Thyroid and Aging

Older adults are more vulnerable to the negative effects of excess thyroid hormone and may even be protected by lower levels of thyroid hormone. The diagnosis and management of thyroid disease in older adults needs to account for aging-related changes in function and resilliance.

A Contemporary Review of the Treatment of Medullary Thyroid Carcinoma in the Era of New Drug Therapies

Medullary thyroid cancer (MTC) is a rare neuroendocrine tumor that can be sporadic or inherited and is often associated with mutations in the RET (Rearranged during Transfection) oncogene. The primary treatment for MTC is surgical resection of all suspected disease, but recent advances in targeted therapies for MTC, including the selective RET inhibitors selpercatinib and pralsetinib, have led to changes in the management of patients with locally advanced, metastatic, or recurrent MTC. In this article, we review updates on the evaluation and management of patients with MTC, focusing on new and emerging therapies that are likely to improve patient outcomes.

Repeat Fine-Needle Aspiration With Molecular Analysis in Management of Indeterminate Thyroid Nodules

OBJECTIVE

To analyze clinical outcomes in a series of indeterminate thyroid nodules (ITNs) with repeat fine-needle aspiration (FNA) biopsy and results of genomic classifier.

STUDY DESIGN

Historical chart review.

SETTING

Tertiary care center.

METHODS

We reviewed FNA samples from subjects with Bethesda III or IV diagnoses from January 2015 to December 2018 at a single institution and selected those with repeat FNA and ThyroSeq testing of the same nodule. Patient demographics, Bethesda classifications, ThyroSeq results, treatment detail, and surgical pathology, when available, were analyzed.

RESULTS

Ninety-six patients with cytologic diagnosis of ITN, repeat FNA, and ThyroSeq testing were identified. Following repeat FNA, 55 nodules (57%) remained ITN; 40 (42%) were reclassified as benign; and 1 (1%) was reclassified as suspicious for malignancy. In 31 patients with ThyroSeq analysis accompanying initial and repeat FNA, 26 (84%) had the same result on each, while 5 (16%) tested ThyroSeq positive following an initially negative result (κ = 0.24). Most nodules that were downgraded to Bethesda II on repeat FNA (37/40, 93%) were managed nonsurgically. Patients with ThyroSeq-positive results were treated with surgery more often (25/28, 89%) than patients with ThyroSeq-negative results (11/68, 16%; P < .0001). In excised nodules, the prevalence of malignancy and noninvasive follicular thyroid neoplasm with papillary-like nuclear features was 28% (n = 10) and 22% (n = 8), respectively, and all malignancies were low risk.

CONCLUSION

In this case series, repeat FNA helped patients with ITNs avoid diagnostic surgery through reclassification to benign cytology. The risk of high-risk malignancy in ThyroSeq-positive nodules with repeat indeterminate cytology was low.

A Nod to the Nodes: An Overview of the Role of Central Neck Dissection in the Management of Papillary Thyroid Carcinoma

Lymph node metastasis in thyroid cancer is common and associated with an increased risk of locoregional recurrence (LRR). Although therapeutic central neck dissection is well established, prophylactic central node dissection (pCND) for microscopic occult nodal involvement is controversial and recommendations are based on low-level evidence. The potential benefits of pCND such as reducing LRR and re-operation, refining staging, and improving surveillance are enthusiastically debated and the decision to perform pCND must be weighed up against the increased risks of complications.

The enigma of persistent symptoms in hypothyroid patients treated with levothyroxine: A narrative review

A significant minority of patients with hypothyroidism report persistent symptoms despite achieving normal thyroid biochemistry after levothyroxine (L-T4) replacement. Four principal lines of thinking, which are not mutually exclusive, may explain this enigma. The 'low tissue liothyronine hypothesis' emphasizes the potential imperfections of L-T4 replacement therapy that may lead to hypothyroidism in some tissues such as the brain, while others (eg hypothalamus) are euthyroid. The 'Somatic Symptom and Related Disorders hypothesis' draws attention to an incidental coexistence of a diagnosis of Somatic Symptom and Related Disorders in patients with treated hypothyroidism. The 'autoimmune neuroinflammation hypothesis' highlights the potential consequences of inflammatory mediators due to thyroid autoimmunity (the commonest cause of hypothyroidism) on the brain. The 'comorbidities and psychosocial hypothesis' implicates a variety of physical and psychosocial factors that have been noted to be associated with a diagnosis of hypothyroidism, which may be primarily the cause of persistent complaints. Over the past twenty years, a great deal of time and effort has been expended pursuing the 'low tissue liothyronine hypothesis', which has failed to yield results that translate to patient benefits. This has skewed the balance in clinical practice, in favour of pursuing answers relating to L-T4 and liothyronine combination treatment, while the alternative explanations have been downplayed and potentially useful interventions have been given insufficient attention.

Cervical exenteration and its variants for locally advanced thyroid cancer: when, why, and how?

PURPOSE OF REVIEW

To describe the modern surgical approach for management of advanced thyroid cancers infiltrating the cervicovisceral axis with special attention to well differentiated tumors not amenable to organ-sparing techniques. In particular, cervical exenteration, herein defined as the sum of total thyroidectomy, central compartment and lateral neck dissections, variously associated with total laryngectomy and possible partial or total pharyngoesophagectomy, represents an extreme surgical procedure that, in properly selected cases, allows for reasonable palliation of central compartment life-threatening signs/symptoms if not cure for an advanced oncologic condition.

RECENT FINDINGS

Cervical exenteration is not contraindicated by the presence of limited distant metastases at presentation. Even though it requires that the patient is in general good health as it can be associated with a number of complications and long in-hospital stay, when appropriately planned and performed according to the most recent reconstructive nuances, it allows good oncologic outcomes that are not inferior to those described for similarly advanced primaries of the upper aerodigestive tract. In addition, quality of life and functional results are not significantly different from those described after total laryngectomy for primary laryngeal squamous cell carcinomas.

SUMMARY

Cervical exenteration requires a tertiary, expert, multidisciplinary effort in terms of diagnosis, surgical performance, and postoperative care. A patient-centered decision process is strongly warranted taking into consideration alternative therapeutic and symptom-based palliative strategies.

Incidence of Vocal Cord Paralysis in Medullary Thyroid Cancer

OBJECTIVE

Medullary thyroid cancer (MTC) is a neuroendocrine tumor that comprises 3-5% of all thyroid cancers in the United States. Vocal cord paralysis (VCP) may be due to involvement of the recurrent laryngeal nerve (RLN) preoperatively, or nerve sacrifice during surgery. The purpose of this study was to demonstrate the incidence of VCP in MTC and evaluate whether VCP has an impact on overall survival.

METHODS

This was a retrospective chart review of patients with MTC treated at Loyola University Medical Center from 2007 to 2021. Information on demographics, cancer diagnosis and treatment, laboratory data, and survival were collected.

RESULTS

A total of 79 patients were included in our study. 47 (59.5%) patients were female. The average age at the time of diagnosis was 51.3 years (SD 13.58). VCP was identified in 13 out of 79 (16.5%) patients. There were 71 patients with at least 1-year follow-up with median (Q1, Q3) years of 7.2 (3.9, 11.0). Those with VCP within 1 year had 7.2 (95% CI: 2.3, 22.7) times the risk of death compared to those without (p < 0.001).

CONCLUSION

MTC is a rare thyroid cancer, however, its incidence is on the rise. Our study suggests that the incidence of VCP in these patients appears to be higher than seen in other thyroid malignancies, and VCP is associated with a statistically significant negative impact on survival.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:890-894, 2023.

Age-Dependent Clinicopathological Characteristics of Patients with T1b Papillary Thyroid Carcinoma: Implications for the Possibility of Active Surveillance

BACKGROUND

Active surveillance (AS) of low-risk T1a papillary thyroid carcinoma (PTC) is generally accepted as an alternative to immediate surgery. The cut-off in the size criterion for AS has recently been extended in select individuals, especially older patients. We evaluated the clinicopathological differences of T1b PTC according to age to investigate the possibility of AS in older patients.

PATIENTS AND METHODS

From a cohort study of 1269 patients undergoing lobectomy for PTC, 1223 PTC patients with T1 stage disease (tumor ≤ 2 cm) were enrolled. The clinicopathological characteristics between T1a and T1b patients according to age were analyzed.

RESULTS

Among the 1223 T1 cases, 918 (75.1%) were T1a (≤ 1 cm) and 305 (34.9%) T1b (> 1 and ≤ 2 cm). T1b PTC was associated with male sex, minimal extrathyroidal extension, lymphovascular invasion, occult central lymph node (LN) metastasis, and a higher number of metastatic LNs than T1a. However, in patients over 55 years of age, the clinicopathological features of the patients with T1a and T1b PTC were not significantly different except for minimal extrathyroidal extension, although many clinicopathological differences were observed in patients under 55 years of age.

CONCLUSION

The clinicopathological features of patients with T1b PTC over 55 years of age are similar to those with T1a PTC and less aggressive than those with T1b PTC under 55 years of age. These findings suggest that AS may be possible in patients with T1b PTC over 55 years of age without high-risk features on preoperative examinations.

Extent of Surgery for Follicular Thyroid Carcinoma

OBJECTIVES

To examine the association between the extent of surgery and overall survival in follicular thyroid cancer (FTC) patients.

STUDY DESIGN

Retrospective analysis of the National Cancer Database (NCDB).

METHODS

Patients who underwent surgical intervention for FTC from 2004 to 2015 were selected. Patients were >18 years old, with tumor size 1-4 cm, no other malignancies, and >0 follow up time. Patients were divided into two cohorts based on extent of surgery: lobectomy (≥1 lobe resected) and thyroidectomy (total or near total resection). Pearson's chi-squared analysis was used to compare cohorts. Kaplan-Meier survival and Cox hazards models were utilized to determine overall survival between two cohorts with p < 0.05 used for significance.

RESULTS

A total of 6871 patients were identified with FTC, of which 1507 patients underwent lobectomy and 5364 patients underwent total thyroidectomy. There were no significant differences in patient demographics, comorbidity index, local spread, or tumor grade. Patients undergoing lobectomy had mean survival of 12.94 versus 12.71 years for those undergoing thyroidectomy. Extent of surgery was not associated with a significant difference in survival (5 years OS = 96% in lobectomy and 95.5% in total thyroidectomy, p = 0.08). Stratification by tumor grade resulted in no significant difference in survival between lobectomy and thyroidectomy.

CONCLUSION

Survival time was not significantly different in patients with more extensive resection of FTC.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:993-999, 2023.

Novel germline variants of CDKN1B and CDKN2C identified during screening for familial primary hyperparathyroidism

PURPOSE

CDKN1B mutations were established as a cause of multiple endocrine neoplasia 4 (MEN4) syndrome in patients with MEN1 phenotype without a mutation in the MEN1 gene. In addition, variants in other cyclin-dependent kinase inhibitors (CDKIs) were found in some MEN1-like cases without the MEN1 mutation. We aimed to describe novel germline mutations of these genes in patients with primary hyperparathyroidism (PHPT).

METHODS

During genetic screening for familial hyperparathyroidism, three novel CDKIs germline mutations in three unrelated cases between January 2019 and November 2021 were identified. In this report, we describe clinical features, DNA sequence analysis, and familial segregation studies based on these patients and their relatives. Genome-wide DNA study of loss of heterozygosity (LOH), copy number variation (CNV), and p27/kip immunohistochemistry was performed on tumour samples.

RESULTS

DNA screening was performed for atypical parathyroid adenomas in cases 1 and 2 and for cystic parathyroid adenoma and young age at diagnosis of PHPT in case 3. Genetic analysis identified likely pathogenic variants of CDKN1B in cases 1 and 2 and a variant of the uncertain significance of CDKN2C, with uniparental disomy in the tumour sample, in case 3. Neoplasm screening of probands showed other non-endocrine tumours in case 1 (colon adenoma with dysplasia and atypical lipomas) and case 2 (aberrant T-cell population) and a non-functional pituitary adenoma in case 3.

CONCLUSION

Germline mutations in CDKIs should be included in gene panels for genetic testing of primary hyperparathyroidism. New germline variants here described can be added to the current knowledge.

Risk factors for the lateral cervical lymph node metastasis of papillary thyroid carcinoma: A clinical study

Currently, there is a lack of evidence-based risk factors for the lateral cervical lymph node metastasis of papillary thyroid carcinoma (PTC). Thus, the risk factors and recurrence rate of lateral cervical lymph node metastasis were investigated in the present study for patients with PTC who underwent initial radical surgery. The data of 274 patients with PTC who underwent initial radical surgery over a 10-year period from January, 2009 to December, 2018 were retrospectively analyzed. By applying univariate analysis, lymphovascular invasion, venous invasion, extrathyroidal infiltration, paratracheal lymph node metastasis and tumor size were designated as significant risk factors for lateral cervical lymph node metastasis. As regards multivariate analysis, paratracheal lymph node metastasis and tumor size were identified as independent risk factors. The recurrence rate was higher in patients presenting with lateral cervical lymph node metastasis, and the disease-free survival rate was significantly lower in the patient group presenting with lateral cervical lymph node metastasis. On the whole, the present study demonstrated that paratracheal lymph node metastasis and tumor size were independent risk factors for lateral cervical lymph node metastasis.

Long-term predictive value of highly sensitive thyroglobulin measurement

OBJECTIVE

To examine the predictive value of unremarkable nonstimulated highly sensitive thyroglobulin (hsTg) measurement with regard to the results of stimulated thyroglobulin (Tg) measurement, diagnostic whole-body scintigraphy, recurrence and differentiated thyroid cancer (DTC)-related death.

DESIGN, PATIENTS AND MEASUREMENTS

We retrospectively analysed the data of all 461 (410 without anti-Tg-antibodies [TgAbs], 51 with) DTC patients who were referred to our department for treatment and follow-up care of differentiated thyroid cancer from 2004 onwards, and in whom at least one posttreatment Tg value was measured in our hospital at least 3 months after I-131 ablation.

RESULTS

In the group of TgAb-negative patients, 2.0% of patients with an unstimulated Tg < 0.1 ng/ml showed a stimulated Tg ≥ 1.0 ng/ml, whereas this happened in 77.6% with an unstimulated Tg ≥ 0.1 but <1.0 ng/ml. An unstimulated hsTg ≥ 0.1 ng/ml had a sensitivity specificity positive and negative predictive value of 90.0%, 94.1%, 77.6% and 97.6%, respectively, for a stimulated Tg ≥ 1.0 ng/ml. In TgAb-positive patients, this was 75%, 97%, 75% and 97%, respectively. An unstimulated Tg ≥ 0.1 ng/ml did not significantly discriminate with regard to the risk of DTC-related death (p = .06), but ≥1.0 ng/ml did (p = .012), as did a stimulated Tg ≥ 1.0 ng/ml (p = .029). Excluding patients with distant metastases at diagnosis nullifies this significance.

CONCLUSION

Except for patients with distant metastases, both TgAb negative and TgAb positive patients with an undetectable nonstimulated hsTg measurement have a very good prognosis. The high net present value of unstimulated hsTg testing means that further diagnostic procedures can be omitted in such patients.

Lobectomy or Total Thyroidectomy-Where Is the Pendulum now for Differentiated Thyroid Cancer?

Thyroid surgery remains an essential treatment of thyroid cancer. The historical one-size-fits-all approach to differentiated (papillary and follicular) thyroid carcinoma of total thyroidectomy with central lymph node dissection has been shown to be overtreatment with associated risk of perioperative complications including nerve palsy and hypoparathyroidism. Furthermore, thyroid lobectomy may obviate life-long thyroid hormone replacement. Low-risk thyroid cancers have a low risk of recurrence and those that do recur can be salvaged with reoperation without compromising prognosis. Perioperative risk stratification for recurrence and death greatly influence the need for total thyroidectomy.

Gut microbiota is associated with response to (131)I therapy in patients with papillary thyroid carcinoma

PURPOSE

Radioactive iodine (¹³¹I) therapy is a conventional post-surgery treatment widely used for papillary thyroid carcinoma (PTC). Since ¹³¹I is orally administered, we hypothesize that it may affect gut microbiome. This study aims to investigate alterations of intestinal microbiome caused by ¹³¹I therapy in PTC patients and explore its association with response to ¹³¹I therapy.

METHODS

Fecal samples of 60 PTC patients pre- and post-¹³¹I therapy were collected to characterize the ¹³¹I therapy-induced gut microbiota alterations using 16S rRNA gene sequencing. According to the inclusion criteria, sequence data of 40 out of the 60 patients, divided into excellent response (ER) group and non-excellent response (NER) group, were recruited to investigate the possible connection between gut microbiota and response to ¹³¹I therapy. Multivariate binary logistic regression was employed to construct a predictive model for response to ¹³¹I therapy.

RESULTS

Microbial richness, diversity, and composition were tremendously altered by ¹³¹I therapy. A significant decline of Firmicutes to Bacteroides (F/B) ratio was observed post-¹³¹I therapy. ¹³¹I therapy also led to changes of gut microbiome-related metabolic pathways. Discrepancies in β diversity were found between ER and NER groups both pre- and post-¹³¹I therapy. Furthermore, a predictive model for response to ¹³¹I therapy with a p value of 0.003 and an overall percentage correct of 80.0% was established, with three variables including lymph node metastasis, relative abundance of g_Bifidobacterium and g_Dorea. Among them, g_Dorea was identified to be an in independent predictor of response to ¹³¹I therapy (p = 0.04).

CONCLUSION

For the first time, the present study demonstrates the gut microbial dysbiosis caused by ¹³¹I therapy in post-surgery PTC patients and reveals a previously undefined role of gut microbiome as predictor for ¹³¹I ablation response. G_Dorea and g_Bifidobacterium may be potential targets for clinical intervention to improve response to ¹³¹I in post-operative PTC patients.

TRIAL REGISTRATION

ChiCTR2100048000. Registered 28 June 2021.

Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis

Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT₄], or high free tri-iodothyonine [FT₃]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT₄ concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (¹³¹I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.

Effect of metformin alone and in combination with etoposide and epirubicin on proliferation, apoptosis, necrosis, and migration of B-CPAP and SW cells as thyroid cancer cell lines

Background and purpose

There has not been a comprehensive study on the simultaneous effects of metformin, etoposide, and epirubicin on thyroid cancer cells. Hence, the current research proposed the in vitro study on the effect of metformin alone and in combination with etoposide and epirubicin on the rate of proliferation, apoptosis, necrosis, and migration against B-CPAP and SW-1736 cells as thyroid cancer cell lines.

Experimental approach

MTT-based proliferation assay, combination index method, flow cytometry, and scratch wound healing assays were used to evaluate the simultaneous effects of the three approved drugs against thyroid cancer cells.

Findings/Results

This study showed that the toxic concentration of metformin on normal Hu02 cells was more than 10 folds higher than B-CPAP and SW cancerous cells. Metformin in combination with epirubicin and etoposide could increase percentages of B-CPAP and SW cells in early and late apoptosis and necrosis phases in comparison with their single concentrations, significantly. Metformin in combination with epirubicin and etoposide could arrest the S phase in B-CPAP and SW cells, significantly. Metformin in combination with epirubicin and etoposide could reduce ~100% migration rate, whereas single concentrations of epirubicin and etoposide could reduce ~50% migration rate.

Conclusion and implication

Combined treatment of metformin with anticancer drugs epirubicin and etoposide can increase the mortality in thyroid cancer cell lines and reduce the toxicity of these drugs on the normal cell line, which could be the starting point for proposing a new combination strategy in the therapy of thyroid cancer to induce more potency and reduce acute toxicity.

Clinical and ultrasonic risk factors for high-volume central lymph node metastasis in cN0 papillary thyroid microcarcinoma: A retrospective study and meta-analysis

OBJECTIVE

Papillary thyroid microcarcinoma (PTMC) comprises more than 50% of all newly detected cases of papillary thyroid carcinoma (PTC). High-volume lymph node metastasis (involving >5 lymph nodes) (hv-LNM) is associated with PTMC recurrence. In half of the clinically node-negative (cN0) PTMC patients, central lymph node metastasis (CLNM) is pathologically present. However, clinical risk factors for high-volume CLNM (hv-CLNM) in cN0 PTMC have not been defined well. Therefore, we aimed to obtain evidence for hv-CLNM risk factors in cN0 PTMC.

DESIGN

Data on patients who visited our hospital between January 2020 and December 2021 were collected; a preoperative diagnosis of cN0 and a postoperative pathological confirmation of PTMC were obtained. After filtering by inclusion versus exclusion criteria, the obtained data (N = 2268) were included in the meta-analysis. Relevant studies published as of 10 April 2022, were identified from the Web of Science, PubMed, WANFANG, and CNKI databases. These eligible studies were included in the meta-analysis and the association between clinicopathological factors and hv-CLNM in cN0 PTMC was assessed. SPSS and MetaXL were used for statistical analyses.

RESULTS

The meta-analysis included 10 previous studies (11,734 patients) and 2268 patients enroled in our hospital for a total of 14,002 subjects. The results of which suggested that younger age (<40, odds ratio [OR] = 3.28, 95% confidence interval [CI] = 2.75-3.92, p < .001 or <45 odds ratio [OR] = 2.93, 95% CI = 2.31-3.72, p < .001), male sex (OR = 2.81, 95% CI = 2.25-3.52, p < .001), tumour size >5 mm (OR = 1.85, 95% CI = 1.39-2.47, p < .001), multifocality (OR = 1.88, 95% CI = 1.56-2.26, p < .001), extrathyroidal extension (OR = 2.58, 95% CI = 2.02-3.30, p < .001), capsule invasion (OR = 2.02, 95% CI = 1.46-2.78, p < .001), microcalcification (OR = 3.25, 95% CI = 2.42-4.36, p < .001) and rich blood flow (OR = 1.65, 95% CI = 1.21-2.25, p = .002) were the significant factors related to an elevated hv-CLNM risk in cN0 PTMC patients. Hashimoto thyroiditis (OR = 0.76, 95% CI = 0.55-1.07, p = .114), irregular margin (versus regular margin, OR = 0.96, 95% CI = 0.68-1.33, p = .787) and hypoechoic (versus nonhypoechoic, OR = 1.27, 95% CI = 0.84-1.92, p = .261) showed no significant association with hv-CLNM.

CONCLUSIONS

Younger age, tumour size >5 mm, males, extrathyroidal extension, multifocality, microcalcification, capsular invasion, and rich blood flow were the significant clinicopathological risk factors for hv-CLNM risk in cN0 PTMC patients. These predictors may compensate for the sensitivity of imaging diagnosis in the preoperative period, thus helping in the effective identification of PTMCs with an invasive phenotype.

Outcomes and Trends of Treatments in High-Risk Differentiated Thyroid Cancer

OBJECTIVES

To analyze the variant-specific survival benefits and usage patterns of standardized treatment combinations of surgery (S), radioactive iodine ablation (RAI), and thyroid-stimulating hormone suppression therapy (THST) for high-risk differentiated thyroid cancer.

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database.

METHODS

The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for high-risk papillary, follicular, or Hurthle cell thyroid cancer. Cox proportional hazards and Kaplan-Meier analyses assessed for treatment-associated survival.

RESULTS

Of 21,076 cases, 18,214 underwent survival analysis with a mean ± SD age of 50.6 ± 17.1 years (71.3% female). When compared with surgery alone, S + RAI was associated with reduced mortality in papillary (hazard ratio [HR], 0.574; P < .001) and follicular (HR, 0.489; P = .004) thyroid cancer. S + RAI + THST was associated with reduced mortality in papillary (HR, 0.514; P < .001), follicular (HR, 0.602; P = .016), and Hurthle cell (HR, 0.504; P = .021) thyroid cancer. In papillary thyroid cancer, S + RAI (91.3%), S + THST (89.2%), and S + RAI + THST (92.7%) were associated with higher 5-year overall survival rates than surgery (85.4%, all P < .001). Papillary thyroid cancer treatments involving THST were associated with higher 5-year overall survival rates than corresponding regimens without THST (all P < .001). In follicular thyroid cancer, S + RAI (73.9%) and S + RAI + THST (78.7%) were associated with higher 5-year overall survival rates than surgery (65.6%, all P < .05). In Hurthle cell thyroid cancer, S + RAI (66.5%) and S + RAI + THST (73.4%) were associated with higher 5-year overall survival rates than surgery (53.7%, all P < .05). On linear regression, THST usage increased by 77.5% (R² = 0.944, P < .001), while RAI usage declined by 11.3% (R² = 0.320, P = .035).

CONCLUSIONS

High-risk differentiated thyroid cancer exhibited varying susceptibilities to different treatment combinations depending on histology, with greatest responses to regimens that included RAI. Physician practices have trended toward decreased RAI and increased THST usage.

Warthin-Like Papillary Thyroid Microcarcinoma With Coincidental Ipsilateral Warthin Tumor of the Parotid Gland Detected on 131 I-SPECT/US and 18 F-PET/US Fusion Imaging

ABSTRACT

A 66-year-old woman was referred with an incidental finding of a bilateral papillary thyroid microcarcinoma after thyroidectomy. On the right side, a Warthin-like variant was observed. After radioiodine therapy, whole-body scan revealed an unclear iodine uptake on the right-sided neck. For further clarification, 131 I-SPECT/US and 18 F-PET/US fusion imaging were performed, unambiguously revealing iodine and glucose uptake within a hypoechoic lesion located in the parenchyma of the right parotid gland. Surgical excision confirmed a Warthin tumor ipsilateral to the Warthin-like variant of the papillary thyroid microcarcinoma. Because the extensive imaging, targeted minimal-invasive surgery was possible.

Value of CEUS combined with feeding artery ablation in the microwave ablation of large solid benign thyroid nodules

OBJECTIVES

To investigate the value of contrast-enhanced ultrasound (CEUS) combined with feeding artery ablation in the microwave ablation (MWA) of large solid benign thyroid nodules (LSBTNs) with a diameter ≥ 4 cm.

METHODS

We retrospectively analyzed 122 patients with LSBTN ≥ 4 cm in diameter treated with MWA. During evaluations before and after MWA, 53 patients who underwent conventional ultrasound examination were classified as the routine group, and 69 patients who underwent CEUS combined with feeding artery ablation were classified as the union group. The differences in ablation energy required per milliliter (AERPM), complication rate, regrowth rate, and volume reduction rate (VRR) were compared between the two groups.

RESULTS

The AERPM of the union group was significantly less than that of the routine group (956.3 ± 38.5 J/mL vs. 1025.9 ± 121.5 J/mL, p < 0.001). The complication rate of the routine group was significantly higher than that of the union group (13.2% vs. 2.9%, p = 0.031). The regrowth rate of the routine group (22.6%, 12/53) was significantly higher than that of the union group (7.2%, 5/69) (p = 0.015). At the 1st, 3rd, 6th, 12th, 18th, and 24th month after ablation, the mean VRRs of the routine group were significantly less than those of the union group, with p values of < 0.001, < 0.001, 0.002, 0.007, 0.013, and < 0.001, respectively.

CONCLUSIONS

The application of CEUS combined with feeding artery ablation in the MWA of LSBTNs is helpful to reduce the regrowth rate, improve the ablation efficiency, and reduce bleeding.

KEY POINTS

• CEUS combined with feeding artery ablation in MWA of LSBTNs is helpful to reduce regrowth rate. • CEUS combined with feeding artery ablation can help improve ablation efficiency than conventional ultrasound in LSBTNs. • CEUS combined with feeding artery ablation helps reduce the incidence of bleeding during MWA.

The 5(th) edition of WHO classification of tumors of endocrine organs: changes in the diagnosis of follicular-derived thyroid carcinoma

The 5^th edition of the World Health Organization (WHO) classification of endocrine tumors was released in 2022. Several novelties have been introduced concerning the nomenclature and histopathological diagnosis of follicular-derived thyroid neoplasms. Tumor types have been sharply classified according to prognostic risk categories into benign tumors, low-risk neoplasms and malignant neoplasms. A grading system for differentiated thyroid carcinomas has been implemented with the aim of improving the stratification of tumors. Particular attention has been paid to the molecular profile of well-differentiated histotypes. In this review, the main changes introduced by the latest edition of the WHO system are presented. The practical effects on the diagnostic pathology of thyroid tumors, along with the clinical implications expected with the new classification scheme, are critically discussed.

The evaluation of locoregional tumoral involvement in the cooccurrence of hashimoto thyroiditis with papillary thyroid cancer: a case controlled study

BACKGROUND

Papillary thyroid carcinoma PTC is the most prevalent of all thyroid carcinomas. On the other hand, Hashimoto's thyroiditis (HT), as part of the spectrum of autoimmune thyroid diseases, is a major cause of thyroid hypofunction worldwide. Several studies have aimed to indicate a possible correlation between PTC and HT over the years. This study aims to investigate the correlation between HT disease and PTC tumor invasion rate.

METHOD

In the present cross-sectional study, PTC patients with HT were selected among patients referred to the surgical ward of Shariati hospital from 2016 to 2019 and compared in terms of tumor invasion and central LN dissection. Also, a similar group of PTC patients without HT undergoing total thyroidectomy was selected for comparison. The tumor invasion rate was assessed based on invasion indices obtained from postoperative permanent pathology specimens. These indices included tumor type and size, number of involved LNs, lymphovascular involvement, perineural involvement, thyroid capsule involvement, multifocal or unifocal tumor, extrathyroidal proliferation, marginal status, and necrosis. Data were obtained and compared in the two groups with SPSS version 22.0 software.

RESULTS

Based on the postoperative pathology reports, 50 (56.2%) PTC patients with Hashimoto thyroiditis were compared against 39 PTC patients without Hashimoto thyroiditis. No significant difference was found between the two groups regarding tumor invasion factors such as multifocality, lymphovascular invasion, marginal invasion, extrathyroidal invasion, capsular invasion, and necrosis.

CONCLUSION

HT could not be mentioned as an aggravating factor of PTC invasion based on the invasion factors evaluated in pathology specimens.

Single inferior parathyroid autotransplantation during total thyroidectomy with bilateral central lymph node dissection for papillary thyroid carcinoma: a retrospective cohort study

BACKGROUND

Management of the inferior parathyroid gland using total thyroidectomy (TT) with central lymph node dissection (CLND) is still controversial. Therefore, we evaluated the safety and effectiveness of single inferior parathyroid autotransplantation.

METHODS

The clinical data of patients with papillary thyroid carcinoma (PTC) who underwent TT with bilateral CLND from January 2018 to December 2020 were collected. Quality of life (QoL) was assessed using the Chinese version of the EORTC QLQ-C30 and THYCA-QOL. The patients were divided into an autotransplantation group and a preservation group according to whether a single inferior parathyroid gland was transplanted. The incidence of permanent hypoparathyroidism, the number of resected central lymph nodes (CLNs), the rate of recurrence reoperation, the rate of radioactive iodine (RAI) treatment, and the QoL score were compared between the two groups.

RESULTS

A total of 296 patients were included in the study; there were 99 patients in the autotransplantation group and 197 in the preservation group. The incidence of permanent hypoparathyroidism was 3.0% (3/99) and 4.6% (9/197) in the autotransplantation and preservation groups, respectively (P = 0.532). The median number of resected CLNs was 12 (8-17) and 10 (6-14) in the autotransplantation and preservation groups, respectively (P = 0.015). No reoperations were performed for patients with CLN recurrence, and the rates of lateral lymph node (LLN) recurrence reoperation were 2.0% (2/99) and 3.6% (7/197) in the autotransplantation and preservation groups, respectively (P = 0.473). The RAI treatment rates were 12.1% (12/99) and 22.3% (44/197) in the autotransplantation and preservation groups, respectively (P = 0.034). A total of 276 questionnaires were recovered, including 84 in the autotransplantation group and 192 in the preservation group. The QoL of the two groups of patients is similar (P > 0.05).

CONCLUSION

Single inferior parathyroid autotransplantation during thyroidectomy can be used to prevent permanent hypoparathyroidism and can enable more extensive CLND.

Diagnostic Performance of Six Ultrasound Risk Stratification Systems for Thyroid Nodules: A Systematic Review and Network Meta-Analysis

BACKGROUND. Risk stratification systems for evaluating thyroid nodules on ultrasound use varying approaches to classify levels of suspicion for malignancy, leading to variable performance. OBJECTIVE. The purpose of this study was to perform a network meta-analysis comparing six risk stratification systems used to evaluate thyroid nodules on ultrasound in terms of their diagnostic performance for the detection of thyroid cancer. EVIDENCE ACQUISITION. Five bibliometric databases were searched for studies published through August 31, 2022, that compared at least two of six ultrasound risk stratification systems (the American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi [AACE/ACE/AME] system; American College of Radiology Thyroid Imaging Reporting and Data System [ACR TI-RADS]; the American Thyroid Association [ATA] risk stratification system; European Thyroid Association Thyroid Imaging Reporting and Data System [EU-TIRADS]; the Korean Thyroid Imaging Reporting and Data System [K-TIRADS] endorsed by the Korean Thyroid Association and the Korean Society of Thyroid Radiology; and the Thyroid Imaging Reporting and Data System developed by Kwak et al. [Kwak TIRADS]) in terms of their diagnostic performance for the detection of thyroid cancer, with cytologic or histologic evaluation used as a reference standard. The studies' risk of bias was evaluated using the Newcastle-Ottawa Scale. A meta-analysis of each system was performed to identify the risk category threshold that had the highest accuracy as well as the highest sensitivity and specificity at this threshold. Network meta-analysis was used to perform hierarchic ranking and identify the systems having the highest sensitivities and specificities at each system's most accurate threshold. EVIDENCE SYNTHESIS. The analysis included 39 studies with 49,661 patients. All studies were of fair (n = 17) or good (n = 22) quality. The most accurate risk category thresholds were class 3 (high risk) for the AACE/ACE/AME system, TR5 (highly suspicious) for ACR TI-RADS, EU-TIRADS 5 (high risk) for EU-TIRADS, 4c (moderate concern but not classic for malignancy) for Kwak TIRADS, K-TIRADS 5 (high suspicion) for K-TIRADS, and high suspicion for the ATA system. At these thresholds, the systems had sensitivity of 64-77% and specificity of 82-90%. Network meta-analysis identified the highest sensitivity and highest specificity for ACR TI-RADS, followed by K-TIRADS. CONCLUSION. Of six risk stratification systems, ACR TI-RADS had the highest diagnostic performance for the detection of thyroid nodules on ultrasound. CLINICAL IMPACT. This network meta-analysis can inform decisions regarding implementation of the risk stratification systems and can aid future system updates.

Redifferentiation of Differentiated Thyroid Cancer: Clinical Insights from a Narrative Review of Literature

Background: Patients who have metastatic differentiated thyroid cancer (mDTC) frequently have negative diagnostic and/or post-therapy radioiodine scans. As a result, ¹³¹I therapy is frequently no longer considered a therapeutic option for these patients. However, with the knowledge of genomic alterations of patients with mDTC, the use of selected agents in specific patient groups may be used with the intention to re-establish ¹³¹I uptake (i.e., redifferentiation) and additional ¹³¹I therapy. The objectives of this narrative review are to present definitions of related terminology, a brief overview of the molecular mechanisms of redifferentiating agents, and a narrative review of the literature for redifferentiation in patients who have radioiodine refractory mDTC. Summary: We searched multiple electronic databases and reviewed the relevant English-language literature reported after 2010. Fourteen articles were included in this narrative review. Conclusions: Preliminary data suggest that select agents may offer potential for re-establishing ¹³¹I uptake in selected patients with radioiodine refractory mDTC (e.g., negative diagnostic and/or post-therapy radioiodine scans). These agents may also enhance uptake (e.g., uptake enhancement) in patients who have ¹³¹I uptake in mDTC on a diagnostic and/or post-therapy radioiodine scan. As a result, this may facilitate higher absorbed dose delivered (Gy (rad]) per ¹³¹I activity administered [GBq (mCi)]. This in turn may increase the likelihood of a better therapeutic effect for the planned administered ¹³¹I activity or a reduction in the originally planned administered ¹³¹I activity, while achieving the same intended therapeutic effect with potentially less untoward effects. Further studies are warranted to confirm these preliminary observations and to confirm acceptable subsequent ¹³¹I therapy responses after redifferentiation and/or uptake enhancement.

Infertility and Pregnancy Rates in Female Thyroid Cancer Survivors: A Retrospective Cohort Study Using Health Care Administrative Data from Israel

Background: Thyroid cancer (TC) is one of the most common carcinomas in young women. Concerns have been raised regarding the impact of the disease and its treatment on reproductive function. The aim of the study was to investigate the association of TC diagnosis and radioactive iodine (RAI) treatment on infertility and pregnancy rates in women. Methods: The comprehensive computerized database of a health management organization in Israel was screened for all female patients who were diagnosed with TC at age ≤40 years in 2000-2020. Rates of infertility (based on a documented diagnosis or purchase of fertility medications in the patient files) and pregnancy were compared with healthy age-matched controls. Results: The cohort included 1164 patients with TC (median age at diagnosis 31.6 years; interquartile range [IQR]: 26.7-35.4) and 5030 controls, followed for a median period of 10 years (IQR: 5.0-15.0). The infertility rate was higher in the TC group than in the control group (23.9% vs. 20.4%, p = 0.008). Still, the postdiagnosis/referent date pregnancy rates were comparable in the whole cohort (46.9/47.7%, p = 0.625) and across all age quartiles. The median time to the first pregnancy postdiagnosis/referent date was longer in TC patients than in controls (37 vs. 31 months, p < 0.001). Within the TC group, women who received repeated radioactive iodine treatment (n = 611, 52.5%) had comparable rates of infertility and pregnancy as those who did not. However, their time to the first postdiagnosis pregnancy was longer (median 45 vs. 29 months, p = 0.020). Conclusions: Our study provides reassuring evidence about the reproductive characteristics of women treated for TC. Pregnancy rates in TC survivors were comparable with controls. However, a higher infertility rate and a longer time to conceive were observed in the TC group compared with the control group. These findings were consistent in women who received single or repeated RAI treatments.

Oxidative stress mediates the associations between phthalate exposures and thyroid cancer/benign nodule risk

Epidemiological studies have suggested that phthalate exposures are associated with increased risks of thyroid cancer and benign nodule, while the underlying mechanisms are largely unknown. Here, we explored the mediation effects of oxidative stress (OS) biomarkers in the associations between phthalate exposures and the risks of thyroid cancer and benign nodule. Urine samples collected from 143 thyroid cancer, 136 nodule patients, and 141 healthy controls were analyzed for 8 phthalate metabolites and 3 OS biomarkers [8-hydroxy-2-deoxyguanosine (8-OHdG), 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA), and 8-iso-prostaglandin F_2α (8-isoPGF_2α)]. Multivariable linear or logistic regression models were used to explore the associations of OS biomarkers with phthalate metabolite concentrations and the risks of thyroid cancer and nodule. The mediation role of OS biomarkers was also investigated. Urinary monoethyl phthalate (MEP), monomethyl phthalate (MMP), mono (2-ethyl-5-oxohexyl) phthalate (MEOHP), mono (2-ethylhexyl) phthalate (MEHP), and mono (2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) were positively associated with at least 2 OS biomarkers (all P-values<0.01), and part of these positive associations varied in different subgroups. All 3 OS biomarkers were positively associated with the risks of thyroid nodule and cancer (P-values<0.001). The mediation analysis showed that OS biomarkers significantly mediated the associations between urinary MEHOP concentration and nodule, as well as between urinary MMP, MEHP, and MEHHP concentrations and cancer and nodule, with the estimated proportions of mediation ranging from 15.8% to 85.6%. Our results suggest that OS is a potential mediating mechanism through which phthalate exposures induce thyroid carcinogenesis and nodular formation.

The role of miR-139-5p in radioiodine-resistant thyroid cancer

PURPOSE

Radioiodine I-131 (RAI) is the therapy of choice for differentiated thyroid cancer (DTC). Between 5% and 15% of DTC patients become RAI refractory, due to the loss of expression/function of iodide metabolism components, especially the Na/I symporter (NIS). We searched for a miRNA profile associated with RAI-refractory DTC to identify novel biomarkers that could be potential targets for redifferentiation therapy.

METHODS

We analyzed the expression of 754 miRNAs in 26 DTC tissues: 12 responsive (R) and 14 non-responsive (NR) to RAI therapy. We identified 15 dysregulated miRNAs: 14 were upregulated, while only one (miR-139-5p) was downregulated in NR vs. R tumors. We investigated the role of miR-139-5p in iodine uptake metabolism. We overexpressed miR-139-5p in two primary and five immortalized thyroid cancer cell lines, and we analyzed the transcript and protein levels of NIS and its activation through iodine uptake assay and subcellular protein localization.

RESULTS

The finding of higher intracellular iodine levels and increased cell membrane protein localization in miR-139-5p overexpressing cells supports the role of this miRNA in the regulation of NIS function.

CONCLUSIONS

Our study provides evidence of miR-139-5p involvement in iodine uptake metabolism and suggests its possible role as a therapeutic target in restoring iodine uptake in RAI-refractory DTC.

Immunotherapy or targeted therapy: What will be the future treatment for anaplastic thyroid carcinoma?

Anaplastic thyroid carcinoma (ATC) is a rare and aggressive form of thyroid carcinoma (TC). Currently, there are no effective treatments for this condition. In the past few years, targeted therapy and immunotherapy have made significant progress in ATC treatment. Several common genetic mutations have been found in ATC cells, involving different molecular pathways related to tumor progression, and new therapies that act on these molecular pathways have been studied to improve the quality of life of these patients. In 2018, the FDA approved dabrafenib combined with trametinib to treat BRAF-positive ATC, confirming its therapeutic potential. At the same time, the recent emergence of immunotherapy has also attracted wide attention from researchers. While immunotherapy for ATC is still in the experimental stage, numerous studies have shown that immunotherapy is a potential therapy for ATC. In addition, it has also been found that the combination of immunotherapy and targeted therapy may enhance the anti-tumor effect of targeted therapy. In recent years, there has been some progress in the study of targeted therapy or immunotherapy combined with radiotherapy or chemotherapy, showing the prospect of combined therapy in ATC. In this review, we analyze the response mechanism and potential effects of targeted therapy, immunotherapy, and combination therapy in ATC treatment and explore the future of treatment for ATC.

Explore the diagnostic performance of 2020 Chinese Thyroid Imaging Reporting and Data Systems by comparing with the 2017 ACR-TIRADS guidelines: a single-center study

OBJECTIVE

To compare the diagnostic efficacy of the Chinese Thyroid Imaging Reporting and Data Systems (C-TIRADS) with the well-accepted ACR-TIRADS guidelines in identifying benign from malignant thyroid nodules.

METHODS

A total of 2064 nodules were collected from 1627 patients undergoing thyroid ultrasonography in our center between October 2019 and November 2021. Nodules were divided into two groups: "≥1 cm" and "<1 cm". Ultrasound features of each nodule were observed and recorded by two physicians with more than 15 years of experience and classified according to the ACR-TIRADS and C-TIRADS guidelines, respectively.

RESULTS

The area under the curve of the ACR-TIRADS guideline was higher than that of the C-TIRADS guideline (0.922, P = 0.017), the specificity and positive predictive value of the C-TIRADS guideline were higher (81.64%, 88.72%, all P < 0.05), which was more significant in the subgroup of nodules <1 cm (P = 0.001). In addition, there was no statistical difference between the two guidelines in the diagnostic efficacy indicators for nodules ≥1 cm. The ACR-TIRADS effectively reduced unnecessary biopsies compared with the C-TIRADS (P < 0.05).

CONCLUSIONS

There was high agreement between the two guidelines for the diagnosis of thyroid nodules, C-TIRADS guidelines had a higher specificity and simplicity while were inferior to the ACR-TIRADS guidelines in terms of reducing the number of biopsies.

Challenges and strategies to combat resistance mechanisms in thyroid cancer therapeutics

BACKGROUND

BRAF V600E and K/N/H RAS mutations and oncogenic kinase fusions involving NTRK, RET, ALK and ROS1 have been identified as actionable targets in thyroid cancer. These driver alterations lead to onocogene addiction which has been successfully exploited through tyrosine kinase inhibitors. Acquired resistance may develop following an initial response requiring a therapeutic pivot to new therapies.

SUMMARY

Several pathways for development of acquired resistance have been identified. These encompass acquired on-target gene mutation impeding drug activity and upregulation of bypass kinase signaling pathways leading to tumour progression. Biopsy of resistant lesions (liquid or tissue) and subsequent molecular analysis can assist with new therapeutic strategies.

CONCLUSIONS

Progression-free survival is curtailed by developing acquired resistance. To minimise this therapeutic liability, clinicians must be anticipatory in identifying the drivers and characterising mechanisms of on target resistance.

Endoscopic techniques for gastric neuroendocrine tumors: An update

Gastric neuroendocrine neoplasms (gNENs) are a rare type of gastric neoplasm, even if their frequency is increasing according to the latest epidemiologic revisions of the main registries worldwide. They are divided into three main subtypes, with different pathogeneses, biological behaviors, and clinical characteristics. GNEN heterogeneity poses challenges, therefore these neoplasms require different management strategies. Update the knowledge on the endoscopic treatment options to manage g-NENs. This manuscript is a narrative review of the literature. In recent years, many advances have been made not only in the knowledge of both the pathogenesis and the molecular profiling of gNENs but also in the endoscopic expertise towards innovative treatment options, which proved to be less aggressive without losing the capability of being radical. The endoscopic approach is increasingly applied in the field of gastrointestinal (GI) luminal neoplasms, and this is true not only for adenocarcinomas but also for gNENs. In particular, different techniques have been described for the endoscopic removal of suspected lesions, ranging from classical polypectomy (cold or hot snare) to endoscopic mucosal resection (both with “en bloc” or piecemeal technique), endoscopic submucosal dissection, and endoscopic full-thickness resection. GNENs comprise different subtypes of neoplasms with distinct management and prognosis. New endoscopic techniques offer a wide variety of approaches for GI localized neoplasms, which demonstrated to be appropriate and effective also in the case of gNENs. Correct evaluation of size, site, morphology, and clinical context allows the choice of tailored therapy in order to guarantee a definitive treatment.

False-positive radioiodine uptake after radioiodine treatment in differentiated thyroid cancer

BACKGROUND AND PURPOSE

False-positive radioiodine uptake can sometimes be observed with post-radioiodine treatment (RIT) whole body scanning. Radioiodine pitfall has often been reported as being caused by benign or inflammatory disease, or, in some cases, by tumor lesions. This paper reviews the possible causes of such false-positive imaging, and suggests possible reasons for suspecting these pitfalls.

METHODS AND RESULTS

Online databases, including MEDLINE (via PubMed), Embase, ISI Web of Science, Google Scholar, and Scopus, were systematically examined, using different keyword combinations: "radioiodine false-positive imaging", "131 I false-positive imaging" and " RAI false-positive imaging". An illustrative case was described. Excluding cases in which SPECT/CT was not performed, a total of 18 papers was found: 17 case reports and one series regarding false-positive iodine-131 uptake after RIT.

CONCLUSIONS

The prevalence of radioiodine pitfall was significantly reduced through the use of SPECT/CT imaging, though its possible presence has always to be taken into account. Inflammation, passive iodine accumulation, other tumors, and, sometimes, unknown causes can all potentially generate false-positive imaging. Missing detection of false-positive imaging could result in over-staging and inappropriate RIT or it could lead to the non-detection of other cancers. We examine the reasons for these possible pitfalls.

The association of pregnancy with disease progression in patients previously treated for differentiated thyroid cancer: A propensity score-matched retrospective cohort study.. [DOI: 10.1101/2023.03.15.23287341] [Cited by in Crossref: 0] [Impact Index Per Article: 0] IMPORTANCEDifferentiated thyroid cancer (DTC) is increasingly common in women of reproductive age. However, whether pregnancy increases the risk of progression/recurrence of DTC after treatment remains controversial due to the effect of confounding.OBJECTIVETo assess the effect of pregnancy on structural or biochemical progression in patients previously treated for DTC in a retrospective cohort using propensity score matching (PSM).DESIGN, SETTING, AND PARTICIPANTSThis cohort study included 123 pregnant women and 1,376 non-pregnant women after initial treatment for DTC at Peking University Third Hospital between January 2012 and December 2022. To control the effect of confounding, we carefully matched pregnancy (n = 102) and non-pregnancy groups (n = 297) in terms of age, Hashimoto’s thyroiditis, lymph node dissection, extra-thyroid invasion, initial risk of recurrence after treatment, and time interval between treatment and last follow up by using PSM.EXPOSURESDTC patients became pregnant after previous treatment.MAIN OUTCOMES AND MEASURESThe risk of structural or biochemical progression was assessed in the pregnancy and PSM matched non-pregnancy groups, respectively.Conditional logistics regression models were used to control important confounders and consider the matching properties of the data.RESULTSAt baseline, the pregnancy (n = 102) and non-pregnancy groups (n = 297) were balanced in all matched variables (standardized differences <10% andP> 0.05). After a mean follow-up of approximately 4.5 years, we observed no evidence of difference between the two groups in growth in the size of existing metastatic foci [2 (2.0 %) vs. 2 (0.7 %);P= 0.346], percentage of patients developing new lymph node metastases [4 (3.9 %) vs. 21 (7.1 %);P= 0.519], node growth in the contralateral thyroid lobe [4 (3.9 %) vs. 16 (5.4 %);P= 0.324 ], or biochemical progression [2 (2.0 %) vs. 9 (3.0 %);P= 0.583]. Results from conditional logistic regressions and several sensitivity analyses also showed no evidence of association of pregnancy with the risk of progression, after adjusting for potential confounders of age, tumor size, initial risk stratification, Hashimoto’s thyroiditis, lymph node dissection, the time interval between treatment and follow-up, and achievement of TSH inhibition target (P= 0.354). The pregnancy-progression association observed longer than 4.5 years showed no evidence of difference with that observed shorter than 4.5 years (Pfor interaction was 0.283). We further classified the pregnancy patients into 3 subgroups based on the time interval between treatment and pregnancy (< 1 year, 1-2 years, ≥ 2 years) and found that the shorter the time interval, the higher the risk of DTC progression (Pfor trend was 0.043).CONCLUSIONS AND RELEVANCEThe risk of DTC progression/recurrence in the pregnant women was not higher than that in the well-matched, non-pregnant women. For young women previously treated for DTC, disease progression might not be a concern for their future pregnancy plan, but it seems safer to wait an appropriate amount of time before pregnancy.Key PointsQuestionDoes pregnancy increase the risk of disease progression/recurrence in patients previously treated for differentiated thyroid cancer (DTC)?FindingsThis propensity score-matched retrospective cohort study included 399 patients previously treated for DTC. In a mean follow-up of approximately 4.5 years, the risk of progression in the pregnant group was not higher than the well-matched, non-pregnancy group, but the shorter time interval between treatment and pregnancy (≤ 2 years) appeared to increase the risk of disease progression.MeaningFor young women previously treated for DTC, disease progression might not be a concern for their future pregnancy plan, but it seems safer to wait an appropriate amount of time before pregnancy

IMPORTANCE

Differentiated thyroid cancer (DTC) is increasingly common in women of reproductive age. However, whether pregnancy increases the risk of progression/recurrence of DTC after treatment remains controversial due to the effect of confounding.

OBJECTIVE

To assess the effect of pregnancy on structural or biochemical progression in patients previously treated for DTC in a retrospective cohort using propensity score matching (PSM).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 123 pregnant women and 1,376 non-pregnant women after initial treatment for DTC at Peking University Third Hospital between January 2012 and December 2022. To control the effect of confounding, we carefully matched pregnancy (n = 102) and non-pregnancy groups (n = 297) in terms of age, Hashimoto’s thyroiditis, lymph node dissection, extra-thyroid invasion, initial risk of recurrence after treatment, and time interval between treatment and last follow up by using PSM.

EXPOSURES

DTC patients became pregnant after previous treatment.

MAIN OUTCOMES AND MEASURES

The risk of structural or biochemical progression was assessed in the pregnancy and PSM matched non-pregnancy groups, respectively.

Conditional logistics regression models were used to control important confounders and consider the matching properties of the data.

RESULTS

At baseline, the pregnancy (n = 102) and non-pregnancy groups (n = 297) were balanced in all matched variables (standardized differences <10% andP> 0.05). After a mean follow-up of approximately 4.5 years, we observed no evidence of difference between the two groups in growth in the size of existing metastatic foci [2 (2.0 %) vs. 2 (0.7 %);P= 0.346], percentage of patients developing new lymph node metastases [4 (3.9 %) vs. 21 (7.1 %);P= 0.519], node growth in the contralateral thyroid lobe [4 (3.9 %) vs. 16 (5.4 %);P= 0.324 ], or biochemical progression [2 (2.0 %) vs. 9 (3.0 %);P= 0.583]. Results from conditional logistic regressions and several sensitivity analyses also showed no evidence of association of pregnancy with the risk of progression, after adjusting for potential confounders of age, tumor size, initial risk stratification, Hashimoto’s thyroiditis, lymph node dissection, the time interval between treatment and follow-up, and achievement of TSH inhibition target (P= 0.354). The pregnancy-progression association observed longer than 4.5 years showed no evidence of difference with that observed shorter than 4.5 years (Pfor interaction was 0.283). We further classified the pregnancy patients into 3 subgroups based on the time interval between treatment and pregnancy (< 1 year, 1-2 years, ≥ 2 years) and found that the shorter the time interval, the higher the risk of DTC progression (Pfor trend was 0.043).

CONCLUSIONS AND RELEVANCE

The risk of DTC progression/recurrence in the pregnant women was not higher than that in the well-matched, non-pregnant women. For young women previously treated for DTC, disease progression might not be a concern for their future pregnancy plan, but it seems safer to wait an appropriate amount of time before pregnancy.

Key Points

Question

Does pregnancy increase the risk of disease progression/recurrence in patients previously treated for differentiated thyroid cancer (DTC)?

Findings

This propensity score-matched retrospective cohort study included 399 patients previously treated for DTC. In a mean follow-up of approximately 4.5 years, the risk of progression in the pregnant group was not higher than the well-matched, non-pregnancy group, but the shorter time interval between treatment and pregnancy (≤ 2 years) appeared to increase the risk of disease progression.

Meaning

For young women previously treated for DTC, disease progression might not be a concern for their future pregnancy plan, but it seems safer to wait an appropriate amount of time before pregnancy.

Outcome of differentiated thyroid cancer patients with indeterminate response to initial treatment.. [DOI: 10.21203/rs.3.rs-2631374/v1] [Cited by in Crossref: 0] [Impact Index Per Article: 0] Background: Data on long term outcomes of patients with differentiated thyroid cancer (DTC) with indeterminate response to initial treatment (IR) is lacking. Objective: a) to assess long term outcomes of patients with IR, b) to describe differences in evolution according to type of IR positive anti-thyroglobulin antibodies (TgAb) vs positive thyroglobulin (Tg) and c) to determine factors related to worse prognosis in this population Patients and methods: Retrospective study of 58 DTC patients with IR after total thyroidectomy and radioiodine ablation. Population was divided in two groups: TgAb (+) and Tg (+). Results: After a median follow-up of 6.2 years, structural disease was found in 3.4% of cases, all of them in the Tg (+) group. Final IR were more frequent in the TgAb (+) group (75% vs 23% in the Tg (+) group, p <0.0005), they were caused by declining TgAb levels in 83% of cases. Patients with final excellent and IR had smaller tumor at diagnosis (11.5 vs 44.4 mm, p 0.03), initial high risk was less frequent (14.8 vs 60%, p 0.02), and preablation Tg levels were lower (10.1 vs 42.9 ng/ml, p 0.03) compared with patients with structural or biochemical persistence. Conclusions: Most patients with IR had favorable outcomes. Structural disease was found only in patients with Tg (+). Patients with worse final outcomes had adverse initial parameters. Management strategies should be tailored according to these findings. Significance Statement: Our objective was to evaluate the long-term evolution of patients with an indeterminate response to initial treatment, to investigate differences in the final state between the different types of indeterminate response (positive antithyroglobulin antibodies vs. detectable thyroglobulin), and to determine factors that are associated with worse evolution in this population. We found it relevant to study this population given the little evidence published to date on this group of patients

Background: Data on long term outcomes of patients with differentiated thyroid cancer (DTC) with indeterminate response to initial treatment (IR) is lacking. Objective: a) to assess long term outcomes of patients with IR, b) to describe differences in evolution according to type of IR positive anti-thyroglobulin antibodies (TgAb) vs positive thyroglobulin (Tg) and c) to determine factors related to worse prognosis in this population Patients and methods: Retrospective study of 58 DTC patients with IR after total thyroidectomy and radioiodine ablation. Population was divided in two groups: TgAb (+) and Tg (+). Results: After a median follow-up of 6.2 years, structural disease was found in 3.4% of cases, all of them in the Tg (+) group. Final IR were more frequent in the TgAb (+) group (75% vs 23% in the Tg (+) group, p <0.0005), they were caused by declining TgAb levels in 83% of cases. Patients with final excellent and IR had smaller tumor at diagnosis (11.5 vs 44.4 mm, p 0.03), initial high risk was less frequent (14.8 vs 60%, p 0.02), and preablation Tg levels were lower (10.1 vs 42.9 ng/ml, p 0.03) compared with patients with structural or biochemical persistence. Conclusions: Most patients with IR had favorable outcomes. Structural disease was found only in patients with Tg (+). Patients with worse final outcomes had adverse initial parameters. Management strategies should be tailored according to these findings. Significance Statement: Our objective was to evaluate the long-term evolution of patients with an indeterminate response to initial treatment, to investigate differences in the final state between the different types of indeterminate response (positive antithyroglobulin antibodies vs. detectable thyroglobulin), and to determine factors that are associated with worse evolution in this population. We found it relevant to study this population given the little evidence published to date on this group of patients.

Identification of potential LncRNAs as papillary thyroid carcinoma biomarkers based on integrated bioinformatics analysis using TCGA and RNA sequencing data

The roles and mechanisms of long non-coding RNAs (lncRNAs) in papillary thyroid cancer (PTC) remain elusive. We obtained RNA sequencing (RNA-seq) data of surgical PTC specimens from patients with thyroid cancer (THCA; n = 20) and identified differentially expressed genes (DEGs) between cancer and cancer-adjacent tissue samples. We identified 2309 DEGs (1372 significantly upregulated and 937 significantly downregulated). We performed Gene Ontology, Kyoto Encyclopedia of Genes and Genomes, gene set enrichment, and protein-protein interaction network analyses and screened for hub lncRNAs. Using the same methods, we analyzed the RNA-seq data from THCA dataset in The Cancer Genome Atlas (TCGA) database to identify differentially expressed lncRNAs. We identified 15 key differentially expressed lncRNAs and pathways that were closely related to PTC. Subsequently, by intersecting the differentially expressed lncRNAs with hub lncRNAs, we identified LINC02407 as the key lncRNA. Assessment of the associated clinical characteristics and prognostic correlations revealed a close correlation between LINC02407 expression and N stage of patients. Furthermore, receiver operating characteristic curve analysis showed that LINC02407 could better distinguish between cancerous and cancer-adjacent tissues in THCA patients. In conclusion, our findings suggest that LINC02407 is a potential biomarker for PTC diagnosis and the prediction of lymph node metastasis.

Zinc in microscopic calcifications isolated from thyroid fine needle aspiration may serve as a biomarker of thyroid nodule malignancy: A promising proof-of-concept

Thyroid nodules (TNs) are common neck ultrasonography (US) findings, yet only 5-10% of these nodules harbor thyroid cancer (TC). When US characteristics are consistent with an intermediate or high suspicion for TN malignancy, fine needle aspiration for cytology (FNAC) is indicated. The main limitation of FNAC is that cytological results can be indeterminate in up to 30% of cases, necessitating reevaluation through repeated FNAC, expensive molecular testing, or diagnostic thyroid lobe resection. As such, there is a need for further refinement of current diagnostic algorithms for TNs without subjecting patients to additional invasive procedures. As calcifications detected during thyroid US are considered a high-risk feature for malignancy, we used the material remaining following routine thyroid FNAC to isolate microscopic calcifications (MCs). We then characterized the elemental composition, morphology, and crystal phases of these MCs, ultimately revealing differences between the MCs from benign and malignant TNs. Specifically, thyroid MCs were identified as calcium phosphate crystals containing varying levels of magnesium, sodium, iron, and zinc. MCs obtained from malignant TNs, mainly papillary thyroid carcinoma, were composed of sub-micrometer spherical particles, whereas MCs from benign TNs consisted of faceted particles. While samples from most patients with a final diagnosis of malignant TNs (50% of them with indeterminate cytology) harbored zinc-containing MCs, zinc was largely absent in MCs from benign TNs (23% with indeterminate or non-diagnostic cytology). Together, these data suggest that the presence of zinc in MCs isolated from samples collected during routine FNAC may potentially offer value as a biomarker of TN malignancy. STATEMENT OF SIGNIFICANCE: As up to 40% of patients assessed for thyroid malignancy do not receive a definite diagnosis following thyroid nodule (TN) fine needle aspiration (FNA), there is a pressing need to improve the accuracy of current diagnostic algorithms. Chemical analyses of microscopic calcifications (MCs) may serve as a diagnostic target. We developed a straightforward protocol to chemically characterize MCs from excess material collected from TNs during routine FNA and found that these MCs differed between benign and malignant TNs. Specifically, zinc in TN-derived MCs may indicate a higher nodule malignancy risk, thus increasing the diagnostic accuracy of the FNA procedure, reducing the need for recurrent biopsies and diagnostic surgical procedures, and decreasing the costs, uncertainty, and stress faced by affected patients.

Anlotinib combined with Sintilimab is win-win cooperation for primary squamous cell carcinoma of the thyroid: A case report and literature review

Background

Primary squamous cell carcinoma of the thyroid (PSCCT) is a rare malignant tumor. The incidence rate of PSCCT is less than 1%. However, the diagnosis and treatment of PSCCT are limited. Surgical resection is considered to be one of the few effective intervention methods. In this article, we reported a case of taking tyrosine kinase inhibitors (TKIs) combined with immune checkpoint inhibitors (ICIs) for PSCCT.

Case summary

An 80-year-old male was admitted to our hospital with dyspnea, cough, wheezing, and hoarseness for a giant thyroid mass. He underwent bronchoscopy and tracheal stent implantation to alleviate the respiratory obstruction. Then he accepted right partial thyroid and right lymph node biopsy. Postoperative pathology revealed squamous cell carcinoma. Subsequently, he underwent an endoscopy to exclude upper gastrointestinal squamous cell carcinoma. Finally, he was diagnosed with PSCCT. The patient was tentatively treated with a combination of Anlotinib and Sintilimab. After two courses, the tumor volume significantly reduced in MRI images and shrank further after five courses of combined treatment. Unfortunately, the patient died of fulminant liver failure and autoimmune liver disease after 5-month-treatment.

Conclusion

TKIs combined with ICIs may be an effective and novel way for PSCCT treatment, but immune-related complications, especially liver damage, should be cared.

Inflammatory biomarkers predict outcomes of patients with radioactive iodine refractory thyroid cancer treated with sorafenib

BACKGROUND

The objective of this multicenter, retrospective cohort study was to evaluate the ability of inflammatory biomarkers representing the host immune system to predict outcomes in 70 patients with progressive radioactive iodine (RAI)-refractory thyroid cancer who were treated with sorafenib.

METHOD

Patients were divided into low and high inflammatory biomarker groups based on median values. Progression-free survival (PFS) and overall survival (OS) were assessed based on the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR).

RESULTS

The median LMR, NLR, and PLR values were 3.4, 2.2, and 140.1, respectively. No significant differences were observed in baseline characteristics of high and low LMR, NLR and PLR groups. Median PFS values were 6.6 and 19.5 months in the low and high LMR groups, respectively (P < 0.001). Compared with the high NLR and PLR groups, PFS was significantly prolonged in the low NLR and PLR groups (P = 0.003 and P = 0.041 respectively). In the multivariate analysis, low LMR and high NLR were associated with poor PFS after adjusting for multiple confounding factors including age, sex, pathology, disease-related symptoms, serum thyroglobulin level, lung-only metastasis, cumulative RAI dose, time from diagnosis, and longer diameter of the target lesion (hazard ratio, HR = 2.42; 95% confidence interval, CI 1.25-4.71; P = 0.009, and HR = 2.09; CI, 1.06-4.14; P = 0.033, respectively). High LMR, low NLR, and low PLR were significantly associated with prolonged OS (P = 0.011, P = 0.023, and P = 0.007, respectively). Patients with at least one risk factors for inflammatory biomarkers presented a significantly lower PFS (HR 2.29; CI, 1.36-3.84; P = 0.003) and OS (HR 2.95; CI, 1.49-5.81; P = 0.006) than patients without any risk factor.

CONCLUSION

Baseline inflammatory biomarkers successfully predicted PFS and OS in patients with progressive RAI-refractory thyroid cancer treated with sorafenib. These prognostic biomarkers might help arrive at appropriate clinical decisions regarding the use of sorafenib.

PD-L1 expression in anaplastic thyroid carcinoma treated with lenvatinib.. [DOI: 10.21203/rs.3.rs-2663618/v1] [Cited by in Crossref: 0] [Impact Index Per Article: 0] Purpose This study aimed to estimate the proportion of patients with anaplastic thyroid carcinoma (ATC) at our institution who are likely to have the efficacy of immune checkpoint inhibitor (ICI) treatment by investigating programmed cell death ligand 1 (PD-L1) expression. Additionally, we investigated the association between PD-L1 expression and treatment outcomes of lenvatinib in patients with ATC. Methods The 19 lenvatinib-treated patients with ATC whose tissue samples available for immunohistochemistry were included in this study. The tumor proportion score (TPS) ≥1%was determined as positive for PD-L1 expression Results Of the 19 patients, 5 (26%) and 14 (74%) had a partial response to lenvatinib treatment and PD-L1 expression positivity, respectively. The median TPS was 30% in patients with positive PD-L1 expression. The median OS for all 19 patients was 4.8 (95% confidence interval [CI], 2.8–6.6) months with a 6-month OS rate of 36.8%. Furthermore, the median OS for patients with positive or negative PD-L1 expression was 5.3 (95% CI, 1.6–7.8) and 4.2 (95% CI, 1.1–not available) months, respectively (p = 0.277). Conclusion No correlation was observed between the PD-L1 expression in the ATC tissue samples and efficacy of lenvatinib. Furthermore, in our study, 14 (74%) of 19 patients with ATC had PD-L1 expression positivity. Although lenvatinib monotherapy may have limited efficacy, some patients with ATC have the possibility that the addition of ICI on lenvatinib is effective

Purpose This study aimed to estimate the proportion of patients with anaplastic thyroid carcinoma (ATC) at our institution who are likely to have the efficacy of immune checkpoint inhibitor (ICI) treatment by investigating programmed cell death ligand 1 (PD-L1) expression. Additionally, we investigated the association between PD-L1 expression and treatment outcomes of lenvatinib in patients with ATC. Methods The 19 lenvatinib-treated patients with ATC whose tissue samples available for immunohistochemistry were included in this study. The tumor proportion score (TPS) ≥1%was determined as positive for PD-L1 expression Results Of the 19 patients, 5 (26%) and 14 (74%) had a partial response to lenvatinib treatment and PD-L1 expression positivity, respectively. The median TPS was 30% in patients with positive PD-L1 expression. The median OS for all 19 patients was 4.8 (95% confidence interval [CI], 2.8–6.6) months with a 6-month OS rate of 36.8%. Furthermore, the median OS for patients with positive or negative PD-L1 expression was 5.3 (95% CI, 1.6–7.8) and 4.2 (95% CI, 1.1–not available) months, respectively (p = 0.277). Conclusion No correlation was observed between the PD-L1 expression in the ATC tissue samples and efficacy of lenvatinib. Furthermore, in our study, 14 (74%) of 19 patients with ATC had PD-L1 expression positivity. Although lenvatinib monotherapy may have limited efficacy, some patients with ATC have the possibility that the addition of ICI on lenvatinib is effective.

Migration of Risk Classification Between the JAES Versus ATA guidelines for Papillary Thyroid Carcinoma

BACKGROUND

This study aimed to investigate outcomes in the same cohort of patients with papillary thyroid carcinoma (PTC) risk-stratified according to the Japan Association of Endocrine Surgery (JAES) and American Thyroid Association (ATA) guidelines.

METHODS

A total of 1044 patients with PTC who underwent initial thyroidectomy at Yokohama City University Medical Center between January 2000 and June 2022 were included.

RESULTS

According to the JAES guidelines, 480 (46%), 386 (37%), and 178 (17%) patients were classified as low, intermediate, or high risk, respectively. Furthermore, according to the ATA guidelines, 590 (57%), 261 (25%), and 193 (18%) patients were reclassified as low, intermediate, or high risk, respectively. Among 1044 patients with PTC, the 10-year cause-specific survival (CSS) rates of patients with JAES low and intermediate risk were 99.7 and 98.6%, respectively, and there was no statistically difference (p = 0.096). However, the 10-year CSS rates of patients with ATA low and intermediate risk were 100 and 99.5%, respectively (p = 0.007). Among 1001 patients with M0 PTC, the 10-year distant metastasis-free survival (DMFS) rates of patients with JAES intermediate and high risk were 94.2, and 76.7%, respectively (p < 0.001). However, the 10-year DMFS rates of patients with ATA intermediate and high risk were 88.1 and 86.6%, respectively (p = 0.233), and there was no statistically difference.

CONCLUSIONS

Both JAES and ATA risk classifications properly stratified the PTC patients. Furthermore, the ATA risk classification more precisely extracted patients with better and worse prognoses.

Application of the American Thyroid Association Risk Assessment in Patients with Differentiated Thyroid Carcinoma in a German Population

Background: The American Thyroid Association (ATA) uses criteria to assess the risk for persistent disease in differentiated thyroid carcinoma (DTC) after radioiodine therapy (RAI). There are no data available showing that this classification can be adopted unadjusted by Germany. Aim: The aim of our study is to investigate whether the ATA classification can be applied to a German population for short-term prognosis. Furthermore, we investigated the influence of an age cutoff value. Methods: We retrospectively analyzed 121 patients who were referred to our tertiary referral center. Patients were classified into risk categories, and the therapy response was determined according to ATA. Results: A total of 73/83 (88%) ATA low-risk patients and 12/19 (63%) intermediate-risk patients showed an excellent response; 2/19 (11%) high-risk patients had a biochemical, and 6 (31%) had a structural incomplete response. Of all 39 patients ≥55 years, 84% had an excellent response. Using a cut off of 50 years, 50/62 (81%) of the older patients showed an excellent response. Conclusion: The ATA risk classification is able to estimate the response to RAI therapy in a German population. A shift from 55 to 50 years as an age cutoff value does not result in any relevant change in the treatment response.

A Comparison of Outcomes in Medullary Thyroid Carcinoma Patients With and Without a Preoperative Diagnosis: A Multicenter Retrospective Cohort Study

Background: Cytological limitations pose a challenge to preoperative diagnosis of medullary thyroid carcinoma (MTC) and therefore, a significant subset of patients is only diagnosed postoperatively. The objective of this study was to investigate the impact of knowledge of a preoperative MTC diagnosis on disease management and outcomes. Methods: Multicenter, retrospective, cohort study of MTC patients treated in Israel from January 2000 to June 2021. We compared cohorts of patients according to the presence or absence of a preoperative MTC diagnosis. Results: Ninety-four patients with histologically confirmed MTC were included (mean age 56.2 ± 14.3 years, 43% males). Fifty-three patients (56%) had a preoperative MTC diagnosis (preop-Dx group), and 41 (44%) were confirmed only postoperatively (no-Dx group). The extent of surgical resection, including completion procedures, was as follows: total thyroidectomy in 83% versus 100% (p = 0.002), central lymph node dissection (LND) in 46% versus 98% (p < 0.001), ipsilateral lateral LND in 36% versus 79% (p < 0.001), and contralateral lateral LND in 17% versus 28% (NS), in the no-Dx versus the preop-Dx group, respectively. Pathology confirmed a smaller median tumor size of 16 ± 17.4 mm versus 23 ± 14.0 mm (p = 0.09), a higher proportion of micro-MTC (size ≤10 mm) 32% versus 15% (p = 0.03), and a higher rate of co-occurrence of follicular cell-derived carcinoma 24% versus 4% (p = 0.003), in the no-Dx compared to the preop-Dx group, respectively. The rates of extrathyroidal and extranodal tumor extension were not significantly different between the groups. At the last follow-up, the biochemical cure was attained in 55% [CI 0.38-0.71] compared to 64% [CI 0.50-0.77] of the no-Dx and the preop-Dx group, respectively (p = 0.41). After the exclusion of patients with micro-MTC, biochemical cure was more commonly achieved in the preop-Dx group (33% [CI 0.14-0.52] vs. 62% [CI 0.46-0.77], p = 0.04). Preop-Dx patients had improved overall survival compared to the no-Dx group (log-rank p = 0.04) over a median follow-up of 82 months (interquartile range [IQR] 30-153). Conclusions: Preoperatively, the diagnosis of MTC is often missed. An accurate preoperative diagnosis of MTC may enable guideline-concordant surgical treatment and ultimately contribute to an overall survival benefit in MTC patients.

Integrated gene profiling of fine-needle aspiration sample improves lymph node metastasis risk stratification for thyroid cancer

BACKGROUND

Lymph node metastasis risk stratification is crucial for the surgical decision-making of thyroid cancer. This study investigated whether the integrated gene profiling (combining expression, SNV, fusion) of Fine-Needle Aspiration (FNA) samples can improve the prediction of lymph node metastasis in patients with papillary thyroid cancer.

METHODS

In this retrospective cohort study, patients with papillary thyroid cancer who went through thyroidectomy and central lymph node dissection were included. Multi-omics data of FNA samples were assessed by an integrated array. To predict lymph node metastasis, we built models using gene expressions or mutations (SNV and fusion) only and an Integrated Risk Stratification (IRS) model combining genetic and clinical information. Blinded histopathology served as the reference standard. ROC curve and decision curve analysis was applied to evaluate the predictive models.

RESULTS

One hundred and thirty two patients with pathologically confirmed papillary thyroid cancer were included between 2016-2017. The IRS model demonstrated greater performance [AUC = 0.87 (0.80-0.94)] than either expression classifier [AUC = 0.67 (0.61-0.74)], mutation classifier [AUC = 0.61 (0.55-0.67)] or TIRADS score [AUC = 0.68 (0.62-0.74)] with statistical significance (p < 0.001), and the IRS model had similar predictive performance in large nodule [>1 cm, AUC = 0.88 (0.79-0.97)] and small nodule [≤1 cm, AUC = 0.84 (0.74-0.93)] subgroups. The genetic risk factor showed independent predictive value (OR = 10.3, 95% CI:1.1-105.3) of lymph node metastasis in addition to the preoperative clinical information, including TIRADS grade, age, and nodule size.

CONCLUSION

The integrated gene profiling of FNA samples and the IRS model developed by the machine-learning method significantly improve the risk stratification of thyroid cancer, thus helping make wise decisions and reducing unnecessary extensive surgeries.

ESTIMation of the ABiLity of prophylactic central compartment neck dissection to modify outcomes in low-risk differentiated thyroid cancer: A Prospective Randomized Trial.. [DOI: 10.21203/rs.3.rs-2643673/v1] [Cited by in Crossref: 0] [Impact Index Per Article: 0] Background Prophylactic central neck dissection in clinically low-risk cT1bT2N0 papillary thyroid carcinoma is controversial, due to a large number of conflicting retrospective studies, some showing an advantage in terms of locoregional recurrence, others showing no advantage. These previous studies all show high rates of excellent response. We aim to demonstrate the non inferiority of thyroidectomy alone as compared to total thyroidectomy with prophylactic central neck dissection in conjunction with adjuvant RAI 30 mCi with rTSH stimulation in terms of excellent response at 1 year. Trial Design and Methods Prospective randomized open multicenter phase III trial including patients with 11-40 mm papillary thyroid carcinoma (Bethesda VI) or suspicous cytology (Bethesda V) confirmed malginant on intraoperative frozen section analysis, with no suspicious lymph nodes on a specialized preoperative ultrasound examination. Patients will be randomized 1:1 into two groups : the reference group total thyroidectomy with bilateral prophylactic central neck dissetion, and the comparator group total thyroidectomy alone. All patients will receive an ablative dose of 30mCi of radioactive iodine (RAI) within 4 months of surgery. The primary outcome is to compare the rate of excellent response at 1 year after surgery between the groups, as defined by an unstimulated serum thyroglobulin (Tg) level ≤ 0.2 ng/mL with no anti-Tg antibodies, an normal neck ultrasound and no ectopic uptake on the post-RAI scintiscan. Non-inferiority will be demonstrated if the rate of patients with excellent response at 1 year after randomization does not differ by more than 5%. Setting the significance level at 0.025 (one-sided) and a power of 80% requires a sample size of 598 patients (299 per group). Secondary outcomes are to compare Tg levels at 8 +/- 2 postoperative weeks, before RAI ablation, the rate of excellent response at 3 and 5 years, the rate of other responses at 1, 3 and 5 years (biochemical incomplete, indeterminate and structurally incomplete responses), complications, quality of life and cost-utility. Discussion (potential implications) If non-inferiority is demonstrated with this high-level evidence, prophylactic neck dissection will have been shown to not be necessary in clinically low risk papillary thyroid carcinoma. Trial Registration : NCT 03570021

Background Prophylactic central neck dissection in clinically low-risk cT1bT2N0 papillary thyroid carcinoma is controversial, due to a large number of conflicting retrospective studies, some showing an advantage in terms of locoregional recurrence, others showing no advantage. These previous studies all show high rates of excellent response. We aim to demonstrate the non inferiority of thyroidectomy alone as compared to total thyroidectomy with prophylactic central neck dissection in conjunction with adjuvant RAI 30 mCi with rTSH stimulation in terms of excellent response at 1 year. Trial Design and Methods Prospective randomized open multicenter phase III trial including patients with 11-40 mm papillary thyroid carcinoma (Bethesda VI) or suspicous cytology (Bethesda V) confirmed malginant on intraoperative frozen section analysis, with no suspicious lymph nodes on a specialized preoperative ultrasound examination. Patients will be randomized 1:1 into two groups : the reference group total thyroidectomy with bilateral prophylactic central neck dissetion, and the comparator group total thyroidectomy alone. All patients will receive an ablative dose of 30mCi of radioactive iodine (RAI) within 4 months of surgery. The primary outcome is to compare the rate of excellent response at 1 year after surgery between the groups, as defined by an unstimulated serum thyroglobulin (Tg) level ≤ 0.2 ng/mL with no anti-Tg antibodies, an normal neck ultrasound and no ectopic uptake on the post-RAI scintiscan. Non-inferiority will be demonstrated if the rate of patients with excellent response at 1 year after randomization does not differ by more than 5%. Setting the significance level at 0.025 (one-sided) and a power of 80% requires a sample size of 598 patients (299 per group). Secondary outcomes are to compare Tg levels at 8 +/- 2 postoperative weeks, before RAI ablation, the rate of excellent response at 3 and 5 years, the rate of other responses at 1, 3 and 5 years (biochemical incomplete, indeterminate and structurally incomplete responses), complications, quality of life and cost-utility. Discussion (potential implications) If non-inferiority is demonstrated with this high-level evidence, prophylactic neck dissection will have been shown to not be necessary in clinically low risk papillary thyroid carcinoma. Trial Registration : NCT 03570021