A Trial Comparing USG-HIFU vs AS in Management of Low-risk PTMC
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|ClinicalTrials.gov Identifier: NCT03327636|
Recruitment Status : Not yet recruiting
First Posted : October 31, 2017
Last Update Posted : September 7, 2018
Papillary thyroid microcarcinoma (PTMC) is a common tumor in Hong Kong. Early immediate surgery has traditionally been recommended. However, given its excellent prognosis, some have recommended Active Surveillance (AS) as an alternative. AS involves monitoring the patients who have PTMC until the tumor progresses. On the other hand, a new technology of ablation has been developing to be an alternative treatment for thyroid nodules comparing with traditional surgery, named High intensity focused ultrasound (HIFU). In our previous study, HIFU is proved in shrinking the size of target site by 6 months gradually and effectively.
The investigator hypothesize that HIFU is an effective treatment for PTMC. Compared to AS, HIFU may be a better option as it not only halts disease progression but also has a longer progression-free survival, longer time to tumor progression and is less likely to harbor active disease.
|Condition or disease||Intervention/treatment||Phase|
|Papillary Thyroid Microcarcinoma||Device: Echopulse||Not Applicable|
Differentiated thyroid cancer has been rising in incidence and is expected to be a leading cancer by the year 2030 . However, the rise has been mostly attributed to an increased detection of incidentally-discovered papillary thyroid microcarcinoma (PTMC). PTMC is a papillary thyroid carcinoma (PTC) measuring ≤ 10mm in its greatest dimension. Previous screening and autopsy studies have confirmed these lesions are common and could be found in up to 15% of normal healthy individuals.
However, since the incidence of clinically-significant PTC has historically been <0.5% (i.e. 100 times less than the occult rate), most occult PTMCs probably do not cause harm in one's life-time and could be safely observed without immediate surgery.
As a result, several groups of investigators worldwide began evaluating the feasibility and safety of observing PTMC without surgery. Rather than offering immediate surgery, well selected patients with low-risk PTMC (i.e. no extrathyroidal extension, nodal and distant metastases) were followed with regular ultrasound (USG) alone and only proceeded to definitive to surgery when the PTMC showed progression. As expected, >90% PTMCs did not progress and of those who progressed and had surgery, all were cured. This meant even when the initial surgery was deferred, there was no compromise in the chance of cure.
With a recent shift towards a more conservative approach in the management of PTC, it has become increasingly accepted that perhaps active surveillance (AS) might be a safe alternative in well selected low-risk PTMCs.
However, despite the fact that AS is a viable alternative, there are issues and challenges. First, although the majority of occult tumors do not progress initially, the accumulative risk of tumor progression increases with time. From an analysis of the 1479 PTMCs observed over 5 years, 212 (14.3%) eventually met the progression criteria (such as tumor enlargement, local invasion, new lymph node metastasis or becoming clinical disease) and had surgery. Therefore, with longer observation, a greater proportion of patients would end up having surgery. Second some patients tend to find it difficult to accept AS as a treatment. Even if they do initially, the "wait and see" approach may distress patients leading to non-compliance. To date, little is known how this may affect patients' well-being and health-related quality of life (HRQOL) over time. Third, since there are no clinical or molecular parameters to predict which tumors are more likely to progress, patients often need life-long follow-up. However, this may be challenging because patients may move to different places. Lastly, there are now less invasive, non-surgical options available to potentially eradicate PTMCs. Image-guided thermal ablation (IGTA) using laser ablation or radiofrequency ablation appears promising. With technological advances, they may eventually replace surgery in the future. However, reports have so far been non-randomized, uncontrolled and short follow-up. Furthermore, despite being less-invasive, they still require a small skin incision.
High intensity focused ultrasound (HIFU) is a form of IGTA that needs no skin incision or needle insertion and so, is a truly noninvasive treatment. Under USG guidance, it is able to cause irreversible tissue destruction deep to the skin and subcutaneous layer. Apart from being non-invasive, it is less dependent on the operator's skill as the treatment could be controlled by an automated program. In fact, HIFU is highly successful in a number of solid cancers. In the thyroid, it induces tissue damage via the cavitation and thermal effects. To date, several groups (including us) have confirmed that HIFU ablation is highly effective in inducing shrinkage of benign thyroid nodules.
|Study Type :||Interventional (Clinical Trial)|
|Estimated Enrollment :||103 participants|
|Intervention Model:||Parallel Assignment|
|Intervention Model Description:||Participants will be arranged into either HIFU group or AS group randomly|
|Masking:||None (Open Label)|
|Official Title:||A Prospective Randomized Trial Comparing Ultrasound-guided High Intensity Focused Ultrasound (HIFU) Ablation With Active Surveillance (AS) in the Management of Low-risk Papillary Thyroid Microcarcinoma (PTMC)|
|Estimated Study Start Date :||April 1, 2019|
|Estimated Primary Completion Date :||August 31, 2021|
|Estimated Study Completion Date :||December 31, 2021|
Experimental: High Intensity Focused Ultrasound
Apply the machine 'Echopulse' with High Intensity Focused Ultrasound to treat the papillary thyroid microcarcinoma.
This is a machine to apply high intensity focused ultrasound to ablation the target zone. In this study, we would apply it to the papillary thyroid microcarcinoma.
Other Name: High Intensity Focused Ultrasound (HIFU)
No Intervention: Active surveillance
The participants will be monitored by the doctors actively, like more frequent in follow-up to observe their current situation.
- The proportion of tumors exhibiting disease progression [ Time Frame: 24 months ]To compare the proportion of patients with PTMC exhibiting signs of progression between HIFU and AS group at 24 months
- Median duration of progression-free survival [ Time Frame: 24 months ]To examine the median duration of progression-free survival within 2 years
- Change in tumor volume [ Time Frame: 24 months ]Tumor volume change from baseline (%) at 2 years
- Proportion of patients with active disease [ Time Frame: 24 months ]The proportion of patients with active disease confirmed by re-biopsy and CEUSG (%) at 2 years
- Proportion of patients undergoing planned and unplanned thyroidectomy [ Time Frame: 24 months ]To calculate the proportion of patients who undergoing thyroidectomy in planned or unplanned.
- Health related quality of life (HRQOL) [ Time Frame: 24 months ]To examine participants HRQOL during the study with a questionnaire combined with different measurement tools: SF-12 (12-Item Short Form Health Survey), SF-6D (Short Form 6 Dimensions), EQ-5D-5L (EuroQoL 5 Dimensions 5 Levels) and FACT-G (Functional Assessment of Cancer Therapy - general scale). The total score would be the health score of participants, as high score as high quality of life.
- Incidence of potential side-effects from intensity focused ultrasound treatment [ Time Frame: 24 months ]To examine any treatment-related side-effects after the treatment
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03327636
|Contact: Hung Hin, Brian Lang, MBBS (Hons)||+852 2255 email@example.com|
|Principal Investigator:||Hung Hin, Brian Lang, MBBS (Hons)||The University of Hong Kong|