Thyroid groups: Perioperative risk stratification paramount in cancer treatment plan
Accurate risk stratification during the immediate perioperative period that incorporates molecular theranostics can help better guide decision-making for thyroid cancer treatment, according to a new joint statement published in Thyroid.
The current risk-adapted approach to thyroid cancer management aligns the intensity of therapeutic interventions, including surgical treatment, subsequent radioactive iodine (RAI) therapy and thyroid-stimulating hormone suppressive therapy, with clinical outcome risks, Seza Gulec, MD, of Florida International University Herbert Wertheim College of Medicine, and colleagues wrote in the joint statement. The approach, they noted, typically results in more aggressive interventions for high-risk patients and less aggressive therapies for low-risk patients.
“Unfortunately, there is no guarantee that more aggressive therapies will necessarily improve clinical outcomes in high-risk patients or conversely that more minimalistic therapies would necessarily be effective for low-risk patients,” they wrote.
An inter-societal working group, including the American Thyroid Association, the European Association of Nuclear Medicine, the European Thyroid Association, and the Society of Nuclear Medicine and Molecular Imaging, addressed current controversies and evolving concepts in three main areas: perioperative risk stratification; the role of diagnostic RAI imaging in initial staging; and indicators of response to RAI therapy.
The working group highlighted several points of agreement:
- Initial patient management decisions should be guided by perioperative risk stratification that should include the eighth edition American Joint Committee on Cancer staging system to predict disease-specific mortality, the modified 2009 ATA risk stratification system to estimate structural disease recurrence, with judicious incorporation of molecular theranostics to further refine management recommendations.
- Diagnostic RAI scanning in ATA intermediate-risk patients should be utilized selectively rather than considered mandatory or not necessary for all patients in this category.
- A consistent, semiquantitative reporting system should be used for response evaluations after RAI therapy until a reproducible and clinically practical quantitative system is validated.
The researchers noted that traditional risk stratification systems can be refined by incorporating patient- and tumor-specific molecular markers via molecular cytology, molecular pathology and molecular imaging that have theranostic power to optimize patient-specific treatment decisions. Molecular theranostics refers to the selection of appropriate therapeutic interventions based on data regarding genomic alterations and their functional proteomic expressions, which are the prime determinants of RAI oncophysiology.
“It has the potential to devise patient-specific interventions, including surgical treatment and RAI therapy,” the researchers wrote.
Additionally, RAI imaging is “an indispensable component of dynamic and theranostic risk stratification,” according to the statement, and posttreatment scans “should always be obtained for staging of RAI-avid disease and identification of tumors that are not RAI avid.”
“The ‘value-added’ role for pretreatment diagnostic RAI molecular imaging has to be clarified and redefined,” the researchers wrote.
The researchers also wrote that there is an “obvious need” for a uniform classification system to describe response to RAI therapy in structural disease.
“The components of such a system should include anatomic as well as functional imaging criteria,” the researchers wrote.