The role of multidisciplinary approach in the clinical management of differentiated thyroid cancer

Description

Thyroid cancer is, in general, the most frequent endocrinological neoplasm, characterized however by an extremely low mortality rate, morbidity and persistence of disease. This is due in part to the often indolent nature of the disease, but also to the ever increasing appropriateness of primary treatments, often capable of eradicating the disease in the face of low burdens of adverse events. The availability of increasingly targeted approaches to the specific condition of the individual patient makes it necessary for shared management among the various specialist figures involved in the treatment of the pathology. During the PhD course, some of the issues relating to multidisciplinary management and the integration of skills in the diagnostic-therapeutic pathway of thyroid cancer were studied, from the initial stages to the treatment of advanced disease. After the diagnosis, the surgical approach represents the first line of treatment of the disease. Over the last few years, the use of increasingly less invasive techniques has made it possible to reduce adverse events and complications. However, this must be based on a correct classification and estimation of the risk of recurrence. In particular, papillary microcarcinoma (mPTC) has demonstrated a particularly indolent behavior and a minimal recurrence rate. In this sense, we evaluated a cohort of patients affected by mPTC and studied the factors that could predict its recurrence and therefore be considered in the treatment definition. Following surgery, the need for radioiodine therapy (RAI), aimed at identifying and selectively targeting any residual thyroid tissue, must also be evaluated on the basis of the characteristics of the surgically removed disease and the available clinical and biochemical parameters post-surgery. Close cooperation between the endocrinologist, pathologist and nuclear doctor is therefore mandatory. From this point of view, we considered the impact of minimal extrathyroidal extension (understood as microscopic invasion beyond the organ capsule) of differentiated thyroid cancer (DTC) on the risk of recurrence, finding that this does not significantly change the risk of recurrence. Another retrospective study was also conducted in order to compare the efficacy and adverse events of RAI performed at standard doses with that at low doses. The latter, now widely approved in patients at low and sometimes intermediate risk of recurrence, has confirmed excellent efficacy data, showing a slightly superior clinical tolerability profile and no significant changes from the haematochemical point of view compared to the standard treatment. An important aspect in the management of patients with thyroid cancer, given the excellent response rate to primary treatments, is represented by the long-term follow-up and the prevention of complications, from an endocrine point of view but above all from a cardiovascular point of view. In this sense, in addition to investigating the association between thyroid cancer and other endocrine pathologies such as hyperparathyroidism, which has demonstrated an independent impact on the patient's prognosis, we evaluated the incidence and possible predictive factors of cardiovascular events in a DTC population with at least 5 years of follow-up, confirming the role of careful cardiovascular evaluation, especially in patients maintained in TSH suppression. Furthermore, the incidence of vascular events, specifically those of a thromboembolic nature (TEE), was also studied in the context of advanced and iodine-refractory thyroid cancer, initially in a small cohort of patients receiving tyrosine inhibitor therapy. kinase, thus evaluating the possible predictive factors of TEE within a court of patients affected by advanced cancer. Finally, with regard to the treatment of advanced and iodine-refractory thyroid cancer, the cooperation of diversified professional figures appears essential, given the great development in this context of target-therapies aimed at the specific typology and mutational profile of the disease. In this regard, a limited case series of patients subjected to mutational and immunohistochemical analysis was retrospectively analysed, confirming the importance of the BRAF, TERT genes and PDL1 expression in defining the prognostic picture and possible therapeutic approaches. Also for these patients, the comparison between the endocrinologist and the nuclear doctor is necessary in order to integrate conventional radiology data with information deriving from functional imaging such as PET with FDG, in order to study the initial prognosis, the progress of the disease and the response to different treatment regimens.

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