Associations between BRAF(V600E) and prognostic factors and poor outcomes in papillary thyroid carcinoma: a meta-analysis

Prediction of cervical lymph node metastasis with contrast-enhanced ultrasound and association between presence of BRAFV600E and extrathyroidal extension in papillary thyroid carcinoma

Objective:

This study aimed to evaluate the correlation between cervical lymph node metastasis (CLNM) and each of the ultrasound features, immunohistochemical factors, and B-type Raf (BRAF^V600E) mutation.

Methods:

A retrospective analysis was performed on 405 patients with single papillary thyroid carcinoma (PTC) nodules, all of whom underwent preoperative sonographic examinations, including gray-scale ultrasound, color Doppler ultrasound, and contrast-enhanced ultrasound (CEUS). All PTC patients were evaluated using 14 clinical and sonographic features, eight immunohistochemical factors, and BRAF^V600E. Multivariate analyses were performed to identify the risk factors for CLNM, and an equation for CLNM was established. The diagnostic value of each modality was compared with a receiver operating characteristic (ROC) curve.

Results:

Among the 405 PTC nodules removed surgically, CLNM was confirmed in 138 patients, whereas extrathyroidal extension was confirmed in 185 patients. Multivariate analyses indicated significant differences between CLNM and non-CLNM groups in three conventional ultrasound features (p < 0.05), whereas other sonographic features, eight immunohistochemical factors, and BRAF^V600E did not indicate significant differences. A ROC curve of 0.757 in the equation exhibited a significant difference compared with the solo factors (p < 0.05 for all). Hyper or isoechoic enhancement at peak time on CEUS was associated with CLNM, whereas the presence of the BRAF^V600E mutation was associated with extrathyroidal extensions although BRAF appeared to be uncorrelated with CLNM in the present study.

Conclusion:

Intensity at peak time, homogeneity, and size are the three most significant features in predicting CLNM in PTC patients, and the presence of the BRAF^V600E mutation was associated with extrathyroidal extensions when PTCs showed a hyper or isoechoic enhancement at peak time in CEUS.

Detection of BRAFV600E in Liquid Biopsy from Patients with Papillary Thyroid Cancer Is Associated with Tumor Aggressiveness and Response to Therapy

The detection of rare mutational targets in plasma (liquid biopsy) has emerged as a promising tool for the assessment of patients with cancer. We determined the presence of cell-free DNA containing the BRAFV600E mutations (cfBRAFV600E) in plasma samples from 57 patients with papillary thyroid cancer (PTC) with somatic BRAFV600E mutation-positive primary tumors using microfluidic digital PCR, and co-amplification at lower denaturation temperature (COLD) PCR. Mutant cfBRAFV600E alleles were detected in 24/57 (42.1%) of the examined patients. The presence of cfBRAFV600E was significantly associated with tumor size (p = 0.03), multifocal patterns of growth (p = 0.03), the presence of extrathyroidal gross extension (p = 0.02) and the presence of pulmonary micrometastases (p = 0.04). In patients with low-, intermediate- and high-risk PTCs, cfBRAFV600E was detected in 4/19 (21.0%), 8/22 (36.3%) and 12/16 (75.0%) of cases, respectively. Patients with detectable cfBRAFV600E were characterized by a 4.68 times higher likelihood of non-excellent response to therapy, as compared to patients without detectable cfBRAFV600E (OR (odds ratios), 4.68; 95% CI (confidence intervals)) 1.26–17.32; p = 0.02). In summary, the combination of digital polymerase chain reaction (dPCR) with COLD-PCR enables the detection of BRAFV600E in the liquid biopsy from patients with PTCs and could prove useful for the identification of patients with PTC at an increased risk for a structurally or biochemically incomplete or indeterminate response to treatment.

The Impact of BRAF Mutation on the Recurrence of Papillary Thyroid Carcinoma: A Meta-Analysis

Previous meta-analyses indicated that the BRAF V600E mutation was associated with an increased recurrence rate of papillary thyroid carcinoma (PTC). However, with recent publications of large cohort studies, the need for an updated meta-analysis increases. Therefore, we conducted a comprehensive meta-analysis to assess the impact of the BRAF V600E mutation on PTC recurrences. We performed a literature search using PubMed, SCOPUS, the Cochrane Database of Systematic Reviews, and the Web of Science Core Collection, from their inception to May 31, 2020. The relevant studies compared recurrence rates using the hazard ratio (HR) of BRAF mutations; 11 studies comprising 4674 patients were identified and included. Recurrence rates in patients with the BRAF V600E mutation were comparable with BRAF wild-type patients (HR 1.16, 95% CI 0.78–1.71), after adjustment for possible confounders. In subgroup analysis, both geographical region (HRs for America, Asia, and Europe were 2.16, 1.31 and 0.66, respectively) and tumor stage (HRs for stage I and II were 1.51 and 4.45, respectively) can affect the HRs of the BRAF mutation for recurrence. In conclusion, the BRAF mutation does not increase the risk of recurrences in patients with PTC. Differences in the geographical region or tumor stage should be considered when interpreting the impact of a BRAF mutation on recurrence.

BRAFV600E mutation, BRAF-activated long non-coding RNA and miR-9 expression in papillary thyroid carcinoma, and their association with clinicopathological features

Background

The incidence of thyroid cancer is increasing worldwide. This study investigated the association of B-type RAF kinase (BRAF)^V600E mutation status, the expression of BRAF-activated long non-coding RNA (BANCR) and microRNA miR-9, and the clinicopathological features of papillary thyroid carcinoma (PTC).

Methods

Clinicopathological data for PTC patients (n = 51) diagnosed and treated between 2018 and 2019 were collected. Carcinoma and adjacent normal tissue samples were analyzed for the presence of the BRAF^V600E mutation and/or expression of BANCR and miR-9.

Results

Larger tumor, higher rate of bilateral tumors and multifocality, extracapsular invasion, and lateral lymph node metastasis (LNM) were observed in PTC patients with BRAF ^V600E mutation. Patients with higher BANCR expression had a higher rate of extracapsular invasion and lateral LNM in carcinoma tissue and a lower frequency of bilateral tumors and multifocality in normal adjacent tissue. Patients with higher miR-9 expression had a lower rate of central and lateral LNM in carcinoma tissue and higher rates of bilateral tumor location and multifocality in normal adjacent tissue. Patients with BRAF^V600E mutation have a higher rate of BANCR overexpression and tended to have a lower rate of miR-9 overexpression (P = 0.057), and a negative association was observed between BANCR and miR-9 expression in carcinoma tissue.

Conclusions

BRAF^V600E mutation and the BANCR and miR-9 expression were closely associated with the tumor size, bilateral tumor location, multifocality, extracapsular invasion, and lateral LNM. PTC patients with these clinicopathological characteristics, BRAFV600E mutation, and high BANCR expression and low miR-9 expression needed earlier surgical treatment and are recommended for total thyroidectomy in primary surgery for reducing the risk of recurrence. These findings provide new insight into the molecular basis for PTC and can inform strategies for the management of PTC.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

BRAF and KRAS mutations in papillary thyroid carcinoma in the United Arab Emirates

Background

Papillary thyroid carcinoma (PTC) is the most common malignant thyroid neoplasm comprising 80–90% of all thyroid malignancies. Molecular changes in thyroid follicular cells are likely associated with the development of PTC. Mutations in serine/threonine-protein kinase (BRAF) and Rat sarcoma viral oncogene homolog (RAS) are commonly seen in PTC.

Methods

In total, 90 cases of PTC are randomly selected from archive paraffin blocks and 10μm sections were cut and processed for DNA extraction. BRAF^V600E mutation and 8 types of KRAS mutations were investigated using Real Time PCR.

Results

BRAF^V600E mutation was identified in 46% of PTC while KRAS mutations were seen in 11% of PTC. There was significant correlation between BRAF^V600E mutation and PTC larger than 5cm in diameter, positive surgical margin and lymph node metastasis. BRAF^V600E mutation was significantly higher in patients with less than 55-year of age than those more than 55-year of age. BRAF^V600E mutation was significantly higher in patients with family history of thyroid cancer than those without. There was no significant difference in BRAF^V600E mutation between males and females, PTC classic and follicular variants, unifocal and multifocal PTC. There was a significant higher percentage of BRAF^V600E mutation in classic PTC than papillary microcarcinoma variant. There was no significant age, gender, histologic type, tumor size, lymph node metastasis, tumor focality, and surgical margin status differences between KRAS mutated and non-mutated PTC.

Conclusion

BRAF^V600E and KRAS mutation are seen in a significant number of PTC in the UAE. BRAF mutation is significantly correlated with large tumor size, positive surgical margins and lymph node metastasis suggesting an association between BRAF^V600E mutation and tumor growth and spread.

Synergistic effect of clinicopathological factors on mortality risk in patients with differentiated thyroid cancer: An analysis using the SEER database

OBJECTIVES

In this study, we analyzed the effects of histology subtypes, lymph node N-stages, and the presence of extrathyroidal extensions on cancer-specific survival (CSS) and overall survival (OS) in patients with differentiated thyroid cancer.

MATERIALS AND METHODS

Cox proportional hazards regression analyses were carried out to evaluate the correlations between clinicopathological factors and CSS/OS. The combined effects of these factors on CSS and OS were then analyzed to determine the relative excess risk, attributable proportion, and synergy index. Kaplan-Meier curves were used to evaluate the mortality rate.

RESULTS

A total of 86033 cases were included in the analysis. Histology subtype, N-stage, and extrathyroidal extension were all found to be risk factors for CSS (hazard ratio [HR] = 1.8, 95% confidence intervals [CI]: 1.4-2.3, p < 0.001; HR = 1.9, 95% CI: 1.6-2.3, p < 0.001; HR = 1.4, 95% CI: 1.0-1.9, p = 0.035, respectively). The risk factors for OS were histology subtype and N-stage (HR = 1.3, 95% CI; 1.2-1.5, p < 0.001; HR = 1. 4, 95% CI: 1.3-1.5, p < 0.001, respectively) but not extrathyroidal extension (HR = 1.1, 95% CI: 0.9-1.3, p = 0.228). Furthermore, histology subtype and N-stage, histology subtype and extrathyroidal extension, and N stage and extrathyroidal extension (relative excess risk, attributable proportion, and synergy index: 48.8, 0.9, 7.6; 50.2, 0.7, 3.9; 7.0, 0.3, 1.6; respectively) were found to have significant synergistic effects.

CONCLUSION

Patients with follicular thyroid carcinoma (FTC) and extrathyroidal extension or lymph node metastasis are at a higher risk of mortality. Histology subtype, N-stage, and extrathyroidal extension appear to have synergistic effects on the increased risk of poor CSS in patients. This result can in the further development of treatment guidelines to improve the outcome of FTC patients.

VE1 Immunohistochemistry Improves the Limit of Genotyping for Detecting BRAFV600E Mutation in Papillary Thyroid Cancer

Detection of BRAF^V600E is useful for making diagnosis and risk stratification of papillary thyroid carcinoma (PTC). Molecular testing, however, is not always available for routine clinical use. To assess the clinical utility and reliability of VE1 immunohistochemistry (IHC) for detecting BRAF^V600E mutation in PTC, VE1 IHC was performed on the tissue microarrays of 514 patients with PTC and was compared with Sanger sequencing results. Of 514 PTC cases, 433 (84.2%) were positive for VE1 expression. Among 6 discordant cases between VE1 IHC and Sanger sequencing, 3 initial VE1-false negative cases turned out to be true false negative on repeat testing, and 3 VE1-false positive cases showed BRAF^V600E mutation using digital PCR analysis. PTCs with low variant allele fraction were positive for VE1 IHC but were not detected using sequencing. VE1 IHC showed 99.3% sensitivity, 100% specificity, 100% positive predictive value, and 96.4% negative predictive value. The BRAF^V600E mutation was significantly associated with older age, multifocality, extrathyroidal extension, lymph node metastasis, and advanced tumor stage. In conclusion, VE1 IHC is a reliable method for detecting BRAF^V600E mutation in PTC specimens.

A meta-analysis evaluating the relationship between B-type Raf kinase mutation and cervical lymphatic metastasis in papillary thyroid cancer

BACKGROUND

B-type Raf kinase (BRAF) mutation is proved to be a critical predictive factor in papillary thyroid cancer (PTC) with aggressive characteristics. However, the association between BRAF mutation and cervical lymphatic metastasis in PTC is controversial.

METHODS

We searched papers on the study of BRAF mutation and cervical lymphatic metastasis in PTC patients through PubMed, Web of Science, Embase, and Cochranelibrary. The BRAF (+) cases, BRAF (-) cases, and cervical lymphphatic metastatic cases in both BRAF (+) and BRAF (-) groups were collected. After Quality assessment, statistical Analysis (funnel plot and Harbord evaluation, Random-effect model, heterogeneity, subgroup analysis, sensitivity analysis, and metacum analysis) were done by the Review Manager (RevMan) 5.3 and stata14 statistical software.

RESULTS

There were 78 cross-section studies which met our inclusion criteria. And all of them had no selection bias, publication bias, or any other bias. A significant association existed between BRAF mutation and cervical lymph node metastasis (LNM) (odds ratio [OR] = 1.63; 95% confidence interval [CI]: 1.44-1.84; P < .05). Overall, 46 studies were conducted among East Asians. Twenty four articles had provided the data of central lymph node metastasis (CLNM), 11 articles with the data of lateral lymph node metastasis (LLNM), and classic/conventional PTC (CPTC) was analyzed in 10 studies. Subgroup analyses were performed based on ethnicity, metastatic site, and subtype of PTC. Significant association between BRAF (+) mutation and cervical LNM were indicated in East Asians (OR = 1.73; 95% CI: 1.49-2.02; P < .05), in non-East Asians (OR = 1.57; 95% CI: 1.26-1.96; P < .05), and in CLNM (OR = 1.80; 95% CI: 1.56-2.07; P < .05). While no significant association was found in LLNM (OR = 1.37; 95% CI: 0.76-2.48; P = .29 > .05) and in CPTC (OR = 1.32; 95% CI: 0.97-1.80; P = .08 > .05). We did not find any other major changes when sensitivity analysis was performed. The metacum analysis showed no significant association existed before 2012. While a significant association began to exist between BRAF mutation and LNM from 2012, and this association became stable from 2017.

CONCLUSIONS

We consider that a significant association exists between BRAF mutation and cervical LNM. Further meta-analysis on subgroup may reveal some valuable factors between BRAF gene mutation and LNM. And we do not recommend that BRAF (+) as the biomarker for LNM in PTC.

GADD45B Transcript Is a Prognostic Marker in Papillary Thyroid Carcinoma Patients Treated With Total Thyroidectomy and Radioiodine Therapy

Currently, there is a lack of efficient recurrence prediction methods for papillary thyroid carcinoma (PTC). In this study, we enrolled 202 PTC patients submitted to total thyroidectomy and radioiodine therapy with long-term follow-up (median = 10.7 years). The patients were classified as having favorable clinical outcome (PTC-FCO, no disease in the follow-up) or recurrence (PTC-RE). Alterations in BRAF, RAS, RET, and TERT were investigated (n = 202) and the transcriptome of 48 PTC (>10 years of follow-up) samples was profiled. Although no mutation was associated with the recurrence risk, 68 genes were found as differentially expressed in PTC-RE compared to PTC-FCO. Pathway analysis highlighted a potential role of cancer-related pathways, including signal transduction and FoxO signaling. Among the eight selected genes evaluated by RT-qPCR, SLC2A4 and GADD45B showed down-expression exclusively in the PTC-FCO group compared to non-neoplastic tissues (NT). Increased expression of GADD45B was an independent marker of shorter disease-free survival [hazard ratio (HR) 2.9; 95% confidence interval (CI95) 1.2-7.0] in our cohort and with overall survival in the TCGA dataset (HR = 4.38, CI95 1.2-15.5). In conclusion, GADD45B transcript was identified as a novel prognostic marker candidate in PTC patients treated with total thyroidectomy and radioiodine therapy.

BRAF Inhibitors in Thyroid Cancer: Clinical Impact, Mechanisms of Resistance and Future Perspectives

The Kirsten rat sarcoma viral oncogene homolog (RAS)/v-raf-1 murine leukemia viral oncogene homolog 1 (RAF)/mitogen-activated protein kinase 1 (MAPK) signaling cascade is the most important oncogenic pathway in human cancers. Tumors leading mutations in the gene encoding for v-raf murine sarcoma viral oncogene homolog B (BRAF) serine-threonine kinase are reliant on the MAPK signaling pathway for their growth and survival. Indeed, the constitutive activation of MAPK pathway results in continuous stimulation of cell proliferation, enhancement of the apoptotic threshold and induction of a migratory and metastatic phenotype. In a clinical perspective, this scenario opens to the possibility of targeting BRAF pathway for therapy. Thyroid carcinomas (TCs) bearing BRAF mutations represent approximately 29–83% of human thyroid malignancies and, differently from melanomas, are less sensitive to BRAF inhibitors and develop primary or acquired resistance due to mutational events or activation of alternative signaling pathways able to reactivate ERK signaling. In this review, we provide an overview on the current knowledge concerning the mechanisms leading to resistance to BRAF inhibitors in human thyroid carcinomas and discuss the potential therapeutic strategies, including combinations of BRAF inhibitors with other targeted agents, which might be employed to overcome drug resistance and potentiate the activity of single agent BRAF inhibitors.

Relationship between BRAF V600E gene mutation and the clinical and pathologic characteristics of papillary thyroid microcarcinoma

OBJECTIVE

This study aims to investigate the relationship between BRAF V600E gene mutation and the clinical and pathologic characteristics of patients with papillary thyroid microcarcinoma (PTMC).

METHODS

A retrospective analysis was conducted on the clinical and pathologic characteristics of 89 patients with PTMC, who had complete medical records. The BRAF V600E gene mutation was detected by real-time immunofluorescence quantitative PCR. Then, the BRAF V600E gene mutation and the clinical and pathologic data of these patients were statistically analyzed.

RESULTS

Among the 89 patients with PTMC, 67 patients had a BRAF V600E mutation with a mutation rate of 75.3%. 38 patients (42.6%) had cervical lymph node metastasis. 43 patients had capsular invasion (48.3%) and 40 patients (44.9%) had tumor multifocality confirmed by postoperative pathology. BRAF V600E mutation was not associated with gender, age, capsular invasion, tumor multifocality, cervical lymph node metastasis, or higher TNM stage. However, cervical lymph node metastasis was associated with age and tumor invasion of the capsule. Thus, cervical lymph node metastasis was most likely in patients < 45 years old and patients with capsular invasion.

CONCLUSION

BRAF V600E mutation is common in PTMC, but is not associated with clinicopathologic factors, such as age, gender, tumor multifocality, cervical lymph node metastasis, capsular invasion, or tumor TNM stage. Cervical lymph node metastasis is more likely in patients < 45 years old and patients with capsular invasion.

Association analysis and the clinical significance of BRAF gene mutations and ultrasound features in papillary thyroid carcinoma

The aim of the present study was to evaluate the associations between the B-Raf proto-oncogene serine/threonine kinase (BRAF)V600E mutation and conventional and contrast-enhanced ultrasonographic features in patients with papillary thyroid carcinoma (PTC), and to subsequently investigate the clinical value of these associations. In total, 207 thyroid nodules (diameter ≤2 cm) were selected. Conventional ultrasound, contrast-enhanced ultrasound, BRAFV600E mutational analysis and ultrasound-guided fine-needle aspiration biopsy were preoperatively performed, and histopathological assessment of PTC was postoperatively confirmed. The nodules were divided into 2 groups based on the BRAFV600E mutational analysis, namely the mutant or the wild-type variant groups, and the association analyses of the ultrasonographic features between these 2 groups were performed. Overall, 74.9% (155/207) of the PTC nodules had the BRAFV600E mutation, while 25.1% (52/207) had the wild-type BRAF allele. The 2 groups were analyzed using univariate logistic regression analysis, which demonstrated no significant differences regarding morphology, boundary, hypoechogenicity of the nodules, blood flow signal, enhancement uniformity, enhancement degree and clearance time (P>0.05). Moreover, the 2 groups demonstrated significant differences regarding the aspect ratio, microcalcification, nodule size following enhancement, enhancement mode and enhancement time (P<0.05). A multivariate logistic regression analysis was performed to further validate the association of these features with the BRAFV600E mutation; however, only microcalcification [odds ratio (OR), 2.256; 95% confidence interval (CI), 1.160–5.500; P=0.020] and nodule size following enhancement (OR, 2.119; 95% CI, 1.039–4.321; P=0.039) were associated with the BRAF mutational status. The associations found between the two ultrasonographic features and BRAFV600E mutation indicate that they can predict the BRAF mutational status to provide a reliable basis for clinical diagnosis and treatment.

Correlation between TERT C228T and clinic-pathological features in pediatric papillary thyroid carcinoma

The aims of the present study were to reveal the prevalence of the TERT C228T mutation in pediatric papillary thyroid carcinoma (PPTC) and to further investigate the role of the TERT C228T mutation in PPTC. We also tested another TERT mutation, TERT C250T, although this was not detected in PPTC patients. In this study, 48 patients with PPTC (41 with classic PPTC) were enrolled. DNA was extracted from PPTC tissues and TERT C228T mutation analysis was performed. Chi-squared analysis, Fisher's exact test, and a t-test were applied to test the significance of differences. The TERT C228T mutation presented in 13 (27.1%) of the 48 PPTC patients and 10 (24.4%) of the 41 classical PPTC patients. There were significant differences between PPTC patients with the TERT C228T mutation and those without in terms of modified radical neck dissection, multifocality, capsular invasion, extrathyroidal invasion, and American Joint Committee on Cancer (AJCC) tumor stage (P<0.05). In classical PPTC, there were additional significant differences in other clinic-pathological features, such as AJCC nodal stage (P=0.009) and American Thyroid Association (ATA) PPTC stage (P=0.021) between patients with and without the TERT C228T mutation. These findings indicate that the TERT C228T mutation is significantly correlated with certain aggressive clinic-pathological features of PPTC.

Prognostic significance of TERT promoter and BRAF mutations in TIR-4 and TIR-5 thyroid cytology

OBJECTIVE

Follicular-derived thyroid cancers generally have a good prognosis, but in a minority of cases, they have an aggressive behavior and develop distant metastases, with an increase in the associated mortality. None of the prognostic markers currently available prior to surgery can identify such cases.

METHODS

TERT promoter and BRAF gene mutations were examined in a series of 436 consecutive TIR-4 and TIR-5 nodes referred for surgery. Follow-up (median: 59 months, range: 7-293 months) was available for 384/423 patients with malignant nodes.

RESULTS

TERT promoter and BRAF mutations were detected in 20/436 (4.6%) and 257/434 thyroid nodules (59.2%), respectively. At the end of the follow-up, 318/384 patients (82.8%) had an excellent outcome, 48/384 (12.5%) had indeterminate response or biochemical persistence, 18/384 (4.7%) had a structural persistence or died from thyroid cancer. TERT promoter mutations correlated with older age (P < 0.0001), larger tumor size (P = 0.0002), oxyntic and aggressive PTC variants (P = 0.01), higher tumor stages (P < 0.0001), distant metastases (<0.0001) and disease outcome (P < 0.0001). At multivariate analysis, TERT promoter mutation was not an independent predictor of disease outcome. TERT promoter mutation- (OR: 40.58; 95% CI: 3.06-539.04), and N1b lymph node metastases (OR: 40.16, 95% CI: 3.48-463.04) were independent predictors of distant metastases. BRAF mutation did not predict the outcome, and it correlated with a lower incidence of distant metastases (P = 0.0201).

CONCLUSIONS

TERT promoter mutation proved an independent predictor of distant metastases, giving clinicians the chance to identify many of the patients who warranted more aggressive initial treatment and closer follow-up.

Targeting the BRAF Signaling Pathway in CD133pos Cancer Stem Cells of Anaplastic Thyroid Carcinoma

Background:

Cancer stem cells (CSCs) with a self-renewal ability in tumor cells population, execute a pivotal function in tumorigenesis, retrogression, and metastasis of malignant cancers such as anaplastic thyroid carcinoma (ATC).

Materials and Methods:

In this study, we isolated CSCs subpopulation with CD133 surface marker from three ATC cell lines by magnetic cell sorting assay. After confirming the segregation by the flow cytometry method, BRAF and sodium-iodide symporter (NIS) genes were investigated in them before and after incubation with BRAF inhibitor. Also, we evaluated the NIS protein expression and localization.

Results:

Established upon q-RT PCR data, when compared to human normal thyrocytes, the BRAF^V600E gene was over-expressed in CD133^pos cells (>1705.99 ± 55.55 fold, Mean ± SEM, n=3, P- value<0.05), whilst the expression of NIS gene was very restricted (< 0.0008 ± 5.43 fold, Mean ± SEM, n=3, P- value<0.05) in them. Also, our results showed that BRAF inhibition affected NIS protein expression and localization.

Conclusions:

Current study showed that the differentiate genes/proteins expression can be induced in the CSCs via focus on signal transduction pathways and targeting their molecules, that are involved in expression of these genes/proteins. Therefore, attention to targeting CSCs along with routine thyroid cancer therapy, can help to ATC treatment.

Immunohistochemical assessment of growth factor signaling molecules: MAPK, Akt, and STAT3 pathways in oral epithelial precursor lesions and squamous cell carcinoma

Several growth factors and their receptors, such as epidermal growth factor receptor, have been studied as prognostic biomarkers for many epithelial malignancies. The signal transduction cascade of those receptors includes RAS/RAF/ERK, PI3K/Akt/mTOR, and STAT3 pathways. The aim of this study was to investigate the expression levels of several key proteins of those pathways in patients with oral squamous cell carcinoma (OSCC) and oral epithelial precursor lesions (OEPLs), and to correlate the expressions of these proteins with clinicopathologic features and prognosis. Fifteen leukoplakia (LP), 15 low-grade epithelial dysplasia, 15 high-grade epithelial dysplasia (HD), and 132 OSCC specimens were immunohistochemically examined for KRAS, HRAS, NRAS, BRAF, pERK1/2, pAkt, pmTOR, and pSTAT3 expression. Immunoreactivity for these molecules predominantly occurred in regions OEPL basal to prickle layers and in most OSCC cells. KRAS and NRAS expression was significantly lower in OSCC than in OEPLs, while pAkt and pmTOR showed higher expression in OSCC than in OEPLs. pERK1/2 expression was significantly higher in HD than in LP. In OSCC, KRAS and NRAS immunoreactivity was significantly higher in advanced age and male gender. In addition, higher immunoreactivity was shown in pERK1/2 in female gender and advanced TNM stage, pAkt in advanced T classification and cases without postoperative metastasis, pmTOR in advanced mode of invasion, and pSTAT3 in invasion depth. Correlations between these markers and clinicopathological variables were also noted. MAPK, Akt, and STAT3 pathways might play diverse roles in oral carcinogenesis.

Evaluation of MEDAG gene expression in papillary thyroid microcarcinoma: associations with histological features, regional lymph node metastasis and prognosis

Papillary thyroid microcarcinoma accounts for a large proportion of papillary thyroid carcinoma, especially among new cases. Many  PTMC patients have regional lymph node metastasis, with some experiencing recurrence and even death. However, the risk factors and mechanism by which PTMC relates to these factors are unknown. In this study, differentially expressed genes were identified with microarray from The Cancer Genome Atlas, followed by analysis using the Kyoto Encyclopedia of Genes and Genomes. Immunohistochemistry, immunofluorescence, western blot and Oil Red O staining were carried out to evaluate expression levels and functional alterations. Mesenteric Estrogen Dependent Adipogenesis expression was observed in almost all cases of papillary thyroid microcarcinomas, and the location of expression was associated with histological subtype. High expression was correlated with metastasis and poor disease-free survival. Furthermore, the enrichment analysis indicated that Mesenteric Estrogen Dependent Adipogenesis expression may be associated with metabolic reprogramming to influence metastasis and prognosis. These findings contribute to a better understanding of how Mesenteric Estrogen Dependent Adipogenesis affects metastasis and the prognosis of papillary thyroid microcarcinoma patients and suggest that Mesenteric Estrogen Dependent Adipogenesis expression may be a novel prognostic marker in these patients. 

BRAF V600E Status and Stimulated Thyroglobulin at Ablation Time Increase Prognostic Value of American Thyroid Association Classification Systems for Persistent Disease in Differentiated Thyroid Carcinoma

BACKGROUND

Stimulated thyroglobulin levels measured at the time of remnant ablation (A-hTg) and BRAFV600E mutation had shown prognostic value in predicting persistent disease in differentiated thyroid cancer (DTC). The aim of this study was to evaluate the prognostic role of A-hTg combined with the BRAFV600E status in association with the revised American Thyroid Association (ATA) risk stratification.

MATERIAL AND METHODS

620 patients treated for a DTC were included in this study with a median follow-up duration of 6.1 years. All patients underwent total thyroidectomy followed by radioiodine ablation. Patients with positive anti-thyroglobulin antibodies were excluded. The predictive value of A-hTg was calculated by receiver operating characteristic curve (ROC curve) analysis. The Cox proportional hazard regression model, including the BRAF status, A-hTg, and ATA classification system, was assessed to evaluate the existing persistent disease risk.

RESULTS

Taken together, the BRAF status and A-hTg levels improve the ATA risk classification in all categories. In particular, in the low-risk ATA classification, only the combination of BRAFV600E+A-hTg > 8.9ng/ml was associated with persistent disease (P = 0.001, HR 60.2, CI 95% 5.28-687). In the intermediate-risk ATA classification, BRAFWT+A-hTg > 8.9ng/ml was associated with persistent disease (P = 0.029, HR 2.71, CI 95% 1.106-6.670) and BRAFV600E+A-hTg > 8.9ng/ml was also associated with persistent disease (P < 0.001, HR 5.001, CI 95% 2.318-10.790). In the high-risk ATA classification, both BRAFV600E+A-hTg < 8.9ng/ml and BRAFV600E+A-hTg > 8.9 ng/ml were associated with persistent disease (P = 0.042, HR 5.963, CI 95% 1.069-33.255 and P = 0.002, HR 11.564, CI 95% 2.543-52.576, respectively).

CONCLUSIONS

The BRAF status and stimulated thyroglobulin levels at ablation time improve the ATA risk stratification of differentiated thyroid cancer; therefore, even A-hTg could be included in risk classification factors.

PFKFB2 Promoter Hypomethylation as Recurrence Predictive Marker in Well-Differentiated Thyroid Carcinomas

Despite the low mortality rates, well-differentiated thyroid carcinomas (WDTC) frequently relapse. BRAF and TERT mutations have been extensively related to prognosis in thyroid cancer. In this study, the methylation levels of selected CpGs (5-cytosine-phosphate-guanine-3) comprising a classifier, previously reported by our group, were assessed in combination with BRAF and TERT mutations. We evaluated 121 WDTC, three poorly-differentiated/anaplastic thyroid carcinomas (PDTC/ATC), 22 benign thyroid lesions (BTL), and 13 non-neoplastic thyroid (NT) tissues. BRAF (V600E) and TERT promoter (C228T and C250T) mutations were tested by pyrosequencing and Sanger sequencing, respectively. Three CpGs mapped in PFKFB2, ATP6V0C, and CXXC5 were evaluated by bisulfite pyrosequencing. ATP6V0C hypermethylation and PFKFB2 hypomethylation were detected in poor-prognosis (PDTC/ATC and relapsed WDTC) compared with good-prognosis (no relapsed WDTC) and non-malignant cases (NT/BTL). CXXC5 was hypomethylated in both poor and good-prognosis cases. Shorter disease-free survival was observed in WDTC patients presenting lower PFKFB2 methylation levels (p = 0.004). No association was observed on comparing BRAF (60.7%) and TERT (3.4%) mutations and prognosis. Lower PFKFB2 methylation levels was an independent factor of high relapse risk (Hazard Ratio = 3.2; CI_95% = 1.1–9.5). PFKFB2 promoter methylation analysis has potential applicability to better stratify WDTC patients according to the recurrence risk, independently of BRAF and TERT mutations.

Understanding Pathways to the Diagnosis of Thyroid Cancer: Are There Ways We Can Reduce Over-Diagnosis?

BACKGROUND

The incidence of thyroid cancer has rapidly increased, and ecological evidence suggests this is due in some part to over-diagnosis. Understanding pathways to diagnosis could help determine whether unnecessary diagnosis can be avoided.

METHODS

A population-based sample (n = 1007) of thyroid cancer patients diagnosed between July 2013 and August 2016 was recruited from Queensland, Australia (response rate 67%). Information from structured telephone interviews was used to describe diagnostic pathways for thyroid cancer, to investigate factors associated with diagnostic pathways, and to assess the most prevalent modes of diagnoses by which the lowest-risk, potentially over-diagnosed thyroid cancers (intrathyroidal microcarcinomas) are detected.

RESULTS

Only 38% of participants presented with symptoms potentially related to thyroid cancer. Older age at diagnosis was associated with a lower prevalence of symptomatic diagnosis (prevalence ratio [PR] = 0.46 [confidence interval (CI) 0.31-0.68] for 70-79 vs. <30 years), as was frequent medical contact, while living in rural/regional areas was associated with a higher prevalence of symptomatic diagnosis (PR = 1.17 [CI 1.00-1.37] for rural/regional areas vs. major cities). Symptomatic diagnosis also occurred more for those whose tumors had adverse histopathological features (larger size, lymph node involvement, lymphovascular invasion). The likelihood of diagnosis of intrathyroidal microcarcinomas was greatest for those having surgical resection or monitoring for benign thyroid disease (PR = 3.87 [CI 2.81-5.32] and PR = 2.21 [CI 1.53-3.18], respectively).

CONCLUSIONS

A minority of newly detected thyroid cancer cases were diagnosed because of symptoms. Access to medical care and factors related to cancer aggressiveness were associated with how diagnoses occurred. The likelihood of diagnosing the lowest-risk thyroid cancers was higher in situations related to management of other thyroid conditions. Adherence to thyroid management guidelines could reduce some thyroid cancer over-diagnosis, but ultimately better diagnostic tools are needed to differentiate between indolent cancers and those of clinical significance.

Association between BRAF (V600E) mutation and clinicopathological features of papillary thyroid carcinoma: a Brazilian single-centre case series

OBJECTIVES

We aimed to investigate the prevalence of the BRAF (V600E) mutation in consecutive cases of papillary thyroid carcinoma (PTC) in patients diagnosed and treated at the Hospital Sao Rafael (Salvador, BA, Brazil) and evaluate its association with clinical and pathological characteristics of PTC.

SUBJECTS AND METHODS

We retrospectively enrolled in the study a total of 43 consecutive PTC patients who underwent total thyroidectomy. We performed DNA extraction from formalin-fixed paraffin-embedded (FFPE) tumour tissue samples. Polymerase chain reaction (PCR) and direct sequencing were used to determine BRAF (V600E) mutation status. Univariate and multivariate logistic regression analyses were employed to identify independent associations.

RESULTS

The prevalence of BRAF (V600E) mutation was 65.1% (28/43). A high frequency of older patients (p value: 0.004) was observed among the BRAF-mutated PTC group and, in contrast, a low frequency of concurrent Hashimoto's thyroiditis (HT) (p value: 0.011) was noted. Multivariate analysis confirmed that older age (OR: 1.15; 95% CI: 1.00 - 1.33; p value: 0.047) and HT (OR: 0.05; 95% CI: 0.006-0.40; p value: 0.005) were independent factors associated with BRAF (V600E) mutation.

CONCLUSION

We found a high prevalence of BRAF (V600E) mutation in PTC cases. Older age and no concurrent HT were independently associated with BRAF (V600E) mutation.

BRAF mutation in cytologically indeterminate thyroid nodules: after reclassification of a variant thyroid carcinoma

Purpose

Fine-needle aspiration biopsy (FNAB) is regarded by the Bethesda system as the gold-standard investigation for stratifying the risk of malignancy of a thyroid nodule. However, some limitations affect the adequacy of the obtained materials, resulting in 30% of the cytological results remaining in the indeterminate category. We aimed to investigate the diagnostic value of the BRAF mutation in cytologically indeterminate thyroid nodules after the reclassification of a variant thyroid carcinoma.

Patients and methods

In this prospective diagnostic study, 76 patients with FNAB findings of atypia of undetermined significance (AUS) and suspicious for malignancy (SUS) were included. The BRAF V600 mutation from FNAB was confirmed by a PCR-based method (Sanger sequencing combined with allele-specific real-time PCR techniques) and immunohistochemistry (IHC). Pathological specimens and features, including noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), were reviewed and compared to the FNAB results.

Results

Using the PCR-based method, the BRAF mutation was positive in 13/76 cases (17.1%), with the diagnostic values of 16.7% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 82.8% negative predictive value (NPV) in the AUS compared to 73.3% sensitivity, 100% specificity, 100% PPV, and 20% NPV in the SUS. For the IHC technique, only 20 of the 76 cytological specimens were qualified for testing. The BRAF mutation was positive in 13/20 cases, with the diagnostic values of 100% sensitivity, 63.6% specificity, 42.9% PPV, and 100% NPV in the AUS compared to 100% sensitivity and PPV in the SUS. The BRAF mutation was not found in the pathological reports for NIFTP.

Conclusion

The malignancy rate is high in our data, with specific and acceptable accuracy rates for the BRAF mutation from FNAB found by using the PCR-based method. NIFTP has been introduced after the pathological reclassification. Molecular diagnosis might be useful to establish the nature of the disease.

Multiple Simultaneous Rare Distant Metastases as the Initial Presentation of Papillary Thyroid Carcinoma: A Case Report

Papillary thyroid carcinoma (PTC) commonly metastasizes to regional lymph nodes. However, they infrequently cause rare distant metastases (RDMs), with the exclusion of lungs and bone metastases. RDMs are seldom identified prior to a primary thyroid cancer diagnosis. Therefore, cases initially presenting with synchronously multiple RDMs from PTC are extremely infrequent. This is a rare case of a 48-year-old man with initial diaphragm, pancreatic, and liver tumors from PTC. Following resection of the tumors, an ultrasound-guided fine-needle aspiration (US-FNA) cytology of a mass in the thyroid's left lobe revealed PTC. After postoperative recovery for more than 4 months, physical examination identified an irregular large nodule in the thyroid's isthmus and left lobe, a swollen lymph node in the left neck, and a mass in the right parotid gland. Ultrasound reexamination revealed numerous hypoechoic masses as follows: one in the thyroid's isthmus and entire left lobe (7.3 × 5.9 × 5.1 cm) and multiple in the thyroid's right lobe (0.2-0.3 cm). Ultrasound examination also showed several swollen lymph nodes in the left neck, a mass in the left gluteus maximus, and several masses in both the bilateral parotid and salivary region. The US-FNA's pathological examination confirmed metastatic PTCs in the left gluteus maximus and bilaterally located in the parotid and salivary gland. 18-fluorodeoxyglucose positron-emission tomography and computed tomography scan revealed abnormal uptakes in numerous locations (e.g., the thyroid's isthmus and left lobe, bilateral parotid gland, subcutaneous tissues, etc.). The patient underwent palliative therapy, including total thyroidectomy, bilateral central neck dissection, left lateral neck dissection, and excision of the bilateral parotid and salivary gland. A whole-body scan post-therapeutic radioactive iodine ablation showed exclusive thyroid bed uptake. Subsequently, the patient underwent continuous thyroid stimulating hormone repression therapy and was treated with lenvatinib chemotherapy for ~8 months. The primary thyroid tumor, pancreatic metastasis, and cervical lymph node metastasis were both positive for BRAF ^V600E and TERT promoter (C288T) mutations. After 13 months of follow-up, the patient is currently in stable clinical conditions. In conclusion, the present case is an extremely rare occurrence of simultaneous multiple RDMs from PTC as the initial presentation.

Antitumor effects of anlotinib in thyroid cancer

There is no effective treatment for patients with poorly differentiated papillary thyroid cancer or anaplastic thyroid cancer (ATC). Anlotinib, a multi-kinase inhibitor, has already shown antitumor effects in various types of carcinoma in a phase I clinical trial. In this study, we aimed to better understand the effect and efficacy of anlotinib against thyroid carcinoma cells in vitro and in vivo. We found that anlotinib inhibits the cell viability of papillary thyroid cancer and ATC cell lines, likely due to abnormal spindle assembly, G2/M arrest, and activation of TP53 upon anlotinib treatment. Moreover, anlotinib suppresses the migration of thyroid cancer cells in vitro and the growth of xenograft thyroid tumors in mice. Our data demonstrate that anlotinib has significant anticancer activity in thyroid cancer, and potentially offers an effective therapeutic strategy for patients of advanced thyroid cancer type.

A molecular approach combined with American Thyroid Association classification better stratifies recurrence risk of classic histology papillary thyroid cancer

BACKGROUND

Prognosis among patients with differentiated thyroid cancer is widely variable. Better understanding of biologic subtypes is necessary to stratify patients and improve outcomes.

METHODS

In patients diagnosed with classic histology papillary thyroid cancer treated from 1973 to 2009, BRAF V600E mutation status was determined on surgical tumor specimens by restriction fragment length polymorphism analysis. A tissue microarray (TMA) was constructed from tumor specimens in triplicate and stained by immunohistochemistry for RET, phospho-MEK, MAPK(dpERK), PPARγ, and phospho-AKT(pAKT). Stained slides were scored independently and blindly by two investigators and compared to tumor and patient characteristics and outcomes.

RESULTS

A total of 231 patients had archived formalin-fixed, paraffin-embedded tumor tissue available and were included on the TMA. Mean age at diagnosis was 44 years (range 6-82 years); proportion of patients with female sex was (72%); 2015 American Thyroid Association (ATA) risk stratification was low (26%), intermediate (32%), and high (42%). BRAF V600E mutation was found in 74% of specimens, and IHC was scored as positive for RET (61%), MAPK (dpERK) (14%), PPARγ (27%), and pAKT (39%). Positive RET staining was associated with a lower risk of recurrence (HR = 0.46, 95% CI 0.22-0.96). No other molecular biomarkers were independent predictors of recurrence on univariable analysis. On RPA, patients with RET-negative and either MAPK(dpERK)-positive or pAKT-positive tumors were identified to have a high risk of recurrence (HR = 5.4, 95%CI 2.5-11.7). This profile remained associated with recurrence in a multivariable model including ATA risk stratification (HR = 2.8, 95% CI 1.3-6.0).

CONCLUSION

Characterization of molecular pathways involved in cPTC tumorigenesis may add further risk stratification for recurrence beyond the 2015 ATA risk categories alone.

Prognosis of a rare subtype of thyroid cancer: Spindle cell thyroid carcinoma

Systemic illustrations of spindle cell thyroid cancer (SCTC), based on a large cohort, are few. We investigated the prognosis of SCTC compared to the most common subtypes, papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC).Information of patients with a diagnosis of SCTC, PTC, or FTC, between 2004 and 2013, was obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Patient survival curves were investigated using Kaplan-Meier analyses, log-rank tests, and Cox proportional hazards regression analyses.In a Kaplan-Meier analysis of the entire cohort of thyroid cancer patients, cancer specific survival declined sharply for patients with SCTC, but declined more modestly for patients with PTC and FTC. Unadjusted Cox regression analysis and Kaplan-Meier curve analysis showed that SCTC had a poorer cancer-specific mortality and all-cause mortality compared to PTC and FTC. Similar results were obtained after adjustment for different confounding factors.Our study assessed the prognosis of SCTC, based on a large cohort, compared to PTC and FTC, and found relatively accurate hazard ratios of death rate in SCTC as compared to PTC and FTC. Thus, our findings would provide beneficial insights on patients with SCTC, and aid in treatment decision making, more radical treatment like total-thyoridectomy and/or plus central lymph node dissection should be performed for patients with SCTC.

Predictive Value of BRAFV600E Mutation for Lymph Node Metastasis in Papillary Thyroid Cancer: A Meta-analysis

BRAF^V600E mutation has been thought to be a valuable molecular marker that may predict a worse prognosis for papillary thyroid cancer (PTC). But whether BRAF^V600E mutation is associated with lymph node metastasis (LNM) remains controversial. Different surgical strategies may bring a bias in demonsstrating the association between them. In order to delineate a risk stratification to guide a tailored initial approach to tumors that express BRAF^V600E mutation, we performed this meta-analysis by using the articles in which total or near-total thyroidectomy plus bilateral central lymph node dissection was routinely performed to avoid the bias from the surgical strategy. We searched the Medline, Embase and CNKI database for eligible studies from January 2003 to May 2018. Meta-analysis was performed using the STATA 12.0 software. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated under fixed-effects or randomeffects models. Fifteen clinical studies were included with a total of 4909 PTC patients. Our meta-analysis results reported that BRAFV600E mutation was associated with LNM (OR=1.34; 95% CI: 1.09-1.65; P=0.005), as well as central LNM (OR=1.59; 95% CI: 1.35-1.88; P<0.00001). Moreover, in patients with papillary thyroid microcarcinoma, we also confirmed the predictive value of BRAF^V600E mutation for LNM (OR=3.49; 95% CI: 2.02-6.02; P<0.00001). This meta-analysis demonstrates that BRAF^V600E mutation is closely related to LNM in PTC patients. The results suggest that BRAF^V600E mutation can be considered as a risk factor for LNM in PTC. Moreover, combining BRAF^V600E mutation with other risk factors to determine the initial surgical treatment may bring benefits for PTC patients.

Current controversies and future directions in the diagnosis and management of differentiated thyroid cancers

Despite the development of novel diagnostic, surgical, and chemotherapeutic approaches to differentiated thyroid cancers (DTCs), the diagnosis and management of these tumors remains controversial. The most recent American Thyroid Association (ATA) guidelines, released in 2015, reflect a recent shift towards less aggressive management for patients with DTCs. However, many clinicians have expressed concern that more conservative management will put patients at risk for disease recurrence and metastasis. In particular, the management of indeterminate nodules on fine needle aspiration (with special attention to genetic and epigenetic markers of malignancy), the extent of surgery for known differentiated cancers, the role of adjuvant radioactive iodine (RAI) therapy, and novel targeted treatments with tyrosine kinase inhibitors (TKIs) represent current areas of uncertainty and opportunities for future research. In this review, we examine the current state of the art in these areas, and address some of the questions that remain.

BRAF mutation in papillary thyroid carcinoma (PTC) and its association with clinicopathological features and systemic inflammation response index (SIRI)

The aim of the present research was to investigate the association between the BRAF mutation and papillary thyroid carcinoma (PTC), and further explore the relationship between the systemic inflammation response index (SIRI) and BRAF mutation in patients with PTC. The clinicopathological data were extracted from the patients' medical records from June 2012 to June 2014 in our hospital. We enrolled 95 patients with PTC that have received the total or near-total thyroidectomy and pretracheal and paratracheal lymph node dissection. The blood samples were obtained before surgery. According to the BRAF mutation analysis, the patients were divided into two groups: BRAF mutation positive group and BRAF mutation negative group. The receiver operating characteristic curve (ROC) for the presence of BRAF mutation was used to evaluate the optimal cutoff value of SIRI. The ratio closest to the point with maximum sensitivity and specificity was defined as the optimal cutoff value. Univariate and multivariate logistic regression model were used to confirm the independent factors and compare observed and predicted outcomes. The BRAF mutation rates were 62.1% (59/95). The results indicated that BRAF mutation was significantly correlated with pathological TNM stage, monocyte, SIRI and Galectin-3. The pathological TNM stage, monocyte, SIRI and Galectin-3 were the significant risk factors associated with the presence of BRAF mutation. Moreover, we found that patients with low SIRI had higher BRAF mutation percentage than those with high SIRI, and patients with low monocyte had higher percentage than those with high monocyte. BRAF mutation is associated with the pathological TNM stage, monocyte, SIRI and Galectin-3, and SIRI was the significant risk factor with the BRAF mutation and patients with low SIRI have higher BRAF mutation.

Tailored surgery according to molecular analysis in differentiated thyroid carcinomas

Papillary thyroid carcinoma (PTC) is an often indolent disease implying a long survival and in most of the cases an excellent prognosis, but there is still a limited percentage of cases where, in spite of their pre-operative conventional staging, these tumors could better be treated through a more selective surgical approach. Small PTC in fact are generally considered as "low risk" tumors but using simply a TNM classification might lead to a limited surgery such as unilateral hemithyroidectomy, in particular according to the most recent guidelines of the American Thyroid Association. On the other hand though, an absence of the mutation could allow simplifying the follow-up of these patients, for example avoiding unnecessary radioactivated iodine therapy after surgery or even limiting to a unilateral thyroidectomy the operative procedure for these cases. Molecular testing has a peculiar interest for surgeons in two different ways: (I) with respect to diagnosis, in order to reduce the number of indeterminate citologies; (II) with respect to prognosis after both cytology and histology, in order to improve risk stratification and help the surgeon in developing a tailored surgical therapy. The aim of this review is the second issue: how to implement the concept of a tailored surgery according to molecular analysis in differentiated thyroid carcinomas (DTC).

[Clinical, morphological, and prognostic features of papillary thyroid carcinoma with different BRAF mutational status assessed by immunohistochemistry]

The somatic mutation in BRAF^T1799A (BRAF^V600E), the data on the prognostic role of which are contradictory, is one of the most common molecular genetic abnormalities in the cells of papillary thyroid carcinoma (PTC).

OBJECTIVE

To investigate the association of the immunoexpression of mutant BRAF in PTC with different morphological characteristics and long-term treatment results in patients.

MATERIAL AND METHODS

Information on inpatients with PTC was obtained from the database of the Pathology Department, A.F. Tsyb Medical Radiology Research Center (a branch of the National Medical Radiology Research Center, Ministry of Health of the Russia). The paraffin-embedded blocks of surgically removed primary, metastatic, and recurrent PTC tissues were cut and stained with hematoxylin and eosin and anti-mutant BRAF monoclonal antibodies. The results of immunohistochemical tests were assessed and the frequency of BRAF immunoexpression was analyzed in relation to various clinical and morphological parameters of tumor growth, the pattern and volume of treatment in the patients, by taking into account its long-term results (the presence or absence of tumor recurrence and metastases in the postoperative period).

RESULTS

The expression of mutant BRAF (BRAF+) was noted in 29 (39.3%) of the 74 cases of PTC. The BRAF+ group differed from the BRAF group by a higher proportion of male patients, older age, advanced clinical stage of carcinoma, a predominance of papillary structure of tumors, and a higher frequency of their recurrence and/or metastases in the postoperative period.

CONCLUSION

The immunohistochemical assessment of BRAF status opens up a possibility to predict local recurrence and metastases in the postoperative period in patients treated for PTC.

Analysis of circulating tumor DNA does not improve the clinical management of patients with locally advanced and metastatic papillary thyroid carcinoma

BACKGROUND

Circulating cell-free tumor DNA (ctDNA) in plasma is a promising noninvasive instrument for cancer monitoring. Detection of BRAF^V600E on ctDNA of patients with papillary thyroid carcinoma (PTC) may represent an indicator of tumor aggressiveness and progression.

METHODS

Eighty-three plasma samples were collected from 70 patients with thyroid nodules undergoing surgery and from 13 patients with PTC causing distant metastases. A total of 59 PTCs from both groups were evaluated for BRAF mutation on tumor tissue and on ctDNA from plasma samples by real-time polymerase chain reaction (PCR) and digital PCR.

RESULTS

Of 59 PTCs, 22 were BRAF^V600E mutated (37.3%). The corresponding ctDNA was negative by using both techniques.

CONCLUSION

Although highly sensitive techniques were used, in our study, circulating BRAF^V600E alleles were never detected in the plasma of patients with PTC; therefore, our results raise the question about the clinical usefulness of BRAF^V600E analysis on ctDNA of patients with PTC.

Molecular pathology of thyroid tumours of follicular cells: a review of genetic alterations and their clinicopathological relevance

Thyroid cancer is the most common endocrine malignancy. Knowledge of the molecular pathology of thyroid tumours originating from follicular cells has greatly advanced in the past several years. Common molecular alterations, such as BRAF p.V600E, RAS point mutations, and fusion oncogenes (RET-PTC being the prototypical example), have been, respectively, associated with conventional papillary carcinoma, follicular-patterned tumours (follicular adenoma, follicular carcinoma, and the follicular variant of papillary carcinoma/non-invasive follicular thyroid neoplasm with papillary-like nuclear features), and with papillary carcinomas from young patients and arising after exposure to ionising radiation, respectively. The remarkable correlation between genotype and phenotype shows how specific, mutually exclusive molecular changes can promote tumour development and initiate a multistep tumorigenic process that is characterised by aberrant activation of mitogen-activated protein kinase and phosphoinositide 3-kinase-PTEN-AKT signalling. Molecular alterations are becoming useful biomarkers for diagnosis and risk stratification, and as potential treatment targets for aggressive forms of thyroid carcinoma. What follows is a review of the principal genetic alterations of thyroid tumours originating from follicular cells and of their clinicopathological relevance.

Unfavorable efficacy to 131I ablation in BRAFV600E mutant papillary thyroid carcinoma with positive TgAb

The BRAFV600E mutation has shown a close relationship of aggressiveness in papillary thyroid carcinoma (PTC), while it remains unclear about its influence on the therapeutic response. As a common clinicopathologic risk factor, thyroglobulin antibody (TgAb) may have a correlation of prognosis in PTC. The objective was to investigate the relationship between BRAFV600E mutation and TgAb, and their combined effect on efficacy to radioiodine remnant ablation (RRA). This was a retrospective study including 298 PTC patients and they were divided into four groups according to the combined status. The BRAFV600E mutation rates declined along with increasing TgAb levels in the entire cohort. The ablative efficacy in terms of success or failure rate was statistically different among four groups (89.7%, 74.1%, 67.5%, 57.8%, respectively, P=0.009), group with both positive BRAF and TgAb presented the lowest efficacy. The combined status was associated with the poor efficacy to RRA independently (P=0.029). Among patients with positive TgAb, the effect of RRA in reducing TgAb level might be weakened in BRAF mutant status. The combined status of BRAFV600E mutation and positive TgAb predicts low efficacy to RRA and might be served as an independent unfavorable prognostic factor for PTC. BRAF mutant might weaken the effect of RRA in reducing TgAb levels in PTCs.

Squamous Cell Carcinoma of the Thyroid as a Result of Anaplastic Transformation from BRAF-Positive Papillary Thyroid Cancer

Papillary thyroid carcinoma (PTC) is the most common malignant neoplasm of the thyroid. Majority of the PTC carries an excellent prognosis. However, patients with tall cell variant (TCV) of papillary thyroid carcinoma have a worse prognosis than those with the classic variant. On the other hand, squamous cell carcinoma of the thyroid (SCT) is an unusual neoplasm thought to arise as a primary tumor or as a component of an anaplastic or undifferentiated carcinoma. We report a patient with TCV of PTC presenting years later with squamous transformation. In addition, the patient was found to have BRAF mutation. Such dedifferentiation is considered to be a rare phenomenon and has been reported only in the form of case reports in the literature. The relationship between BRAFV600E mutation and squamous cell transformation of papillary thyroid cancer is unknown at this time. Meticulous pathology is needed to identify such variants. Our patient responded to treatment with concurrent chemotherapy with carboplatin and paclitaxel along with radiation.

Identification of distinct cytomorphologic features in the diagnosis of NIFTP at the time of preoperative FNA: Implications for patient management

BACKGROUND

A major reclassification occurred with the redesignation of noninvasive encapsulated follicular variant of papillary thyroid carcinoma as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) due to its indolent nature. The aim of this study was to determine whether distinct cytomorphologic features could be identified on preoperative fine-needle aspiration (FNA) when NIFTP cases were compared with invasive follicular variant of papillary thyroid carcinoma (FVPTC) subtypes.

METHODS

Thyroid resection cases with the diagnosis of FVPTC from 2012 to 2016 were reclassified as NIFTP, invasive encapsulated follicular variant of papillary thyroid carcinoma (IEFVPTC), and invasive FVPTC subtypes. Corresponding FNA specimens were retrieved and retrospectively reviewed. A univariate analysis using Fisher's exact test was performed to determine any differences in the frequencies of various cytomorphologic features among NIFTP, IEFVPTC, and FVPTC cases. A multivariate analysis was performed to identify any independent salient features that would be helpful in differentiating NIFTP from its invasive counterparts.

RESULTS

The study population consisted of 93 cases, including 51 cases of NIFTP, 21 cases of IEFVPTC, and 21 cases of infiltrative FVPTC. Demographics such as age, sex, and tumor size were comparable across the 3 groups. A predominantly microfollicular pattern, an absence of nuclear pseudo-inclusions, and less frequent nuclear elongations and grooves were significantly more likely to be associated with NIFTP versus its invasive counterparts. The absence of nuclear pseudo-inclusions and the presence of a microfollicular pattern were the only independent predictors of a NIFTP diagnosis.

CONCLUSIONS

This study demonstrates that NIFTP cases have distinguishing cytomorphologic characteristics in comparison with invasive FVPTC cases. Therefore, a preoperative cytologic evaluation provides clues that can aid in the distinction between NIFTP and its invasive counterparts. Cancer Cytopathol 2017;125:865-75. © 2017 American Cancer Society.

Correlation between BRAF V600E mutation and clinicopathological features in pediatric papillary thyroid carcinoma

In adults, the presence of the BRAF ^V600E mutation in papillary thyroid cancer (PTC) has been demonstrated to be strongly associated with aggressive cancer-cell characteristics and poor patient prognosis. In contrast, the frequency of this mutation in pediatric PTC has undergone limited study, and the few available estimates range from 0 to 63%. Furthermore, the role of the BRAF ^V600E mutation in pediatric PTC is controversial; thus, the present study aimed to investigate the prevalence and role of the BRAF ^V600E mutation in 48 pediatric patients with PTC, aged 3-13 years. Of these patients, 41 were diagnosed with classic PTC, five were found to have a follicular variant of PTC, and two to exhibit a diffuse sclerosing PTC variant. The BRAF ^V600E mutation was identified to be present in 35.4% of the 48 analyzed patients, and in 41.5% of the patients diagnosed with classical PTC. Furthermore, the presence of the BRAF ^V600E mutation was found to be associated with a patient age at diagnosis of less than ten years (P=0.011), the performance of a thyroidectomy (P=0.03), exhibited tumor multifocality (P=0.02) and/or extra-thyroidal invasion (P=0.003), and both a low MACIS (Metastases, Age, Completeness of resection, Invasion, Size)(P=0.036) and AMES (Age, Metastasis, Extent of tumor, Size)(P=0.001) score. Together, these data suggest that the presence of the BRAF ^V600E mutation may be negatively correlated with partial aggressive clinicopathological features of pediatric PTC.

TERT, BRAF, and NRAS in Primary Thyroid Cancer and Metastatic Disease

CONTEXT

Little is known about the frequency of key mutations in thyroid cancer metastases and its relationship with the primary tumor genotype.

OBJECTIVES

To evaluate the frequency of TERT promoter (TERTp), BRAF, and NRAS mutations in metastatic thyroid carcinomas, analyzing primary thyroid tumors, lymph node metastases (LNMs), and distant metastases.

DESIGN AND PATIENTS

Mutation analysis was performed in 437 tissue samples from 204 patients, mainly with papillary thyroid carcinomas (PTCs; n = 180), including 196 LNMs and 56 distant metastases. All the distant metastases included corresponded to radioiodine-refractory metastatic tissue.

RESULTS

We found the following mutation frequency in primary PTCs, LNMs, and distant metastases, respectively: TERTp: 12.9%, 10.5%, and 52.4%; BRAF: 44.6%, 41.7%, and 23.8%; and NRAS: 1.2%, 1.3%, and 14.3%. There was a significant concordance between the primary tumor genotype and the corresponding LNM for all the genes, in particular BRAF-mutated PTC. The overall concordance between primary tumors and respective distant metastases was low. In the group of patients with PTCs, we found a high frequency of TERTp mutations and a low frequency of BRAF mutations in distant metastases, in comparison with the paired primary tumors. When present in distant metastases, BRAF mutations frequently coexisted with TERTp mutations.

CONCLUSIONS

When the genotype of primary tumors is compared with the genotype of LNMs, the concordance is high for all the genes studied. On the other hand, distant metastases show an enrichment in TERTp mutations and a decrease in BRAF mutations. TERTp mutations may play a role in distant metastases.

The evolution of differentiated thyroid cancer

Differentiated thyroid tumours of follicular cell derivation have traditionally been classified based on architecture, cytology, or both. The features that distinguish the various entities are controversial and diagnostic criteria are inconsistent and often irreproducible. The complexity of classification schemes has not been substantiated by molecular profiling. In this review, a simplistic approach to the diagnosis of well differentiated thyroid neoplasia is provided to challenge the dogma. The proposed classification matches the molecular profiles of these lesions and simplifies the criteria for diagnosis. This approach can be used to support rational treatment algorithms.

The utility of the Bethesda category and its association with BRAF mutation in the prediction of papillary thyroid cancer stage

PURPOSE

This study aims to determine the utility of the Bethesda category and its association with BRAF mutation in prediction of the papillary thyroid cancer (PTC) stage.

METHODS

A prospective study analyzed patients who had ultrasound-suspicious thyroid nodules, underwent FNA and cytological examination, and were classified according to the Bethesda system. Patients from Undetermined Significance Or Follicular Lesion Of Undetermined Significance (AUS/FLUS), Follicular Neoplasm or Suspicious for a Follicular Neoplasm (FN/SFN), Suspicious for Malignant Cells (SMC), and Positive for Malignant Cells (PMC) groups were examined for the BRAF mutation and had a thyroid surgery. Demographical and histological features and stage of the disease were evaluated for PTC patients in accordance with the Bethesda category and its association with BRAF mutation.

RESULTS

Three hundred eight of all patients underwent operation. One hundred forty-three (46.4%) of them were diagnosed with PTC. In 14 (9.8%) PTC cases, FNA biopsies were classified as AUS/FLUS, 23 (16.1%) as FN/SFN, 41 (28.7%) as SMC, and 65 (45.5%) as PMC. I-II stages of PTC were diagnosed for 88 (61.5%) patients and III-IVA for 55 (38.5%). Patients from the SMC and PMC groups had larger tumors, higher incidence of lymph node metastases, classical PTC type, B-type Raf (BRAF) positive, and III-IVA stage cancer, than patients from the AUS/FLUS and FN/SFN groups. When comparing 27 (18.9%) BRAF-negative patients from the AUS/FLUS and FN/SFN groups with 116 (81.1%) BRAF-negative patients from the SMC and PMC groups and all BRAF-positive patients, the prediction of more aggressive histological features and stage was slightly improved.

CONCLUSIONS

Higher Bethesda categories are associated with higher stages of PTC. Association of the Bethesda category with BRAF mutation can slightly improve the value of stage prediction.