, R. (2016). Papillary carcinoma Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Retrieved October 1, 2016 from http://www.pathologyoutlines.com/topic/thyroidglandNIFTP.html • Yang, J. (2015). Comparison of the clinicopathological behavior of the follicular variant of papillary thyroid carcinoma and classical papillary thyroid carcinoma: A systematic review and meta-analysis. MOLECULAR AND CLINICAL ONCOLOGY, 3  • Liu, J. (2006). Follicular Variant of Papillary Thyroid Carcinoma A Clinicopathologic Study of a Problematic Entity. CANCER, 107(6). • Nikiforov, Y. E. (2016). Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma A Paradigm Shift to Reduce Overtreatment of Indolent Tumors. JAMA Oncology, 2 (8). • Perros, P. (2014). British Thyroid Association Guidelines for the Management of Thyroid Cancer. CLINICAL ENDOCRINOLOGY, 81 . • Kolata, G. (2016, April 14). It’s Not Cancer: Doctors Reclassify a Thyroid Tumor. The New York Times

  21. European consensus for the management of patients withdifferentiated thyroid carcinoma of the follicular epithelium 2006

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