2016, 63 (9), 805-810

Original

Pathological characteristics of low-risk papillary thyroid

microcarcinoma with progression during active surveillance
Mitsuyoshi Hirokawa1), Takumi Kudo2), Hisashi Ota3), Ayana Suzuki3) and Akira Miyauchi4)
1)
Department of Diagnostic Pathology, Kuma Hospital, Kobe, Japan
2)
Department of Internal Medicine, Kuma Hospital, Kobe, Japan
3)
Department of Laboratory Medicine, Kuma Hospital, Kobe, Japan
4)
Department of Surgery, Kuma Hospital, Kobe, Japan

Abstract. Papillary thyroid microcarcinoma (PTMC) is generally an indolent disease and active surveillance is conducted
for low-risk cases. This study was carried out to clarify the pathological characteristics of PTMC cases that exhibited
enlarged nodules or nodal metastasis during the surveillance period. A total of 188 PTMC cases that underwent surgery
after active surveillance for ≥ 1 year were examined. Ki-67 labeling indices of > 5% and > 10% were detected in 50.0%
and 22.2% of enlarged cases, respectively, values that were significantly higher than those in non-enlarged cases.
Intraglandular dissemination and psammoma bodies in normal thyroid tissue were associated with new occurrence of nodal
metastasis. Ultrasonographic macrocalcification and follicular variants were observed in 13.8% and 10.6% of non-enlarged
cases, respectively, but not in enlarged or nodal metastatic cases. Intraglandular dissemination and psammoma bodies were
ultrasonographically detected in 50.0% and 40.0% of cases, which was confirmed by microscopy. Thus, high Ki-67
labeling index, intraglandular metastasis, and psammoma bodies in normal thyroid tissue are indicators of progressive
PTMC, and may be identified cytologically or ultrasonographically. In PTMC cases with ultrasonographic macrocalcification,
active surveillance can be proactively implemented.

Key words: Thyroid, Papillary carcinoma, Microcarcinoma, Active surveillance, Ki-67

PAPILLARY THYROID CARCINOMA (PTC) is
a malignant epithelial tumor that exhibits follicular
cell differentiation and is characterized by distinctive
nuclear features, including a ground glass appearance,
grooves, cytoplasmic inclusions, and overlapping [1].
PTC is the most common type of thyroid carcinoma
and its incidence has been increasing around the world
due to widespread use of ultrasonography-guided fine
needle aspiration cytology for small lesions [2, 3].
Small-sized PTC, measuring ≤ 10mm, is referred to as
papillary thyroid microcarcinoma (PTMC) [1].
Although we cannot predict the natural history of
each PTMC case, it is generally an indolent disease.
In 1993, non-operative management — i.e., active sur-
veillance — for low-risk PTMC was proposed by one
Submitted Feb. 29, 2016; Accepted Jun. 3, 2016 as EJ16-0097
Released online in J-STAGE as advance publication Jul. 7, 2016
Correspondence to: Mitsuyoshi Hirokawa, M.D., Ph.D.,
Department of Diagnostic Pathology, Kuma Hospital, 8-2-35
Shimoyamate-dori, Chuo-Ku, Kobe 650-0011, Japan.
E-mail: mhirokawa@kuma-h.or.jp
©The Japan Endocrine Society
of the authors (A.M.) at a doctor’s meeting at Kuma
Hospital and was met with approval, with a trial ini-
tiated in the same year [4-7]. Two years later, the
Cancer Institute Hospital in Tokyo started a similar
clinical trial [8]. Based on the promising early results
from these studies, the strategy was adopted in 2010
in Japanese guidelines for the management of thyroid
tumors [9]. In the trial, we reviewed PTMC cases that
underwent surgical resection after active surveillance
over a period of more than 1 year. The present study
was undertaken in order to establish the pathologi-
cal features of PTMC cases that become enlarged or
exhibit nodal metastasis during follow-up, which has
not been previously reported.
Materials and Methods
We reviewed 2,796 cases with thyroid nodules mea-
suring ≤ 10mm and were diagnosed as PTC by fine
needle aspiration cytology at Kuma Hospital between
May 1995 and December 2012. Of these, 1,252 cases
806 Hirokawa et al.
that gave informed consent for non-operative manage-
ment were followed for 1 year or more because they
were deemed as low risk according to the following
criteria: non-detectable nodal or distant metastasis;
location far from the recurrent laryngeal nerve or tra-
chea; and no cytological findings indicating aggressive
or high-grade malignancy, such as tall or columnar cell
variants [7]. Of the 1,252 cases, 188 (15.0%) under-
went surgical operation for various reasons, includ-
ing enlargement, nodal metastasis, and reconsidera-
tion by the patient. Surgical procedures included total
thyroidectomy (91 cases), near-total thyroidectomy
(one case), subtotal thyroidectomy (one case), lobec-
tomy with isthmusectomy (92 cases), and lobectomy
(three cases). Central neck lymph node dissection
was performed in 185 cases, of which 10 were accom-
panied by lateral neck lymph node dissection. Of
the 188 PTMC cases, 18 (9.6%) showed an enlarge-
ment in diameter of > 4mm and nodal metastasis was
detected in 11 cases (5.9%) by ultrasonography. One
case exhibited both enlargement and nodal metastasis,
and the remaining 160 cases (85.1%) showed neither.
We pathologically examined hematoxylin and eosin-
stained specimens from the 188 PTMC cases based
on the World Health Organization classification [1].
Additionally, we reviewed 150 cases by immunohis-
tochemistry using an antibody against Ki-67 (MIB1,
1:200 dilution; Dako, Carpinteria, CA, USA); in the
remaining 38 cases, no specimens were available for
immunohistochemistry due to calcification. The pro-
tocol was carried out using a Cytomation Autostainer
Universal Staining System and the Envision kit (both
from Dako) according to the manufacture’s recom-
mendations. Ki-67 labeling index (LI) was estimated
Table 1 Clinical features of papillary thyroid microcarcinoma according to clinical course during active surveillance
Non-enlarged (160)
Age
At diagnosis 51 (20–75)
At operation 55 (22–81)
Male 14 (8.8%)
Macrocalcification (by US #) 22 (13.8%)
LN metastasis (by US ##) 0 (0%)
Follow up (days) 367–5,805 (median 1,053)
Size of carcinoma
Initial 3–10 mm (median 7)
Preoperative 3–13 (median 8)
Difference −2 to +3 (median 0)
#
LN, lymph node; US, ultrasound. At diagnosis, ## after follow up. * P < 0.05, ** P < 0.005, *** P < 0.001 vs. non-enlarged cases.
by counting at least 500 carcinoma cells in the hot
area observed at 400× magnification and calculat-
ing the percentage of positively stained nuclei using
WinROOF image processing software for Windows
(Mitani, Tokyo, Japan). Statistical analysis was car-
ried out using StatFlex v.6 software (Artech, Osaka,
Japan) with the χ2 or Student’s t test. P values < 0.05
were considered statistically significant.
Results
Table 1 lists the clinical features of PTMC accord-
ing to the clinical course during active surveillance.
Median ages of non-enlarged, enlarged, and nodal met-
astatic cases at the time of initial diagnosis were 51,
41, and 40 years, respectively. Enlarged and nodal
metastatic cases were significantly younger than non-
enlarged cases (P < 0.05). The proportion of males
was higher among nodal metastatic than among non-
enlarged cases. Ultrasonographically, macrocalci-
fication that was > 2 mm in diameter and associated
with posterior acoustic shadowing was observed in 22
of 160 (13.8%) non-enlarged cases, but this was not
observed in enlarged or nodal metastatic cases. There
were no differences among the three groups in terms of
observation periods and initial size of the carcinoma.
Table 2 shows the pathological findings of PTMC
according to clinical course during active surveillance.
There were no statistical differences in terms of the
location of carcinoma, extrathyroidal invasion, encap-
sulation, sclerotic stroma, or association with chronic
thyroiditis. Intraglandular dissemination (Fig. 1), that
was detected around primary foci, was smaller in size
than PTMC lesions, and was not associated with encap-
Enlarged (18) Nodal metastasis (11)
41 (14–68) * 40 (20–60) *
45 (23–70) 43 (23–61) *
2 (11.1%) 3 (27.3%) *
0 (0%) 0 (0%)
1 (5.6%) ** 11 (100%) ***
492–5,472 (median 1,683) 517–4,941 (median 1,114)
3–10 mm (median 6.5) 3–9 mm (median 7)
7–22 mm (median 18) *** 5–12 mm (median 8)
+4 to +17 (median 5) *** −1 to +9 (median 0)
 Thyroid papillary microcarcinoma 807

sulation or sclerotic stroma, was observed in 22.2% of
enlarged and 36.4% of nodal metastatic cases, which
was significantly higher than the frequencies in non-
enlarged cases (P < 0.001). Nodal metastatic cases
more often exhibited psammoma bodies in normal thy-
roid tissue (Fig. 2) than non-enlarged cases (P < 0.001).
Metastasis in all 11 cases with ultrasonographically
detected nodal metastasis was confirmed by micro-
scopic examination, and was observed in 26.3% of non-
enlarged and 50.0% of enlarged cases (P < 0.05). In 6
(50.0%) of 12 cases with intraglandular dissemination,
the presence was ultrasonographically detected as small,
low-echoic lesions with an irregular margin that were
located around the PTMC (Fig. 3). Two (40.0%) of five
cases with psammoma bodies in normal thyroid tissue
ultrasonographically had tiny punctate hyperechoic foci
without posterior acoustic shadowing (Fig. 4). Ki-67 LI
> 5% and > 10% was observed in 50.0% and 22.2% of
enlarged cases, respectively; these values were signifi-
cantly higher than in non-enlarged cases (P < 0.001).
There was no difference between non-enlarged and
nodal metastatic cases in terms of Ki-67 LI.

Table 2 Pathological findings of papillary thyroid microcarcinoma according to clinical course during active surveillance
Non-enlarged (160) Enlarged (18) Nodal metastasis (11)
Peripheral location 96 (60.0%) 7 (38.9%) 7 (63.6%)
Extrathyroidal invasion 86 (53.8%) 8 (44.4%) 6 (54.5%)
Encapsulation 23 (14.4%) 3 (16.7%) 0 (0%)
Sclerotic stroma 102 (63.8%) 12 (66.7%) 8 (72.7%)
Intraglandular dissemination 4 (2.5%) 4 (22.2%) ** 4 (36.4%) **
Psammoma bodies in normal thyroid tissue 2 (1.3%) 1 (5.6%) 2 (18.2%) **
Nodal metastasis 42 (26.3%) 9 (50.0%) * 11 (100%) **
Ki-67 labeling index
> 5% 8 (5.0%) 9 (50.0%) ** 1 (9.1%)
> 10% 3 (1.9%) 4 (22.2%) ** 1 (9.1%)
Chronic thyroiditis 49 (30.6%) 8 (44.4%) 4 (36.4%)
Histologic type
Conventional 135 (84.4%) 15 (83.3%) 9 (81.8%)
Follicular 17 (10.6%) 0 (0%) 0 (0%)
Warthin tumor-like 7 (4.4%) 2 (11.1%) 1 (9.1%)
Tall cell 1 (0.6%) 0 (0%) 0 (0%)
Cribriform 0 (0%) 1 (5.6%) 0 (0%)
Solid 0 (0%) 0 (0%) 1 (9.1%)
* P < 0.05, ** P < 0.001 vs. non-enlarged cases.

Fig. 1 Intraglandular dissemination Fig. 2 Psammoma bodies

Multiple minute foci of papillary carcinoma are visible Concentric calcified materials are present in normal
that do not exhibit encapsulation or stromal fibrosis. thyroid tissue. No viable carcinoma cells are detected.
808 Hirokawa et al.
Fig. 3 Ultrasound image of papillary thyroid microcarcinoma
A small, low-echoic lesion with an irregular margin
(arrow) suspected as intraglandular dissemination
is shown.
Histologically, most PTMC cases (84.0%) were
conventional. Follicular variants were seen in 10.6%
of non-enlarged cases (17 cases), but not in enlarged or
nodal metastatic cases. One of the non-enlarged cases
exhibited tall cell variant, which is an aggressive type.
There were no aggressive variants in either enlarged or
nodal metastatic cases, and no characteristic findings in
four cases of enlargement of > 10 mm or in seven cases
in which the diameter was diminished > 2mm.
Discussion
PTMC is defined as PTC measuring ≤ 1 cm in diam-
eter, and is the most common form of papillary carci-
noma [1]. Most PTMCs are incidentally detected by
imaging methods such as during ultrasound examina-
tion, and grow very slowly or not at all. Based on
several lines of evidence [10-12], non-operative man-
agement (active surveillance) has been carried out at
Kuma Hospital for PTMC cases without progressive
features, including the presence of nodal or distant
metastasis, extrathyroidal extension, signs or risks of
invasion to a recurrent nerve or trachea, emergence of
aggressive cytological variants, or enlargement during
an earlier observation [4-7].
The previously reported incidence of PTMC with
enlargement was 8% at 10 years of observation; novel
nodal metastasis appeared in 3.8% of cases during the
follow-up period and PTMC tended to increase in size
in patients < 40 years old [5], in accordance with our
results. In another study, increased tumor size and
novel nodal metastasis were detected in 7.3% and
Fig. 4 Ultrasound image of papillary thyroid microcarcinoma
Tiny, punctate hyperechoic foci without posterior
acoustic shadowing (arrows) indicating psammoma
bodies are seen in the extratumoral area of the thyroid.
1.3% of active surveillance cases, respectively [8].
We believe it is critical to proactively identify factors
related to low-risk PTMC that will enlarge or exhibit
nodal metastasis during follow-up.
Ki-67 is a proliferation-related antigen that is pres-
ent during all active phases of the cell cycle and is
expressed in the nucleus. The Ki-67 LI is defined as
the fraction of Ki-67-positive tumor cells; a high LI
is associated with aggressiveness or poor prognosis
in patients with a variety of carcinomas. Some stud-
ies have shown that Ki-67 immunolabeling is useful
for predicting the aggressiveness of PTC; therefore,
an estimate of Ki-67 LI should be considered in rou-
tine PTC histopathology [13-15]. Ki-67 LI in PTC has
been classified into low (≤ 5%), medium (5%–10%),
and high (≥ 10%), and was found to be associated with
disease-free and -specific survival and short thyroglob-
ulin doubling time, which indicates rapid tumor growth
[15]. In the present study, Ki-67 LI values of > 5% and
> 10% were detected in 50.0% and 22.2% of enlarged
cases, respectively. These frequencies were signifi-
cantly higher than in non-enlarged cases, while there
was no difference between non-enlarged and nodal
metastatic cases. These results indicate that high Ki-67
LI is related to tumor enlargement but not nodal metas-
tasis. The reliability of immunocytochemical analy-
sis and usefulness of the Ki-67 LI in FNA samples has
already been discussed [16-19], and the method can
be applied to aspirated materials. Therefore, a preop-
erative analysis of Ki-67 LI by fine needle aspiration
may be useful for determining an appropriate PTMC
management strategy in the future. It was previously
 Thyroid papillary microcarcinoma
reported that high Ki-67 LI in PTMC was related to
nodal metastasis [20]. However, our results did not
support these findings. The reason may be that pro-
gressive PTMC cases, including those with nodal
metastasis, had been already excluded at the time of
diagnosis in the present study. Local proliferation of
the tumor and ability to metastasize appear to be inde-
pendent processes.
Intraglandular dissemination occurs via lymphatic
channels and is correlated with nodal metastasis [21,
22]. It was also reported that two of three patients who
developed clinically apparent nodal metastasis dur-
ing follow-up showed multiple PTMC lesions [8]. As
it is difficult clinically to distinguish between multiple
PTMC lesions and intraglandular dissemination, some
may have been the latter. Psammoma bodies in normal
thyroid tissue are derived from intralymphatic necrotic
carcinoma cells [23, 24]. Thus, the presence of both of
these findings is related to nodal metastasis. Indeed, we
found that intraglandular dissemination and psammoma
bodies in normal thyroid tissue occurred more fre-
quently in cases with than in those without nodal metas-
tasis. Both types of lesion may be detected ultrasono-
graphically [25, 26]. Small low-echoic lesions with
an irregular margin surrounding PTMC are a marker
of intraglandular dissemination. Microcalcification
— i.e., tiny punctate hyperechoic foci without poste-
rior acoustic shadowing — is thought to be the imag-
ing equivalent of psammoma bodies. These tiny lesions
are commonly detected with the increasing use of high-
end ultrasound equipment. In our study, intraglandu-
lar dissemination and psammoma bodies were ultraso-
nographically detected in 50.0% and 40.0% of cases,
respectively, which was confirmed by microscopy. It
was noted that intraglandular dissemination was also
related to tumor size enlargement. We recommend that
ultrasonographic identification of intraglandular dis-
semination and microcalcification in normal thyroid tis-
sue of PTMC cases can be used to predict the occur-
rence of novel nodal metastasis. However, we do not
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The authors have no conflicts of interest to declare
regarding grant support or financial relationships.
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