Completely resected anaplastic thyroid carcinoma combined with adjuvant chemotherapy and irradiation is associated with prolonged survival

Combined radiation and chemotherapy versus monotherapy for anaplastic thyroid cancer: A SEER retrospective analysis

Background

The effect of combined radiation and chemotherapy (combination therapy) versus monotherapy on anaplastic thyroid carcinoma (ATC) has not yet been clear.

Methods

We identified 516 ATC patients during 2010-2015 from the Surveillance, Epidemiology and End Results (SEER) database and evaluated their survival outcome using the Kaplan-Meier method, Cox regression analysis and propensity score matching (PSM) technique.

Results

The median overall survival (OS) among the entire cohort was 3 months (95 % confidence interval [CI], 2.58-3.42 months), and the 6- and 12-month OS rates were 29 % (95 % CI, 25.01%-32.88 %) and 13 % (95 % CI, 10.60%-16.58 %), respectively. Multivariable analysis demonstrated that ATC patients not receiving radiotherapy or chemotherapy were unquestionably associated with worse OS (hazard ratio [HR] 3.000, 95 % CI, 2.390-3.764) and cancer-specific survival (CSS) (HR = 3.107, 95 % CI, 2.388-4.043), compared with those receiving combination therapy. However, combination therapy did not predict better prognosis compared with monotherapy (all P > 0.05). After PSM, the median OS and CSS were also not significantly improved in patients undergoing chemoradiotherapy versus chemotherapy alone (OS, P = 0.382; CSS, P = 0.420) or radiotherapy alone (OS, P = 0.065; CSS, P = 0.251).

Conclusion

Combination therapy, compared to monotherapy, does not have the expected improvement in survival beyond the benefits achievable with each single-modality treatment, necessitating further prospective research to tailor its treatment management.

Surgery combined with adjuvant radiation and chemotherapy prolonged overall survival in stage IVC anaplastic thyroid cancer: a SEER-based analysis

BACKGROUND

Anaplastic thyroid carcinoma (ATC) is a rare but aggressive malignancy, which accounts for only 1-2% of all thyroid cancers. The median overall survival (OS) time for all stages patients is at about 5 months. The benefit of surgery combined with adjuvant radiation and chemotherapy in stage IVC anaplastic thyroid cancer is still controversial. The aim of this study is to investigating surgery combined with adjuvant radiation and chemotherapy and survival outcomes in stage IVC ATC patients.

METHOD

Anaplastic thyroid carcinoma patients from the Surveillance, Epidemiology, and End Results database from 2004 to 2016 were used to conduct a cross-sectional study in the analysis. The endpoint of this study was overall survival.

RESULTS

The median OS of the overall population was 2.0 months. Multivariate analysis showed that age (<67 vs. ≥67 years old, P = 0.017, HR = 1.355, 95% CI: 1.057-1.738), tumor size (<7 cm vs. ≥7 cm, P = 0.001, HR = 1.579, 95% CI: 1.202-2.073), Surgery (thyroidectomy vs. non-surgery, P < 0.001, HR = 0.554, 95% CI: 0.401-0.766), radiation therapy (P < 0.001, HR = 0.571, 95% CI: 0.445-0.733) and chemotherapy (P = 0.003, HR = 0.684, 95% CI: 0.531-0.881) were independent prognostic factor for worse OS in stage IVC ATC patients. Surgery combined with adjuvant radiation and chemotherapy exhibited the better overall survival time for 4 months.

CONCLUSIONS

Surgery combined with adjuvant radiation and chemotherapy can improve overall survival in stage IVC ATC patients. We recommend surgical approach with fully evaluation combined with radiation therapy and chemotherapy for selected stage IVC ATC patients.

The role of targeted therapy and/or immunotherapy therapy in anaplastic thyroid carcinoma

BACKGROUND

Anaplastic thyroid carcinoma (ATC) is a highly invasive malignant tumor with a poor prognosis. Traditional treatment methods have not been effective. However, advancements in targeted therapy and immunotherapy in recent years have shed new light on the management of ATC. The aim of this study was to examine the treatment plan and prognostic factors of ATC.

METHODS

This study conducted a retrospective analysis of ATC patients who received treatment at our institution between 2000 and 2023 to evaluate the clinical characteristics, treatment methods, and factors influencing survival. Survival analysis was performed by the Kaplan‒Meier method and log-rank test, and multivariate analysis was performed using the Cox proportional hazard model.

RESULTS

The 6-month and 1-year disease-specific OS rates were 49% and 29%, respectively. The presence of clinical symptoms and the timing of treatment significantly impacted patient prognosis (P < 0.05). Compared with surgery + radiotherapy/chemotherapy and only surgery, targeted therapy and targeted + immunotherapy represented an improved overall survival, The 6-month/1-year survival rates of which were 81%/61% and 91%/73% (P < 0.05), respectively. Multivariate analysis indicated that the symptoms at initial diagnosis, year of presentation, performance status and treatment plan were independent factors affecting the prognosis. The year of presentation (P = 0.048) and the treatment plan (P = 0.038) were significantly meaningful in predicting prognosis.

CONCLUSION

Targeted therapy and targeted+immune therapy can effectively prolong the survival period of ATC patients. Symptoms at initial diagnosis and treatment plan have a significant impact on the prognosis.

Advances in the management of anaplastic thyroid carcinoma: transforming a life-threatening condition into a potentially treatable disease

Anaplastic thyroid cancer (ATC) is an infrequent thyroid tumor that usually occurs in elderly patients. There is often a history of previous differentiated thyroid cancer suggesting a biological progression. It is clinically characterized by a locally invasive cervical mass of rapid onset. Metastases are found at diagnosis in 50% of patients. Due to its adverse prognosis, a prompt diagnosis is crucial. In patients with unresectable or metastatic disease, multimodal therapy (chemotherapy and external beam radiotherapy) has yielded poor outcomes with 12-month overall survival of less than 20%. Recently, significant progress has been made in understanding the oncogenic pathways of ATC, leading to the identification of BRAF V600E mutations as the driver oncogene in nearly 40% of cases. The combination of the BRAF inhibitor dabrafenib (D) and MEK inhibitor trametinib (T) showed outstanding response rates in BRAF-mutated ATC and is now considered the standard of care in this setting. Recently, it was shown that neoadjuvant use of DT followed by surgery achieved 24-month overall survival rates of 80%. Although these approaches have changed the management of ATC, effective therapies are still needed for patients with BRAF wild-type ATC, and high-quality evidence is lacking for most aspects of this neoplasia. Additionally, in real-world settings, timely access to multidisciplinary care, molecular testing, and targeted therapies continues to be a challenge. Health policies are warranted to ensure specialized treatment for ATC.The expanding knowledge of ATC´s molecular biology, in addition to the ongoing clinical trials provides hope for the development of further therapeutic options.

The role of surgery for anaplastic thyroid carcinoma in the era of targeted therapeutics: A scoping review

Background

Questions exist regarding patient selection for surgery in anaplastic thyroid carcinoma (ATC), particularly with the advent of neoadjuvant-targeted therapeutics. The present scoping review sought to evaluate what extent of surgical resection should be performed in ATC.

Methods

A scoping review was carried out in accordance with Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocols. Included studies were required to provide clear description of the surgery performed for ATC.

Results

The final search identified 6901 articles. Ultimately only 15 articles including 1484 patients met inclusion criteria. A total of 765 patients (51.5%) underwent attempted curative intent surgery. The approach to resection of adjacent tissues varied between studies. Eight studies considered laryngeal ± pharyngeal resection (8/15, 53.3%), eight studies (53.3%) considered tracheal resection and again eight studies (53.3%) considered esophageal resection. More extensive resections increased morbidity without improving overall survival (OS) (<9 months in the 12 studies using a combination of surgery and chemoradiotherapy). In the three studies utilizing targeted therapy in addition to surgery, OS was notably improved while surgical resection following neoadjuvant therapy was less extensive.

Conclusions

There is no clear agreement in the literature regarding the limits of surgical resection in locoregionally advanced ATC. A definition of surgically resectable disease will be required to guide surgical decision making in ATC, particularly with the potential to reduce tumor burden using neoadjuvant targeted treatment in suitable patients.

Level of evidence

III.

Concurrent Anaplastic and Papillary Thyroid Carcinoma Manifesting as a Thyrocutaneous Fistula

Anaplastic thyroid carcinoma (ATC) is a highly aggressive form of thyroid cancer with poor prognosis. Differentiated thyroid carcinoma (DTC) including papillary thyroid carcinoma (PTC) is more common and known to have a favorable outcome after treatment. Here, we report a case of a 59-year-old lady with a long-standing goiter presenting with a discharging anterior neck mass. Fine-needle aspiration cytology (FTAC) of the mass resulted with malignant cells. She underwent surgery, and histopathological examination revealed both ATC and PTC features. Mutation analysis was also performed, and results were positive for BRAF 600VE mutation. She received radiotherapy and also chemotherapy post-surgery. Treatment was well tolerated. The relatively favorable survival of this patient may suggest that synchronous ATC and DTC may have better prognosis than ATC alone. The objective of this article is to report the unique clinical presentation and favorable prognosis with combined treatment modalities.

Valproic acid radiosensitizes anaplastic thyroid cells through a decrease of the DNA damage repair capacity

BACKGROUND

Anaplastic thyroid cancer (ATC) represents a rare lethal human malignancy with poor prognosis. Multimodality treatment, including radiotherapy, is recommended to improve local control and survival. Valproic acid (VA) is a clinically available histone deacetylase inhibitor with a well-documented side effect profile. In this study, we aim to investigate the combined effect of VA with photon irradiation in vitro.

METHODS

Anaplastic thyroid cancer cells (8505c) were used to investigate the radiosensitizing effect of VA.

RESULTS

VA sensitized cells to photon irradiation. VA increased radiation-induced apoptosis and radiation-induced DNA damage measured by γH2AX foci induction. Furthermore, VA prolonged γH2AX foci disappearance over time in irradiated cells and decreased the radiation-induced levels of mRNA of key DNA damage repair proteins of the homologous recombination (HR) and the nonhomologous end joining (NHEJ) pathways.

CONCLUSIONS

VA at a clinically safe dose enhance the radiosensitivity of 8505c cells through an increase in radiation-induced apoptosis and a disruption in the molecular mechanism of HR and NHEJ DNA damage repair pathways.

Development and validation of a nomogram for predicting the early death of anaplastic thyroid cancer: a SEER population-based study

BACKGROUND

Anaplastic thyroid cancer (ATC) is a highly aggressive malignancy with dismal prognosis. This study aimed to identify the independent risk factors and construct a readily-to-use nomogram to predict the probability of early death in ATC patients.

METHOD

Patients diagnosed with ATC between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled in this study for model development and internal validation. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for early death of ATC. Nomograms for predicting the probability of all-cause early death (ACED) and cancer-specific early death (CSED) of ATC were subsequently developed. The performance of the nomograms was comprehensively evaluated and validated in an internal cohort.

RESULT

A total of 696 ATC patients were included in this study, of which 488 patients in the training cohort and 208 patients in the validation cohort. The univariate and multivariate logistic regression analyses identified five independent factors (tumor size, M stage, surgery, radiotherapy and chemotherapy) in the ACED model and six variables in the CSED (gender, tumor size, M stage, surgery, radiotherapy and chemotherapy) model for the establishment of the nomograms. Calibration curves and receiver operating characteristic (ROC) curves showed satisfactory efficacy and consistency both in the training (ACED: AUC values: 0.814 (0.776-0.852); CSED: 0.778 (0.736-0.820)) and validation sets (ACED: 0.762 (0.696-0.827); CSED: 0.745 (0.678-0.812)). In addition, the decision curve analysis (DCA) demonstrated the favorable potential of the two nomograms in clinical application.

CONCLUSION

The two nomograms assist clinicians to identify risk factors and predict the early death probability among ATC patients, thus guide individualized treatment to improve the prognosis.

Exploring the oral-gut microbiota during thyroid cancer: Factors affecting the thyroid functions and cancer development

Thyroid cancer (TC) is categorized into papillary, follicular, medullary, and anaplastic. The TC is increasing in several countries, including China, the United States, the United Kingdom, Canada, France, Australia, Germany, Japan, Spain, and Italy. Thus, this review comprehensively covers the factors that affect thyroid gland function, TC types, risk factors, and symptoms. Lifestyle factors (such as nutrient consumption and smoking) and pollutants (such as chemicals and heavy metals) increased the thyroid-stimulating hormone (TSH) levels which are directly related to TC prevalence. The conventional and recent TC treatments are also highlighted. The role of the oral and gut microbiota as well as the application of probiotics on TC are also discussed. The variations in the composition of oral and gut microbes influence the thyroid function indirectly through alteration in metabolites (such as short-chain fatty acids) that are eminent for cellular energy metabolism. Maintenance of healthy gut and oral microbiota can help in regulating thyroid function by regulating iodine uptake. Oral or gut microbial dysbiosis can be considered as an early diagnosis factor or TC marker. High TSH during TC can increase the oral microbial diversity while disrupting the high ratio of Firmicutes and Bacteroidetes in the gut. Supplementation of probiotics as an adjuvant in TC treatment is beneficial. However, needs more extensive research to explore the direct effect of probiotics on thyroid function.

Nanomaterials: a promising multimodal theranostics platform for thyroid cancer

Thyroid cancer is the most prevalent malignant neoplasm of the cervical region and endocrine system, characterized by a discernible upward trend in incidence over recent years. Ultrasound-guided fine needle aspiration is the current standard for preoperative diagnosis of thyroid cancer, albeit with limitations and a certain degree of false-negative outcomes. Although differentiated thyroid carcinoma generally exhibits a favorable prognosis, dedifferentiation is associated with an unfavorable clinical course. Anaplastic thyroid cancer, characterized by high malignancy and aggressiveness, remains an unmet clinical need with no effective treatments available. The emergence of nanomedicine has opened new avenues for cancer theranostics. The unique features of nanomaterials, including multifunctionality, modifiability, and various detection modes, enable non-invasive and convenient thyroid cancer diagnosis through multimodal imaging. For thyroid cancer treatment, nanomaterial-based photothermal therapy or photodynamic therapy, combined with chemotherapy, radiotherapy, or gene therapy, holds promise in reducing invasiveness and prolonging patient survival or alleviating pain in individuals with anaplastic thyroid carcinoma. Furthermore, nanomaterials enable simultaneous diagnosis and treatment of thyroid cancer. This review aims to provide a comprehensive survey of the latest developments in nanomaterials for thyroid cancer diagnosis and treatment and encourage further research in developing innovative and effective theranostic approaches for thyroid cancer.

Association of Treatment Strategies and Tumor Characteristics With Overall Survival Among Patients With Anaplastic Thyroid Cancer: A Single-Institution 21-Year Experience

Importance

Survival outcomes for anaplastic thyroid cancer (ATC), the most aggressive subtype of thyroid cancers, have remained poor. However, targeted therapies and immunotherapies present new opportunities for treatment of this disease. Evaluations of survival outcomes over time with new multimodal therapies are needed for optimizing treatment plans.

Objective

To evaluate the association of treatment strategies and tumor characteristics with overall survival (OS) among patients with ATC.

Design, Setting, and Participants

This retrospective case series study evaluated the survival outcomes stratified by treatment strategies and tumor characteristics among patients with ATC treated at a tertiary level academic institution from January 1, 2000, to December 31, 2021. Demographic, tumor, treatment, and outcome characteristics were analyzed. Kaplan-Meier method and log rank test modeled OS by treatment type and tumor characteristics. Data were analyzed in May 2022.

Main Outcomes and Measures

Overall survival (OS).

Results

The study cohort comprised 97 patients with biopsy-proven ATC (median [range] age at diagnosis, 70 [38-93] years; 60 (62%) female and 85 [88%] White individuals; 59 [61%] never smokers). At ATC diagnosis, 18 (19%) patients had stage IVA, 19 (20%) had stage IVB, and 53 (55%) had stage IVC disease. BRAF status was assessed in 38 patients; 18 (47%) had BRAF-V600E variations and 20 (53%), BRAF wild type. Treatment during clinical course included surgery for 44 (45%) patients; chemotherapy, 41 (43%); definitive or adjuvant radiation therapy, 34 (RT; 35%); and targeted therapy, 28 (29%). Median OS for the total cohort was 6.5 (95% CI, 4.3-10.0) months. Inferior OS was found in patients who did not receive surgery (hazard ratio [HR], 2.12; 95% CI, 1.35-3.34; reference, received surgery), chemotherapy (HR, 3.28; 95% CI, 1.99-5.39; reference, received chemotherapy), and definitive or adjuvant RT (HR, 2.47; 95% CI, 1.52-4.02; reference, received definitive/adjuvant RT). On multivariable analysis, age at diagnosis (HR, 1.03; 95% CI, 1.01-1.06), tumor stage IVC (HR, 2.65; 95% CI, 1.35-5.18), and absence of definitive or adjuvant RT (HR, 1.90; 95% CI, 1.01-3.59) were associated with worse OS.

Conclusions and Relevance

This retrospective single-institution study found that lower tumor stage, younger age, and the ability to receive definitive or adjuvant RT were associated with improved OS in patients with ATC.

Mutation-based, short-term "neoadjuvant" treatment allows resectability in stage IVB and C anaplastic thyroid cancer

INTRODUCTION

Few available data indicate that a mutation-based "neoadjuvant" therapy in advanced anaplastic thyroid carcinoma (ATC) might convert an initially unresectable primary tumor to resectable and optimize local tumor control. We evaluated a preoperative short-term "neoadjuvant" therapy with a BRAF-directed therapy or, in case of BRAF non-mutated tumors, an mKI/checkpoint inhibitor combination in three patients with ATC stage IVB and C.

METHODS

In the context of preoperative diagnostics, immunohistochemistry (IHC) assessment and genetic analysis was started as soon as possible. The antiangiogenetic therapy with lenvatinib was immediately after diagnosis of ATC started as bridging therapy. In case of a BRAF-mutated ATC, a combination therapy of dabrafenib and trametinib, in case of BRAF-wildtype ATC a combination of pembrolizumab and lenvatinib was given for 4 weeks. If re-staging has shown a significant therapy response due to a decrease in size of > 50%, surgical resection was reconsidered. A primary tumor resection was performed first. As a second step, limited distant metastasis have been resected approximately 4 weeks after thyroid surgery. After postoperative recovery, the targeted systemic therapy was continued.

PATIENTS

Two patients presented with BRAF-wildtype ATC stage IVC, one with BRAF-mutated ATC stage IVB. All patients were evaluated by surgery, nuclear medicine and oncology upon diagnosis of ATC.

RESULTS

In all three cases, the "neoadjuvant" therapy induced a dramatic response and led to local resectability in primarily non-resectable ATC stage IVB or C. We have chosen for the first time a short-term "neoadjuvant" treatment period to reduce the risk of bleeding and/or fistula due to potential rapid tumor shrinkage. The results of surgery after only short-term "neoadjuvant" therapy showed two R0 und one R1 resections. Postoperative histopathological findings confirmed an extent of tumor necrosis or regressive fibrotic tissue between 60 and > 95% in our patients.

CONCLUSIONS

A short-term mutation-based "neoadjuvant" therapy can achieve local resectability in initially unresectable ATC stage IVB or C. A neoadjuvant treatment period of about 4 weeks seems to show similar response as a treatment duration of at least 3 months.

Anaplastic Transformation of Differentiated Thyroid Carcinoma

OBJECTIVES

Anaplastic thyroid carcinoma (ATC) is a rare but highly aggressive form of thyroid cancer. Increasingly, patients with ATC present with concurrent foci of well-differentiated thyroid carcinoma (WDTC); however, the significance of these pathologic findings remains unclear. The objective of this study is to determine whether the presence of WDTC within anaplastic tumors is a prognosticator of survival.

METHODS

A retrospective cohort study of all cases of biopsy-proven ATC managed at a tertiary care academic medical center from 2002 to 2020 was performed. Mean age at diagnosis, median survival time, and locations of distant metastases were assessed. The impact of clinical markers such as presence of differentiation, demographic variables, and oncologic information on overall survival was also determined via univariate and multivariate analysis.

RESULTS

Forty-five patients were included in this study. The mean age at diagnosis was 69.1 years. Median survival time was 6.1 months after diagnosis. The most common location of distant metastases was the lung (40%). The presence of limited areas of WDTC in patients with predominantly anaplastic thyroid tumors was not significantly associated with improved outcomes (p = 0.509). Smaller tumor size and use of chemotherapy in ATC patients were significantly associated with prolonged survival (p = 0.026 and 0.010, respectively).

CONCLUSIONS

Clinical outcomes for ATC remain poor. The presence of foci of differentiation within anaplastic thyroid tumors does not appear to improve overall survival-the anaplastic component evidently drives outcomes. Further studies into novel therapies are needed to improve survival in ATC.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:437-442, 2023.

Radiotherapy and paclitaxel plus pazopanib or placebo in anaplastic thyroid cancer (NRG/RTOG 0912): a randomised, double-blind, placebo-controlled, multicentre, phase 2 trial

BACKGROUND

Anaplastic thyroid cancer is a rare and aggressive cancer with no standard radiotherapy-based local treatment. Based on data suggesting synergy between pazopanib and paclitaxel in anaplastic thyroid cancer, NRG Oncology did a double-blind, placebo-controlled, randomised phase 2 clinical trial comparing concurrent paclitaxel and intensity-modulated radiotherapy (IMRT) with the addition of pazopanib or placebo with the aim of improving overall survival in this patient population.

METHODS

Eligible patients were aged 18 years or older with a pathological diagnosis of anaplastic thyroid cancer, any TNM stage, Zubrod performance status of 0-2, no recent haemoptysis or bleeding, and no brain metastases. Patients were enrolled from 34 centres in the USA. Initially, a run-in was done to establish safety. In the randomised phase 2 trial, patients in the experimental group (pazopanib) received 2-3 weeks of weekly paclitaxel (80 mg/m2) intravenously and daily pazopanib suspension 400 mg orally followed by concurrent weekly paclitaxel (50 mg/m2), daily pazopanib (300 mg), and IMRT 66 Gy given in 33 daily fractions (2 Gy fractions). In the control group (placebo), pazopanib was replaced by matching placebo. Patients were randomly assigned (1:1) to the two treatment groups by permuted block randomisation by NRG Oncology with stratification by metastatic disease. All investigators, patients, and funders of the study were masked to group allocation. The primary endpoint was overall survival in the intention-to-treat population. Safety was assessed in all patients who received at least one dose of study treatment. This trial is registered with Clinicaltrials.gov, NCT01236547, and is complete.

FINDINGS

The safety run-showed the final dosing regimen to be safe based on two out of nine participants having adverse events of predefined concern. Between June 23, 2014, and Dec 30, 2016, 89 patients were enrolled to the phase 2 trial, of whom 71 were eligible (36 in the pazopanib group and 35 in the placebo group; 34 [48%] males and 37 [52%] females). At the final analysis (data cutoff March 9, 2020), with a median follow-up of 2·9 years (IQR 0·002-4·0), 61 patients had died. Overall survival was not significantly improved with pazopanib versus placebo, with a median overall survival of 5·7 months (95% CI 4·0-12·8) in the pazopanib group versus 7·3 months (4·3-10·6) in the placebo group (hazard ratio 0·86, 95% CI 0·52-1·43; one-sided log-rank p=0·28). 1-year overall survival was 37·1% (95% CI 21·1-53·2) in the pazopanib group and 29·0% (13·2-44·8) in the placebo group. The incidence of grade 3-5 adverse events did not differ significantly between the treatment groups (pazopanib 88·9% [32 of 36 patients] and placebo 85·3% [29 of 34 patients]; p=0·73). The most common clinically significant grade 3-4 adverse events in the 70 eligible treated patients (36 in the pazopanib group and 34 in the placebo group) were dysphagia (13 [36%] vs 10 [29%]), radiation dermatitis (8 [22%] vs 13 [38%]), increased alanine aminotransferase (12 [33%] vs none), increased aspartate aminotransferase (eight [22%] vs none), and oral mucositis (five [14%] vs eight [24%]). Treatment-related serious adverse events were reported for 16 (44%) patients on pazopanib and 12 (35%) patients on placebo. The most common serious adverse events were dehydration and thromboembolic event (three [8%] each) in patients on pazopanib and oral mucositis (three [8%]) in those on placebo. There was one treatment-related death in each group (sepsis in the pazopanib group and pneumonitis in the placebo group).

INTERPRETATION

To our knowledge, this study is the largest randomised anaplastic thyroid cancer study that has completed accrual showing feasibility in a multicenter NCI National Clinical Trials Network setting. Although no significant improvement in overall survival was recorded in the pazopanib group, the treatment combination was shown to be feasible and safe, and hypothesis-generating data that might warrant further investigation were generated.

FUNDING

National Cancer Institute and Novartis.

Ga-68 Prostate-Specific Membrane Antigen-HBED-CC Positron Emission Tomography/Computed Tomography in Anaplastic Thyroid Carcinoma

Purpose

Anaplastic thyroid carcinoma (ATC) is the most aggressive thyroid cancer and there is no established treatment that works well. The study was conducted to see prostate-specific membrane antigen (PSMA) expression in ATC as a stepping stone to study its role in potential theranostics.

Materials and Methods

Pathologically proven ATC patients were prospectively included in this study. Ga-68-PSMA positron emission tomography/computed tomography (PET/CT) was done to look for PSMA expression in local and distant sites 45-60 mins after injecting 2-3mCi of tracer.

Results

Twenty patients were enrolled in this study. Nodal metastases were seen in all patients, while distant metastases were seen in 17/20. The mean SUVmax of primary lesion was 6.72 ± 4.6. Mean SUVmax of node and lung lesions was 5.7 ± 5.6 and 2.9 ± 1.98, respectively. Mean SUVmax of liver, mediastinum, and parotid gland was 5.95 ± 3.03, 1.54 ± 0.68, and 9.03 ± 3.75, respectively. Mean Tumor to background ratio (liver = TBRl; mediastinum = TBRm; parotid = TBRp) were 1.21, 4.49 and 0.78, respectively.

Conclusion

ATC showed variable PSMA expression on Ga-68-PSMA-PET/CT and this attribute may be potentially useful in ATC theranostics.

Role of surgery to the primary tumor in metastatic anaplastic thyroid carcinoma: pooled analysis and SEER-based study

PURPOSE

Anaplastic thyroid carcinoma (ATC) is an orphan disease with a fatal outcome. Surgery to the primary tumor in metastatic ATC is controversial. Determination of specific surgical techniques may help facilitate local control and, hence, beneficial overall and disease-specific survival.

METHODS

Using individualized patient data derived from our systematic review of literature and our single center study (n = 123), conducting a Surveillance, Epidemiology, and End Results register (SEER)-based study (n = 617) we evaluated surgery, its combination with systemic and local therapies in metastatic ATC.

RESULTS

Pooled cohort study showed surgery (p < 0.001), RT ≥ 30 Gy (p < 0.001), ChT (p < 0.001) and multimodal treatment (p = 0.014) to result in improved OS univariately. In the multivariate analysis, surgery (1.997 [1.162-3.433], p = 0.012) and RT ≥ 30 Gy (1.877 [1.232-2.843], p = 0.012) were independent predictors for OS. In SEER-based study of patients undergoing any tumor-directed treatment (n = 445) total thyroidectomy (p = 0.031), administration of ChT (p = 0.007), RT (p < 0.001), combination of surgery and RT ± ChT (p < 0.001) and multimodal treatment (p < 0.001) correlated with an improved DSS univariately. On the multivariate analysis, debulking surgery was an independent predictor for a worse outcome (HR 0.535, 95%CI 0.332-0.862, p = 0.010), whereas RT administration correlated with a longer DSS (HR 2.316, 95%CI 1.362-3.939, p = 0.002). Among operated patients from SEER register total thyroidectomy (p = 0.031), ChT (p = 0.007), RT (p < 0.001), combination of surgery and RT ± ChT (p < 0.001) and multimodal treatment (p < 0.001) correlated with an improved DSS in the univariate analysis, whereas debulking surgery was inversely correlated with the DSS (p < 0.001). On the multivariate analysis, debulking surgery was an independent predictor for a worse DSS (HR 0.535, 95%CI 0.332-0.862, p = 0.010), whilst RT administration correlated with a longer DSS (HR 2.316, 95%CI 1.362-3.939, p = 0.002).

CONCLUSIONS

Surgery to the primary tumor with the aim of R0/R1 resection, but not debulking, is associated with a significant OS and DSS benefit even in systemically metastasized disease.

Anaplastic Thyroid Carcinoma: An Update

Anaplastic thyroid carcinoma (ATC) is a rare and undifferentiated form of thyroid cancer. Its prognosis is poor: the median overall survival (OS) of patients varies from 4 to 10 months after diagnosis. However, a doubling of the OS time may be possible owing to a more systematic use of molecular tests for targeted therapies and integration of fast-track dedicated care pathways for these patients in tertiary centers. The diagnostic confirmation, if needed, requires an urgent biopsy reread by an expert pathologist with additional immunohistochemical and molecular analyses. Therapeutic management, defined in multidisciplinary meetings, respecting the patient's choice, must start within days following diagnosis. For localized disease diagnosed after primary surgical treatment, adjuvant chemo-radiotherapy is recommended. In the event of locally advanced or metastatic disease, the prognosis is very poor. Treatment should then involve chemotherapy or targeted therapy and decompressive cervical radiotherapy. Here we will review current knowledge on ATC and provide perspectives to improve the management of this deadly disease.

Survival Benefit of Intervention Treatment in Advanced Anaplastic Thyroid Cancer

Background

The management of anaplastic thyroid cancer (ATC) is controversial; thus, proper treatment and prognostic factors should be investigated.

Objectives

To compare the survival outcomes of the intervention and palliative treatment in ATC patients.

Methods

A hospital-based retrospective study was conducted at a single tertiary university hospital. The medical record charts were retrieved from November 20, 1987, to December 31, 2016. The final follow-up ended by December 31, 2017. The patients' demographic data, laboratory data, clinical presentation, and treatment modality results were analyzed.

Results

One hundred twenty-one records were analyzed with a one-year overall survival rate of 3.5% (median survival time: 77 days); however, 16 cases had insufficient data to classify staging and treatment modalities. Therefore, 105 ATC patients (37 with stage IVa, 39 with stage IVb, and 29 with stage IVc disease) were included with a one-year overall survival rate of 4.0% (median survival time of 82 days). Intervention treatment allowed longer median survival times (p < 0.05) and a better survival rate (p < 0.05). Among the interventional treatment groups, postoperative chemoradiation yielded the longest median survival time (187 days) and the highest survival rate (20%) (p < 0.05). The intervention modality allowed a better median survival time at all stages, particularly in stage IVa (p < 0.05). Unfavorable prognostic factors were adjusted for in a multiple Cox regression model showing that significant factors included age ≥65 years (hazard ratio HR: 2.57), palliative treatment (HR: 1.85), and leukocytosis ≥10,000 cells/mm³ (HR: 2.76).

Conclusions

Intervention treatment provided a better survival outcome in all stages, particularly in stage IVa, with a significantly better median survival time. Among interventional treatments, postoperative chemoradiation led to the longest survival rate, suggesting that this treatment should be considered in ATC patients with resectable tumors and no poor prognostic factors, such as older age and leukocytosis.

Multimodality Treatment Improves Locoregional Control, Progression-Free and Overall Survival in Patients with Anaplastic Thyroid Cancer: A Retrospective Cohort Study Comparing Oncological Outcomes and Morbidity between Multimodality Treatment and Limited Treatment

BACKGROUND

Patients with anaplastic thyroid cancer (ATC) have poor overall survival, and the optimal management approach remains unclear. The aim of this study is to evaluate our experience with multimodality (MMT) versus limited treatment (LT) for ATC.

PATIENTS AND METHODS

A cohort study of patients with ATC managed in a tertiary referral center was undertaken. The outcomes of MMT were compared with those of LT. The primary outcome measures were locoregional control and progression-free and overall survival. Secondary outcome measures were treatment-related complications and factors associated with improved survival.

RESULTS

In total, 59 patients (35 females) with a median age of 73 years (range 39-99 years) and ATC stage IVA (n = 2), IVB (n = 28), or IVC (n = 29) were included. LT was utilized in 25 patients (42%), and 34 cases had MMT. MMT patients had a longer time of locoregional control (18.5 versus 1.9 months; p < 0.001), progression-free survival (3.5 versus 1.2 months; p < 0.001), and overall survival (6.9 versus 2.0 months; p < 0.001) when compared with LT. For patients with stage IVC ATC, locoregional control (p = 0.03), progression-free survival (p < 0.001), and overall survival (p < 0.001) were superior in the MMT cohort compared with LT. MMT had more treatment-related complications than LT (p < 0.001). An Eastern Cooperative Oncology Group performance status < 2 (HR 0.30; p = 0.001) and MMT (HR 0.35; p = 0.008) were associated with improved overall survival.

CONCLUSION

MMT is likely to improve locoregional control, progression-free survival, and overall survival in selected ATC patients including stage IVC tumors but comes with a greater complication risk.

A relook at the 8th edition of the AJCC TNM staging system of anaplastic thyroid carcinoma: A SEER-based study

OBJECTIVE

In the 8th edition American Joint Committee on Cancer (AJCC) tumour-node-metastasis (TNM) staging system (TNM-8), changes have been made regarding anaplastic thyroid carcinoma (ATC) compared with the 7th edition (TNM-7). The major changes are that anaplastic ATC now has the same T stage definitions as differentiated thyroid cancer, and new staging of IVA and IVB is implemented. However, the clinical impact of the new edition for ATC remains unclear due to scarce and conflicting data. In this study, we compared the AJCC TNM-7 and TNM-8 in the same group of patients.

DESIGN

In this retrospective study, we included patients who were diagnosed with ATC between 2004 and 2015; data were gathered from the Surveillance, Epidemiology and End Results (SEER) database.

METHODS

Overall survival (OS) was evaluated according to T stage and TNM stage according to the 7th and 8th editions. Kaplan-Meier and log-rank testing was used to analyse OS. The effect of potential predictors was estimated using the Cox regression model.

RESULTS

We included 669 patients in the study. The median age of the cohort was 70 years. During the follow-up, 600 (89.7%) patients died, 528 of whom died of thyroid cancer. The TNM-8 T staging more effectively predicted survival than the 7th edition (proportion of variation explained: 3.53% vs. 1.72%). However, the clinical stage was almost unchanged according to the TNM-8 (proportion of variation explained: 10.69% vs. 10.73%).

CONCLUSIONS

The new T classification is an effective predictor of survival for patients with ATC. The results support the use of T definitions as per those of differentiated thyroid cancer. However, whether lymph node metastasis should be taken into account for defining ATC TNM staging should be reconsidered.

2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer

Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.

Anaplastic Thyroid Carcinoma: Current Issues in Genomics and Therapeutics

PURPOSE OF REVIEW

Anaplastic thyroid carcinoma is a type of thyroid carcinoma with the most aggressive biological behaviour amongst thyroid cancer. Here, we review the current genomic and the impacts of advances in therapies to improve the management of patients with the cancer.

RECENT FINDINGS

Common mutations being identified in anaplastic thyroid carcinoma are p53 and TERT promoter mutations. Other common mutated genes included BRAF, RAS, EIF1AX, PIK3CA, PTEN and AKT1, SWI/SNF, ALK and CDKN2A. Changes in expression of different microRNAs are also involved in the pathogenesis of anaplastic thyroid carcinoma. Curative resection combined with radiotherapy and combination chemotherapies (such as anthracyclines, platins and taxanes) has been shown to have effects in the treatment of some patients with anaplastic thyroid carcinoma. Newer molecular targeted therapies in clinical trials target mostly the cell membrane kinase and downstream proteins. These include targeting the EGFR, FGFR, VEGFR, c-kit, PDGFR and RET on the cell membrane as well as VEGF itself and the downstream targets such as BRAF, MEK and mTOR. Immunotherapy is also being tested in the cancer. Updated knowledge of genomic as well as clinical trials on novel therapies is needed to improve the management of the patients with this aggressive cancer.

Airway management, symptom relief and best supportive care in anaplastic thyroid cancer

PURPOSE OF REVIEW

Anaplastic thyroid cancer (ATC) is a rare but aggressive form of thyroid cancer that is associated with significant morbidity and mortality. Because ATC is locally invasive, airway management is a critical component of treating these patients. Timely decisions regarding airway interventions can contribute to symptom relief and supportive care for patients. Over the last decade, there has been a paradigm shift in our recommendations for airway management. The purpose of this review is to summarize airway management, symptom relief and best supportive care for patients with ATC.

RECENT FINDINGS

More recent literature discusses the morbidities associated with tracheostomy and instead focuses on the benefits of supportive care and surgical resection. The multidisciplinary treating team should initiate early discussions for airway management, end-of-life care and palliative goals for patients with ATC. Tracheostomy should be offered to patients with careful thought and preoperative planning.

SUMMARY

Our goal in symptom relief and airway management is to improve the quality of life of patients with ATC and avoid the unnecessary morbidity of tracheostomy until clinically indicated.

Hypofractionated Radiotherapy for Anaplastic Thyroid Cancer: Systematic Review and Pooled Analysis

Simple Summary

Anaplastic thyroid carcinoma is an aggressive cancer subtype with a dismal prognosis. Multimodal treatment approaches consisting of surgical resection, radiation therapy (RT) and chemotherapy have resulted in longer overall survival and promising outcomes. Hypofractionated RT is an alternative to conventional RT regimens. In this study, we aim to evaluate the outcome of hypofractionated regimens, perform a systematic review concerning hypofractionated RT and pooled analysis of this treatment modality. Hypofractionated RT appears to be non-inferior compared to conventional RT concerning OS after propensity score matching. In addition, radiation dose escalation correlated with a longer OS. In conclusion, hypofractionated RT is effective with manageable toxicity and could be an integral part in multimodal treatment.

Abstract

Anaplastic thyroid carcinoma (ATC) is associated with a poor prognosis due to aggressive tumor growth and high treatment resistance. Hypofractionated treatment concepts may be more effective and less time consuming compared to normofractionated radiotherapy (RT). In this retrospective study, we aim to evaluate the outcome of hypofractionated regimens and perform a systematic review concerning hypofractionated RT and pooled analysis of this treatment modality. A systematic review using the MEDLINE/Pubmed and Cochrane databases was performed. Data from all eligible studies were extracted, and a pooled analysis of literature and our cohort (n = 60) was carried out to examine patient characteristics, toxicity, and outcomes of patients with ATC. As a result, median overall survival (OS) of the single center cohort was four (range 1–12) months. Survival rates at one, three, and six months were 82%, 55%, and 36%, respectively. In univariate analyses, multimodal treatment (p = 0.006) and gender (p = 0.04) were correlated with an improved OS. Six studies with a total number of 152 patients undergoing hypofractionated RT treatment were analyzed. The pooled analysis included four patient cohorts with 60 patients and showed median OS of 5.3 (range: 1–24) months. Multimodal treatment (p < 0.001) and a cumulative radiation dose ≥50 Gy in equivalent dose in 2 Gy fractions (EQD2) (p = 0.014) correlated with an improved OS. On multivariate analysis, multimodal treatment (p = 0.003, hazard ratio (HR): 0.636, 95% confidence interval (CI): 0.469–0.861) was an independent predictor for longer OS. After propensity score matching (PSM), hypofractionated RT appears to be non-inferior compared to normofractionated RT concerning OS. In conclusion, hypofractionated RT is effective with manageable toxicity. A dose escalation with ≥50 Gy (EQD2) correlated with a longer OS. Hypofractionated RT could be an integral part in multimodal treatment with a promising outcome.

The Benefit of Primary Tumor Surgical Resection in Distant Metastatic Carcinomas of the Thyroid

OBJECTIVES/HYPOTHESIS

Thyroid cancer with distant metastasis (TCDM) at diagnosis has significantly worse survival rates when compared to localized/regional thyroid cancer. This study sought to report on the characteristics of patients presenting with TCDM and the potential survival advantage of surgical resection.

STUDY DESIGN

Data were acquired from the Surveillance, Epidemiology, and End Results (SEER) database with cases from 2004 to 2015.

METHODS

TCDM cases (n = 2,558) were identified from the SEER database. The Bonferroni correction was applied for multivariate analysis. Kaplan-Meier analysis was utilized to obtain disease-specific survival (DSS) rates. Cox regression analysis was utilized to identify independent factors significantly associated with survival.

RESULTS

The average age of diagnosis of TCDM was 62.0 (±17.5) years. Patients were predominantly white (74.6%), female (54.6%), in a relationship (56.0%), and between ages 36 and 80 years (76.4%). Cases consisted of papillary (57.2%), follicular (16.0%), medullary (8.9%), anaplastic (17.9%) TCDM histological variants. Overall 1-, 5-, and 10-year DSS rates were 72.0%, 56.8%, and 43.8%, respectively. Anaplastic and medullary variants had the worst 10-year DSS (0% and 25.5%, respectively). Patients who underwent surgical resection only and surgical resection with radiation were 49% and 59% less likely to die, respectively. Treatment, age, histology, T staging, relationship status, and metastasis site were determined to be significant predictors of survival.

CONCLUSIONS

Surgical resection with radiation was found to be a significant predictor of survival after applying the Bonferroni correction for all thyroid cancer variants except medullary. To increase survival, surgical intervention should be recommended in patients who are deemed to be medically tolerant of surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1026-1034, 2021.

Development and validation of a prognostic nomogram to predict overall survival and cancer-specific survival for patients with anaplastic thyroid carcinoma

Background

Anaplastic thyroid carcinoma (ATC) is a rare malignant tumor with a poor prognosis. However, there is no useful clinical prognostic predictive tool for ATC so far. Our study identified risk factors for survival of ATC and created a reliable nomogram to predict overall survival (OS) and cancer-specific survival (CSS) of patients with ATC.

Methods

A total of 1,404 cases of ATC diagnosed between 1983 and 2013 were extracted from on the Surveillance, Epidemiology and End Results database based on our inclusion criteria. OS and CSS were compared among patients between each variable by Kaplan-Meier methods. The Cox proportional hazards model was used to evaluate multiple prognostic factors and obtain independent predictors. All independent risk factors were included to build nomograms, whose accuracy and practicability were tested by concordance index (C-index), calibration curves, ROC curves, DCA, net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results

Historic stage, tumor size, surgery and radiotherapy were independent risk factors associated with ATC according to multivariate Cox regression analysis of OS. However, gender was also an important prognostic predictor in CSS besides the factors mentioned above. These characteristics were included in the nomograms predicting OS and CSS of patients with ATC. The nomograms predicting OS and CSS performed well with a C-index of 0.765 and 0.773. ROC curves, DCA, NRI and IDI suggested that the nomogram was superior to TNM staging and age.

Conclusion

The proposed nomogram is a reliable tool based on the prediction of OS and CSS for patients with ATC. Such a predictive tool can help to predict the survival of the patients.

Survival advantage of chemoradiotherapy in anaplastic thyroid carcinoma: Propensity score matched analysis with multiple subgroups

BACKGROUND

We compared overall survival (OS) between radiation therapy (RT) and chemoradiotherapy (CRT) in patients with anaplastic thyroid carcinoma (ATC) using a large database.

METHODS

The National Cancer Data Base was queried for ATC patients diagnosed between 2004 and 2013 who received RT or CRT. Groups were balanced by propensity score matching (PSM) on nine relevant variables. OS was also examined in five paired subgroups given known patient heterogeneity.

RESULTS

Of 858 total patients, 575 received CRT and 283 received RT. CRT was associated with decreased risk of death (hazard ratio [HR] 0.66, P < .001), 1-year OS 25.5% vs 14.3%. A survival advantage to CRT was seen using PSM cohorts (HR 0.75, P = .006). Those receiving definitive surgery saw the greatest benefit to CRT over RT (HR 0.65, P = .009), 1-year OS 39.6% vs 20.4%.

CONCLUSIONS

CRT is associated with decreased risk of death in ATC; the magnitude of CRT vs RT benefit varied by subgroup.

Outcomes of multimodal therapy in a large series of patients with anaplastic thyroid cancer

BACKGROUND

The role of radiotherapy (RT) in the treatment of patients with anaplastic thyroid cancer (ATC) for local tumor control is critical because mortality often is secondary to complications of tumor volume rather than metastatic disease. Herein, the authors report the long-term outcomes of RT for patients with ATC.

METHODS

A total of 104 patients with histologically confirmed ATC were identified who presented to the study institution between 1984 and 2017 and who received curative-intent or postoperative RT. Locoregional progression-free survival (LPFS), overall survival (OS), and distant metastasis-free survival were assessed.

RESULTS

The median age of the patients was 63.5 years. The median follow-up was 5.9 months (interquartile range, 2.7-17.0 months) for the entire cohort and 10.6 months (interquartile range, 5.3-40.0 months) for surviving patients. Thirty-one patients (29.8%) had metastatic disease prior to the initiation of RT. Concurrent chemoradiation was administered in 99 patients (95.2%) and 53 patients (51.0%) received trimodal therapy. Systemic therapy included doxorubicin (73.7%), paclitaxel with or without pazopanib (24.3%), and other systemic agents (2.0%). The 1-year OS and LPFS rates were 34.4% and 74.4%, respectively. On multivariate analysis, RT ≥60 Gy was associated with improved LPFS (hazard ratio [HR], 0.135; P = .001) and improved OS (HR, 0.487; P = .004), and trimodal therapy was associated with improved LPFS (HR, 0.060; P = .017). The most commonly observed acute grade 3 adverse events included dermatitis (20%) and mucositis (13%), with no grade 4 subacute or late adverse events noted (adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]).

CONCLUSIONS

RT appears to demonstrate a dose-dependent, persistent LPFS and OS benefit in patients with locally advanced ATC with an acceptable toxicity profile. Aggressive RT should be strongly considered for the treatment of patients with ATC as part of a trimodal treatment approach.

An unsuspicious thyroid nodule with fatal outcome

INTRODUCTION

Over the last few years, several scientific societies have introduced specific evaluation systems to stratify the risk of malignancy of thyroid nodules. Most of these classifications have been created on the basis of ultrasonographic features of the commonest thyroid carcinoma histotype. Herein, we report a case of anaplastic thyroid carcinoma presenting at ultrasound (US) examination as an unsuspicious thyroid nodule associated with distant metastases, which was followed by the patient's death a short time later.

CASE REPORT

A 77-year-old woman, because of worsening weight loss and vague abdominal pain, underwent a whole-body computed tomography scan, which revealed a large mass adherent to the large bowel, multiple pulmonary nodules, and a solitary thyroid nodule of the left lobe. On US, a round, well-defined, mixed solid-cystic, isoechoic lesion with a maximum diameter of 45 mm and peripheral vascularity was confirmed. No microcalcifications, extrathyroidal extension, cervical lateral lymphadenopathy, tracheal deviation, or compression were found. The nodule was classified as low or very low risk according to six US malignancy risk classification systems. Although only two of these recommended fine-needle aspiration cytology, on the basis of a dimensional criterion, the procedure was performed, the cytology report suggesting anaplastic cancer. Following total thyroidectomy, the histological examination revealed the presence of a follicular thyroid carcinoma with diffuse areas of anaplastic dedifferentiation.

CONCLUSION

This case highlights the importance of defining the US characteristics of rare variants of thyroid neoplasms, since an early diagnosis is decisive in defining the patient's prognosis.

Complete Surgical Resection Following Neoadjuvant Dabrafenib Plus Trametinib in BRAFV600E-Mutated Anaplastic Thyroid Carcinoma

Background: When achieved, complete surgical resection improves outcomes in anaplastic thyroid carcinoma (ATC). However, most ATC patients present with advanced inoperable disease, often with impending airway obstruction, increased hemorrhage risk, and significant dysphagia. Novel treatment strategies are critically needed to improve disease control and decrease locoregional morbidity. The objective of this study was to determine the feasibility and effectiveness of a neoadjuvant regimen by using dabrafenib with trametinib followed by surgical resection in patients with initially unresectable BRAF^V600E-mutated ATC. Methods: Case series of six consecutive patients with BRAF^V600E-mutated ATC diagnosed between January 2017 and February 2018. Pathologic confirmation of ATC was obtained before treatment. BRAF^V600E status was ascertained via immunohistochemistry or sequencing of circulating tumor DNA. All patients received dabrafenib and trametinib (DT) followed by surgical resection and adjuvant chemoradiation. Three patients also received pembrolizumab. Results: Complete surgical resection was achieved in all patients. Histopathologic analyses of resected specimens showed high pathologic response rates with significantly decreased ATC viability and residual papillary thyroid carcinoma components. Overall survival at six months and one year was 100% and 83%, respectively. Locoregional control rate was 100%. Two patients died of distant metastases without evidence of locoregional disease at 8 and 14 months from diagnosis. The remaining four patients had no evidence of disease at the last follow-up. Conclusions: We report the first series in the literature of BRAF^V600E-mutated ATC patients with locoregionally advanced disease treated with DT followed by surgical resection. We demonstrated feasibility of complete resection, decreased need for tracheostomy, high pathologic response rates, and durable locoregional control with symptom amelioration.

A Systematic Review of Phase II Targeted Therapy Clinical Trials in Anaplastic Thyroid Cancer

Anaplastic thyroid carcinoma (ATC) is a rare, but devastating disease. Despite multimodal approaches combining surgery, chemotherapy and radiation therapy, ATC is associated with a dire prognosis, with a median overall survival of only three to ten months. Novel treatments are thus urgently needed. Recent efforts towards the characterization of the molecular landscape of ATC have led to the identification of pro-oncogenic targetable alterations, lending promise for novel targeted therapeutic approaches. This systematic review summarizes the results of phase II clinical trials of targeted therapy in ATC, providing an overview of efficacy and safety profiles. The majority of trials to date have consisted of small single-arm studies and have presented modest results. However, only a minority of trials have selected or stratified patients by molecular alterations. In the setting of BRAF V600E mutated ATC, dabrafenib/trametinib combination therapy and vemurafenib monotherapy have both demonstrated efficacy. Everolimus has furthermore shown promising results in patients with PI3K/mTOR/AKT pathway alterations. These studies underscore the importance of molecular profiling of tumors for appropriate patient selection and determination of genomic correlates of response. Clinical trials are underway testing additional targeted therapies as monotherapy, or as a part of multimodal treatment, and in combination with immunotherapy.

Surgical Management and Factors Affecting the Prognosis for Patients with Thyroid Cancer Spinal Metastases: A Retrospective Analysis of 52 Consecutive Patients from a Single Center

BACKGROUND

Thyroid cancer, one of the most common endocrine malignancies in developed areas and China, is associated with favorable prognosis. However, the presence of spinal metastases will remarkably reduce the life expectancy for patients with thyroid cancer. In addition, limited information is available about such disease.

METHODS

Various potential clinical factors were submitted to univariate and multivariate analyses to identify the independent variables that predicted the prognosis for patients. In addition, the survival rate was estimated according to the Kaplan-Meier method, and statistic differences were calculated by the log-rank test. Moreover, factors with a P value of ≤0.1 were performed multivariate analysis using a multivariate Cox proportional hazards model, and factors with a P value of <0.05 were considered as statistically significant.

RESULTS

Seven potential independent prognostic factors had been identified through univariate analysis, which were then subjected to multivariate analysis. Our results suggested that age of ≤50 years, single segment involved, and follicular thyroid cancer were the independent favorable prognostic factors.

CONCLUSIONS

Findings in this study indicate that age of ≤50 years, single segment involved, and follicular thyroid cancer are favorable prognostic factors for patients with thyroid cancer spinal metastases.

Diagnosis and Management of Anaplastic Thyroid Cancer

Anaplastic thyroid cancer (ATC) is a devastating and usually incurable diagnosis. Clinical and pathologic diagnosis is best assessed at a tertiary center with concentrated ATC expertise. Expeditious multidisciplinary management is recommended for optimal patient outcomes. Based on multiinstitutional and population-based studies, multimodal therapy that includes chemoradiotherapy with surgery (when feasible) is the preferred initial treatment because it is associated with incrementally improved overall survival. In ATC that carries a BRAF V600E somatic mutation, combination therapy with BRAF and MEK inhibitors has shown promise but needs further study. Immunotherapeutic agents in neoadjuvant and metastatic settings are being investigated.

An Update of the Appropriate Treatment Strategies in Anaplastic Thyroid Cancer: A Population-Based Study of 735 Patients

BACKGROUND

Anaplastic thyroid cancer (ATC) responds poorly to conventional therapies and requires a multidisciplinary approach to manage. The aim of the current study is to explore whether aggressive treatment is beneficial, especially the appropriate extent of surgery in ATC.

METHODS

Patients diagnosed with ATC from 2004 to 2014 were identified from the Surveillance, Epidemiology, and End Results (SEER) database and included in our study.

RESULTS

A total of 735 ATC patients were identified. The two-year overall survival (OS) rates for stage IVA, IVB, and IVC patients were 36.5%, 15.6%, and 1.4%, respectively. By directly comparing eight treatment modalities, we found that surgery + radiotherapy (RT) ± chemotherapy was the most effective treatment strategy. surgery + chemotherapy and RT + chemotherapy had comparable results (hazard ratio (HR) = 1.461, 95% confidential interval (CI): 0.843-2.531, P = 0.177). Multivariate Cox regression analysis also showed increased mortality risk in patients with increased age (HR = 1.022, P < 0.001), tumor extension to adjacent structures (HR = 1.649, P = 0.013), and distant metastasis (HR = 2.041, P < 0.001), while surgery + RT (HR = 0.600, P = 0.004) and chemotherapy (HR = 0.692, P = 0.010) were independently associated with improved OS. Further analysis revealed that patients undergoing total/near-total thyroidectomy (TT) had superior OS to those receiving less than TT (P < 0.001). In subgroup analysis, the benefit of TT remained significant in patients with tumors larger than 4.0 cm (HR = 0.776, 95% CI: 0.469-0.887, P = 0.007), with adjacent structure extension (HR = 0.642, 95% CI: 0.472-0.877, P = 0.005), including trachea and major vessels, but not in patients with early phase local disease such as tumor ≤ 4.0 cm or tumor within the thyroid or with minimal extrathyroidal extension. Patients with very locally advanced disease or distant metastasis could not benefit from TT as well.

CONCLUSIONS

In operable cases, surgery + RT ± chemotherapy was the optimal treatment modality. Otherwise, RT + chemotherapy was the appropriate strategy. However, TT was not beneficial for very early stage or metastatic ATC.

Lenvatinib as a novel treatment for anaplastic thyroid cancer: A retrospective study

Anaplastic thyroid cancer (ATC) is associated with an extremely poor prognosis and is resistant to the majority of chemotherapies. In 2015, lenvatinib was approved for treating ATC in Japan. The present study aimed to evaluate the overall survival (OS) of patients with ATC treated with lenvatinib. A total of 23 patients with a definitive histological diagnosis of ATC who were treated at Kanagawa Cancer Center (Yokohama, Kanagawa. Japan) were enrolled. Surgical treatment was possible in 10 patients (including one debulking surgery), and lenvatinib treatment was postoperatively started. The remaining 13 patients were not eligible for debulking surgery; thus, lenvatinib was promptly approved as a life-saving treatment. The therapeutic effect was determined according to the Response Evaluation Criteria In Solid Tumors criteria (ver.1.1). The patients exhibited a lenvatinib response rate of 17.4% and a disease control rate of 43.5%. However, lenvatinib was associated with a 100% incidence of treatment-related adverse events (AEs), with hypertension being the most common AE (91.3%). Additionally, dose interruptions and reductions were required due to the development of tumor fistulas or other tumor-related AEs, and 9 (39.1%) patients discontinued treatment due to grade 3 or higher AEs. The median OS time was 166 days. Overall, the present study demonstrated the effectiveness of lenvatinib against ATC, which is often chemotherapy-resistant. Successful treatment of fistulas developing due to tumor necrosis at the site of the primary lesion is crucial for improving the patient outcome. The response to lenvatinib in patients with ATC varies on a case-by-case basis and requires further investigation in future studies.

Management of Anaplastic Thyroid Carcinoma: the Fruits from the ATC Research Consortium of Japan

Anaplastic thyroid carcinoma (ATC) accounts for only 1 to 2% of all thyroid carcinomas, but it is one of the most lethal neoplasms in humans. To obtain further insights into this "orphan disease," we have established the ATC Research Consortium of Japan (ATCCJ) in 2009. It represents a multicenter registry for ATC that have been treated in Japan. To date, 67 institutions have taken part in the collaborative research system and over 1,200 cases have been accumulated in its database. Using this big data, several retrospective studies were carried out to evaluate 1) prognostic factors to determine initial treatment policy, 2) significance of extended radical surgery for Stage IVB cases, 3) characteristics of ATC incidentally found on pathological examination and 4) pathological features of ATC with long-term survival. Moreover, the ATCCJ has conducted an investigator-initiated, nationwide, prospective clinical trial since 2012; namely, the feasibility, safety and efficacy study of weekly paclitaxel administration for patients with ATC (UMIN: 000008574). Revised Japanese guidelines for treatment of thyroid tumors are going to adopt the recommendations from the results of this research. Since 2016, the ATCCJ has started the phase II study assessing the efficacy and safety of lenvatinib, a newly developed tyrosine kinase inhibitor for ATC (UMIN: 000020773). Our nationwide clinical trial network will strengthen the activity to recruit orphan disease patients and may discover new strategies to conquer this dismal malignancy in the near future.

Treatment outcomes of radiotherapy for anaplastic thyroid cancer

Purpose

Anaplastic thyroid cancer (ATC) is a rare tumor with a lethal clinical course despite aggressive multimodal therapy. Intensity-modulated radiotherapy (IMRT) may achieve a good therapeutic outcome in ATC patients, and the role of IMRT should be assessed. We retrospectively reviewed outcomes for ATC treated with three-dimensional conformal radiotherapy (3D-CRT) or IMRT to determine the optimal treatment option and explore the role of radiotherapy (RT).

Materials and Methods

Between December 2000 and December 2015, 41 patients with pathologically proven ATC received RT with a sufficient dose of ≥40 Gy. Among them, 21 patients (51%) underwent surgery before RT. Twenty-eight patients received IMRT, and 13 received 3D-CRT. Overall survival (OS) and progression-free survival (PFS), patterns of failure, and toxicity were examined.

Results

The median follow-up time for survivors was 38.0 months. The median and 1-year OS and PFS rates were 7.2 months and 29%, 4.5 months and 15%, respectively. Surgery significantly improved the prognosis (median OS: 10.7 vs. 3.9 months, p = 0.001; median PFS: 5.9 vs. 2.5 months, p = 0.007). IMRT showed significantly better PFS and OS than 3D-CRT, even in multivariate analysis (OS: hazard ratio [HR] = 0.30, p = 0.005; PFS: HR = 0.33, p = 0.005). Significantly higher radiation dose could be delivered with IMRT than 3D-CRT (EQD2₁₀ 66 vs. 60 Gy, p = 0.005). Only 2 patients had grade III dermatitis after IMRT. No other severe toxicity ≥grade III occurred.

Conclusion

Patients with ATC showed better prognosis through multimodal treatment. Furthermore, IMRT could achieve favorable survival rates by safely delivering higher dose than 3D-CRT.

Case-Control Study of Anaplastic Thyroid Cancer

Aims and background

The aim of the present study was to test some hypothetical risk factors for anaplastic thyroid cancer.

Study design

A case-control study comprised 110 patients with histologically or cytologically verified anaplastic thyroid cancer and 110 hospital controls individually matched with cases by sex, age, place of residence and time of hospitalization. Univariate and multivariate logistic regressions were used for data analysis.

Results

According to the conditional logistic regression analysis, the following factors were significantly and independently related to anaplastic thyroid cancer: history of goiter or thyroid nodules (odds ratio, OR, 37.55; 95% confidence interval, CI, 4.86–290.11), history of residence in endemic goiter area (OR, 2.56; 95% CI, 1.05–6.22), history of previous malignant non-thyroid tumor (OR, 5.51; 95% CI, 1.04–29.25), diabetes mellitus (OR, 4.06; 95% CI, 1.29–12.81) and low educational level (OR, 2.44; 95% CI, 1.17–5.06).

Conclusions

The results are in line with the current knowledge on factors related to thyroid cancer, except for the association between thyroid cancer and diabetes mellitus, which as far as we know has not yet been reported.

Anaplastic thyroid carcinoma in Denmark 1996-2012: A national prospective study of 219 patients

BACKGROUND

Anaplastic thyroid carcinoma (ATC) is the least common but most malignant thyroid cancer. We aimed to examine the characteristics as well as evaluate the incidence, prognostic factors, and if introduction of a fast track cancer program might influence survival in a cohort of ATC patients.

METHODS

A cohort study based on prospective data from the national Danish thyroid cancer database DATHYRCA and the national Danish Pathology Register including 219 patients diagnosed from 1996 to 2012, whom were followed until death or through September 2014.

RESULTS

We found the median age in the 7th decade, the majority of patients being women presenting with a growing mass at the neck, diagnosed with stage T4b disease. At diagnosis, 56% of the patients had lymph node metastasis and 38% distant metastasis. We observed one- and five-year survival of 20.7% and 11.0%, respectively. Both univariate and multivariate analyses showed age (above 73.6 years), respiratory impairment, T4b stage, and distant metastasis at diagnosis to be significant prognostic factors. Further, introduction of a national fast track cancer program increased survival nearly two-fold.

CONCLUSION

As new information, our study adds "respiratory impairment at diagnosis" and "introduction of a national fast track cancer program" to the list of already established prognostic indicators for ATC.

Recent advances and emerging therapies in anaplastic thyroid carcinoma

Anaplastic thyroid cancer is a rare and aggressive thyroid cancer with an overall survival measured in months. Because of this poor prognosis and often advanced age at presentation, these patients have traditionally been treated palliatively and referred for hospice. However, recent progress using novel therapies has energized the field, and several promising clinical trials are now available for these patients. This review will highlight this progress and the potential treatments that could pave the way to improved outcomes and quality of life for patients with this disease.

Anaplastic thyroid carcinoma: from clinicopathology to genetics and advanced therapies

Anaplastic thyroid carcinoma (ATC) is a rare malignancy, accounting for 1-2% of all thyroid cancers. Although rare, ATC accounts for the majority of deaths from thyroid carcinoma. ATC often originates in a pre-existing thyroid cancer lesion, as suggested by the simultaneous presence of areas of differentiated or poorly differentiated thyroid carcinoma. ATC is characterized by the accumulation of several oncogenic alterations, and studies have shown that an increased number of oncogenic alterations equates to an increased level of dedifferentiation and aggressiveness. The clinical management of ATC requires a multidisciplinary approach; according to recent American Thyroid Association guidelines, surgery, radiotherapy and/or chemotherapy should be considered. In addition to conventional therapies, novel molecular targeted therapies are the most promising emerging treatment modalities. These drugs are often multiple receptor tyrosine kinase inhibitors, several of which have been tested in clinical trials with encouraging results so far. Accordingly, clinical trials are ongoing to evaluate the safety, efficacy and effectiveness of these new agents. This Review describes the updated clinical and pathological features of ATC and provides insight into the molecular biology of this disease. The most recent literature regarding conventional, newly available and future therapies for ATC is also discussed.

Poorly Differentiated and Anaplastic Thyroid Cancer

BACKGROUND

Poorly differentiated thyroid carcinoma (PDTC) and anaplastic (undifferentiated) thyroid carcinoma (ATC) comprise a small subset of thyroid tumors that are associated with a poor prognosis and account for a significant portion of the morbidity and mortality related to thyroid cancer. Since management strategies vary between these two entities, it is important for clinicians to be able to differentiate PDTC from ATC.

METHODS

We reviewed the literature on PDTC and ATC and compared clinical and histopathologic features important in defining the disease process.

RESULTS

Both PDTC and ATC display aggressive behavior with increased locoregional and distant disease. In most cases, patients are older and have large, locally advanced tumors. PDTC may represent an intermediate entity in the progression of well-differentiated thyroid carcinoma to ATC. The use of surgical management may be curative or palliative and differs between PDTC and ATC. The roles of radiotherapy and chemotherapy have not been well described.

CONCLUSIONS

PDTC and ATC are rare diseases that carry a poor prognosis. Recognition of their different clinicopathologic features is important to the optimal management of these tumors.

The role of surgery in anaplastic thyroid cancer: A systematic review

OBJECTIVE

To elucidate the role of surgery in the management of anaplastic thyroid cancer.

METHODS

Ovid MEDLINE, Cochrane Library, and Google Scholar databases were searched for publications from December 2000 to July 2016. Selection criterion was a focus on the management of anaplastic thyroid cancer in adults. Studies addressing only nonsurgical management and review articles were excluded. Data extraction was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Kaplan-Meier analysis was performed on a subset of patients.

RESULTS

40 publications were included in the study. Approaches to unresectability and interpretations of resection varied widely. For patients undergoing primary surgery, the median survival was 6.6months. The median survival for non-surgical patients was 2.1months. In the subgroup analysis, the median survival time for patients undergoing surgery was significantly longer in Stage IVB (p=0.022) but not IVC disease. Negative margins did not afford a statistically significant survival benefit.

CONCLUSION

Surgery is a mainstay of treatment for Stage IVA and IVB disease. For Stage IVC cancer, distant metastasis was not a strict criterion against surgical candidacy among surgeons. The extent of resection and the definition of resectability remain controversial. Negative margins did not significantly increase survival.

Radiation therapy dose is associated with improved survival for unresected anaplastic thyroid carcinoma: Outcomes from the National Cancer Data Base

BACKGROUND

The outcomes of patients with unresected anaplastic thyroid carcinoma (ATC) from the National Cancer Data Base (NCDB) were assessed, and potential correlations were explored between radiation therapy (RT) dose and overall survival (OS).

METHODS

The study cohort was comprised of patients who underwent either no surgery or grossly incomplete resection. Correlates of OS were explored using univariate analysis and multivariable analysis (MVA).

RESULTS

In total, 1288 patients were analyzed. The mean patient age was 70.2 years, 59.7% of patients were women, and 47.6% received neck RT. The median OS was 2.27 months, and 11% of patients remained alive at 1 year. A positive RT dose-survival correlation was observed for the entire study cohort, for those who received systemic therapy, and for those with stage IVA/IVB and IVC disease. On MVA, older age (hazard ratio [HR], 1.317; 95% confidence interval [CI], 1.137-1.526), ≥ 1 comorbidity (HR, 1.587; 95% CI, 1.379-1.827), distant metastasis (HR, 1.385; 95% CI, 1.216-1.578), receipt of systemic therapy (HR, 0.637; 95% CI, 0.547-0.742), and receipt of RT compared with no RT (<45 grays [Gy]:HR, 0.843; 95% CI, 0.718-0.988; 45-59.9 Gy: HR, 0.596; 95% CI, 0.479-0.743; 60-75 Gy: HR, 0.419; 95% CI, 0.339-0.517) correlated with OS. The RT dose-survival correlation for patients who received higher (60-75 Gy) versus lower (45-59.9 Gy) therapeutic doses was confirmed by propensity-score matching.

CONCLUSIONS

Survival was poor in this cohort of patients with unresected ATC, and more effective therapies are needed. However, the association of RT dose with OS highlights the importance of identifying patients with unresected ATC who may still yet benefit from multimodal locoregional treatment that incorporates higher dose RT. Cancer 2017;123:1653-1661. © 2017 American Cancer Society.

Treatment and Prognosis of Anaplastic Thyroid Carcinoma: A Clinical Study of 50 Cases

INTRODUCTION

Although anaplastic thyroid carcinoma (ATC) is rare, it is one of the most aggressive human cancers. The optimal multimodal therapy policy of ATC is still debated, and a standardized treatment strategy remains to be established. This study aimed to evaluate the management aspect and prognosis of ATC.

MATERIALS AND METHODS

The data were analyzed retrospectively for 50 patients with ATC to evaluate the clinical characters, management and factors influencing survival. Survival analysis was performed by Kaplan-Merier method and log-rank test, and multivariate analysis was performed using Cox proportional hazard model.

RESULTS

The 1-year and 2-year overall survival rates (OS) were 48.0% and 26.0% respectively in all patients, with the 2-year OS of 40.0% and 31.0% and 6.3% for stage IVA, IVB and IVC respectively (P <0.05). In stage IVA and IVB patients, combined surgery with radiotherapy improved overall survival, and the 2-year OS were 50.0% and 35.7% respectively in the group with combined surgery with radiotherapy and the group with surgery with only (P <0.05). Postoperative radiotherapy improved local control rate in stage IVA and IVB patients (P <0.05). However, surgery, radiotherapy or chemotherapy could not improve the survival of stage IVC patients. Multivariate analysis showed that distant metastases, surgery, radiotherapy and tumor residue could predict the prognosis.

CONCLUSION

Combined surgery and radiotherapy could improve overall survival in stage IVA and IVB patients. Patients with ATC have a bad prognosis. Distant metastases, surgery, radiotherapy and tumor residue are the most important factors affecting the prognosis.

Thyroid Gland Malignancies

Surgery remains the most important effective treatment for differentiated (DTC) and medullary thyroid cancer (MTC). Radioactive iodine (RAI) is another important treatment but is reserved only for DTC whose disease captures RAI. Once patients fail primary therapy, observation is often recommended, as most DTC and MTC patients will have indolent disease. However, in a fraction of patients, systemic therapy must be considered. In recent decades 4 systemic therapies have been approved by the United States FDA for DTC and MTC. Sorafenib and lenvatinib are approved for DTC and vandetanib and cabozantinib for MTC. Anaplastic thyroid cancer (ATC) is a rare and rapidly progressive form of thyroid cancer with a very high mortality rate. Treatment of ATC remains a challenge. Most patients are not surgical candidates at diagnosis due to advanced disease. External beam radiation and radiosensitizing radiation are the mainstay of therapy at this time. However, exciting new drugs and approaches to therapy are on the horizon but it will take a concerted, worldwide effort to complete clinical trials in order to find effective therapies that will improve the overall survival for this devastating disease.

Molecular diagnostics and anaplastic thyroid carcinoma: the time has come to harvest the high hanging fruit

Targeted therapies have played a major role in cancer therapeutics, starting with the discovery of a drug against BCR–ABL rearrangements in chronic myelogenous leukemia. This led to the first approval of a targeted agent in cancer and since, many others have followed. Anaplastic thyroid cancer (ATC) is an aggressive carcinoma with few curative options. Although previous cytotoxic chemotherapy and kinase inhibitor therapies have not proven efficacious in ATC, some of the newer drugs appear to be promising. A case report and a comprehensive review of the current standard of care, genetics, modern therapeutic drugs and clinical trials are presented, in order to outline where we currently stand and where the future lies in the quest for a cure for ATC.

Anaplastic Thyroid Carcinoma: Treatment in the Age of Molecular Targeted Therapy

Anaplastic thyroid carcinoma is one of the most aggressive and deadly cancers in humans and accounts for one to two cases per million persons annually. The rarity of this malignancy and the rapidity by which it grows has been a major barrier to progress in finding effective therapies. Thus, the treatment that is the current standard of care for these patients is largely palliative, and few are cured; however, novel therapies and approaches are being studied in patients with anaplastic thyroid carcinoma and are delineated herein.