Original contribution
The role of surgery in anaplastic thyroid cancer: A systematic review☆

https://doi.org/10.1016/j.amjoto.2017.02.005Get rights and content

Abstract

Objective

To elucidate the role of surgery in the management of anaplastic thyroid cancer.

Methods

Ovid MEDLINE, Cochrane Library, and Google Scholar databases were searched for publications from December 2000 to July 2016. Selection criterion was a focus on the management of anaplastic thyroid cancer in adults. Studies addressing only nonsurgical management and review articles were excluded. Data extraction was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Kaplan-Meier analysis was performed on a subset of patients.

Results

40 publications were included in the study. Approaches to unresectability and interpretations of resection varied widely. For patients undergoing primary surgery, the median survival was 6.6 months. The median survival for non-surgical patients was 2.1 months. In the subgroup analysis, the median survival time for patients undergoing surgery was significantly longer in Stage IVB (p = 0.022) but not IVC disease. Negative margins did not afford a statistically significant survival benefit.

Conclusion

Surgery is a mainstay of treatment for Stage IVA and IVB disease. For Stage IVC cancer, distant metastasis was not a strict criterion against surgical candidacy among surgeons. The extent of resection and the definition of resectability remain controversial. Negative margins did not significantly increase survival.

Introduction

Anaplastic thyroid carcinoma (ATC) is a highly aggressive form of thyroid cancer, with a reported median survival rate of only 4 months. While multimodal therapy is frequently advocated, the precise role of surgery for patients with advanced disease is unclear. The approach to surgical management for patients with ATC varies across institutions and surgeons. Studies have drawn conflicting conclusions regarding aggressiveness of tumor resection in the presence of extrathyroidal extension. Some experts have concluded that patients undergoing radical resection with negative margins have no survival benefit over those with positive microscopic or macroscopic margins [1], [2], [3]. Other authors have shown that complete resection is a positive prognostic factor [4], [5], [6]. Likewise, in patients with tumors considered unresectable, the role of debulking or ultraradical surgery has been debated. We perform the first systematic review of the role of surgery in the management of ATC with the goal of developing a framework or algorithm for decision-making.

Section snippets

Methods

We aimed to identify all full-text, peer-reviewed publications pertaining to the treatment of ATC. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was used to identify and collate studies [1]. The searches were conducted in the Ovid MEDLINE, Cochrane Library and Google Scholar databases for studies published from December 2000 to July 1, 2016. The following search terms were used: anaplastic thyroid, treatment. Results were combined with the terms,

Results

89 articles underwent full review after screening 561 abstracts, and 40 publications met criteria for inclusion. The search strategy and flow diagram (Fig. 1) are presented using the PRISMA guidelines [7]. No relevant level 1, 2, or 3 studies were found. The results of the 40 studies are summarized in Table 1 [2], [3], [4], [5], [6], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]

Discussion

ATC presents most commonly as a rapidly enlarging neck mass and is often diagnosed at an advanced stage with a poor prognosis. Invasion into mediastinal vessels or prevertebral fascia is broadly accepted as definitive criteria for unresectability, although this review demonstrates the differing perspectives on the definition of resectability. Radical extirpative surgery, requiring the sacrifice of speech and swallowing function, is of questionable benefit to the patient, even when clear margins

Conclusions

The improved survival seen with surgery and multimodal therapy for ATC may be explained by a reduced risk of dying from local progression of the tumor, which is the most rapidly fatal manifestation of ATC [11]. In certain patients, wide surgical resection followed by adjuvant therapy can improve OS, may ameliorate the subsequent QOL, and plays a role in palliation and decompression. However, the benefit of aggressive surgery is often of limited clinical significance in advanced cases and

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    ☆

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. None of the authors have any conflicts of interest to declare.

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