The Role of postoperative external beam radiotherapy for differentiated thyroid carcinoma: A Systematic review and meta-analysis

External beam radiation therapy for recurrent or residual thyroid cancer: What is the best treatment time and the best candidate for long-term local disease control?

INTRODUCTION

Cervical disease control might be challenging in advanced thyroid cancer (DTC). Indications for cervical external beam radiation therapy (EBRT) are controversial.

PURPOSE

To identify clinical and molecular factors associated with control of cervical disease with EBRT.

METHODS

Retrospective evaluation and molecular analysis of the primary tumor DTC patients who underwent cervical EBRT between 1995 and 2022 was performed.

RESULTS

Eighty adults, median age of 61 years, were included. T4 disease was present in 43.7%, lymph node involvement in 42.5%, and distant metastasis in 47.5%. Those with cervical progression were older (62.5 vs. 57.3, p = 0.04) with more nodes affected (12.1 vs. 2.8, p = 0.04) and had EBRT performed later following surgery (76.6 vs. 64 months, p = 0.05). EBRT associated with multikinase inhibitors showed longer overall survival than EBRT alone (64.3 vs. 37.9, p = 0.018) and better local disease control. Performing EBRT before radioiodine (RAI) was associated with longer cervical progression-free survival (CPFS) than was RAI before (67.5 vs. 34.5, p < 0.01). EBRT ≥2 years after surgery was associated with worse CPFS (4.9 vs. 34, p = 0.04). The most common molecular alterations were ERBB2, BRAF, FAT1, RET and ROS1 and TERT mutation was predictive of worse disease control after EBRT (p = 0.04).

CONCLUSION

Younger patients, with fewer affected nodes and treated earlier after surgery had better cervical disease control. Combination of EBRT with MKI improved OS. TERT mutation might indicate worse responders to EBRT; however, further studies are necessary to clarify the role of molecular testing in selecting candidates for cervical EBRT.

The new insights into autophagy in thyroid cancer progression

In recent decades, the incidence of thyroid cancer keeps growing at a shocking rate, which has aroused increasing concerns worldwide. Autophagy is a fundamental and ubiquitous biological event conserved in mammals including humans. Basically, autophagy is a catabolic process that cellular components including small molecules and damaged organelles are degraded for recycle to meet the energy needs, especially under the extreme conditions. The dysregulated autophagy has indicated to be involved in thyroid cancer progression. The enhancement of autophagy can lead to autophagic cell death during the degradation while the produced energies can be utilized by the rest of the cancerous tissue, thus this influence could be bidirectional, which plays either a tumor-suppressive or oncogenic role. Accordingly, autophagy can be suppressed by therapeutic agents and is thus regarded as a drug target for thyroid cancer treatments. In the present review, a brief description of autophagy and roles of autophagy in tumor context are given. We have addressed summary of the mechanisms and functions of autophagy in thyroid cancer. Some potential autophagy-targeted treatments are also summarized. The aim of the review is linking autophagy to thyroid cancer, so as to develop novel approaches to better control cancer progression.

Prognosis of thyroid carcinoma patients with osseous metastases: an SEER-based study with machine learning

OBJECTIVE

Osseous metastasis (OM) is the second most common site of thyroid cancer distant metastasis and presents a poor prognosis. Accurate prognostic estimation for OM has clinical significance. Ascertain the risk factors for survival and develop an effective model to predict the 3-year, 5-year overall survival (OS) and cancer-specific survival (CSS) for thyroid cancer patients with OM.

METHODS

We retrieved the information of patients with OMs between 2010 and 2016 from the Surveillance, Epidemiology, and End Result Program. The Chi-square test, and univariate and multivariate Cox regression analyses were performed. Four machine learning (ML) algorithms, which were most commonly used in this field, were applied.

RESULT

A total of 579 patients having OMs were eligible. Advanced age, tumor size ≥ 40 mm, combined with other distant metastasis were associated with worse OS in DTC OMs patients. Radioactive iodine (RAI) significantly improved CSS in both males and females. Among four ML models [logistic regression, support vector machines, extreme gradient boosting, and random forest (RF)], RF had the best performance [area under the receiver-operating characteristic curve: 0.9378 for 3-year CSS, 0.9105 for 5-year CSS, 0.8787 for 3-year OS, 0.8909 for 5-year OS]. The accuracy and specificity of RF were also the best.

CONCLUSIONS

RF model shall be used to establish an accurate prognostic model for thyroid cancer patients with OM, not only from the SEER cohort but also intended for all thyroid cancer patients in the general population, which may be applicable in clinical practice in the future.

Management of Recurrent Well-Differentiated Thyroid Carcinoma in the Neck: A Comprehensive Review

Surgery has been historically the preferred primary treatment for patients with well-differentiated thyroid carcinoma and for selected locoregional recurrences. Adjuvant therapy with radioactive iodine is typically recommended for patients with an intermediate to high risk of recurrence. Despite these treatments, locally advanced disease and locoregional relapses are not infrequent. These patients have a prolonged overall survival that may result in long periods of active disease and the possibility of requiring subsequent treatments. Recently, many new options have emerged as salvage therapies. This review offers a comprehensive discussion and considerations regarding surgery, active surveillance, radioactive iodine therapy, ultrasonography-guided percutaneous ablation, external beam radiotherapy, and systemic therapy for well-differentiated thyroid cancer based on relevant publications and current reference guidelines. We feel that the surgical member of the thyroid cancer management team is empowered by being aware and facile with all management options.

External beam radiotherapy for thyroid cancer: Patients, complications, and survival

BACKGROUND

Patterns of utilization of external beam radiation therapy (EBRT) in thyroid cancer are incompletely described. We characterize therapeutic intent, complications, and survival in thyroid cancer treated with EBRT.

METHODS

In this retrospective study of 105 thyroid cancer patients treated with EBRT at one institution (2008-2018), the primary outcome was overall survival. Secondary outcomes included incomplete treatment, emergency department (ED) visits, weight change, and gastrostomy placement.

RESULTS

Dominant histopathology was differentiated (44%), anaplastic (45%) and poorly-differentiated (11%) disease. EBRT was mainly utilized for locoregional control (differentiated 87%, poorly-differentiated 75%, anaplastic 92%). Palliative EBRT was more common in poorly-differentiated disease (42%). Weight loss was greater in aggressive/advanced disease (differentiated 10 lb, poorly-differentiated 27 lb, anaplastic 18 lb). Anaplastic cancer had higher rates of gastrostomy (34%) and lowest rates of treatment completion (83%). ED encounters were common (differentiated 44%, poorly-differentiated 50%, anaplastic 45%). Gastrostomy was associated with mortality on multivariable analysis in non-anaplastic malignancy.

CONCLUSIONS

EBRT was most frequently administered for locoregional control in thyroid cancer. Despite complications, the majority of patients completed EBRT therapy.

Effect of postoperative radiotherapy for patients with differentiated thyroid cancer

OBJECTIVE

We evaluated the efficacy and safety of postoperative radiotherapy (PORT) for differentiated thyroid cancer (DTC) with high risk features.

MATERIALS AND METHODS

This retrospective study analyzed 187 patients treated for DTC from 1985 to 2019. DTC referred to nonanaplastic thyroid cancer originating from follicular cells. PORT was defined as the administration of external beam radiation to the thyroid and regional lymph nodes following surgery for initially diagnosed DTC. The patients were included in the analysis if they received PORT or exhibited any of the following features: (a) pT4 or pN1b according to the 8th American Joint Committee on Cancer, (b) poorly differentiated thyroid cancer (PDTC), or (c) unfavourable variants such as anaplastic foci and etc. After 1:1 propensity matching, a total of 108 patients were analyzed according to PORT receipt. The median follow-up duration of the matched group was 10.4 years.

RESULTS

After matching, most of the variables became balanced, but the PORT group still had more PDTC and DTC with anaplastic foci. Radioactive iodine (RAI) was less frequently administered in the PORT group. PORT yielded a significantly higher 5-year locoregional recurrence free survival (LRFS) than the No PORT group (5-year LRFS 86.1% vs. 72.7%, p = 0.022), but the 10-year cancer specific survival (CSS) was similar between them (97.8% vs. 85.9%, p = 0.122). The multivariable analysis indicated that PORT was a favourable prognostic factor (Hazard ratio 0.3, 95% Confidence interval 0.1-0.8, p = 0.02) for LRFS, but not for CSS. Among 133 patients without PORT for initial disease, 39 of them received salvage surgery followed by salvage PORT. No severe toxicity after PORT was reported.

CONCLUSION

PORT reduced locoregional recurrence in DTC patients without severe toxicity. PORT can be an effective and safe treatment to improve locoregional control in DTC with high risk features. However, further study is warranted to identify those who can benefit from PORT.

American Head and Neck Society Endocrine Surgery Section and International Thyroid Oncology Group consensus statement on mutational testing in thyroid cancer: Defining advanced thyroid cancer and its targeted treatment

BACKGROUND

The development of systemic treatment options leveraging the molecular landscape of advanced thyroid cancer is a burgeoning field. This is a multidisciplinary evidence-based statement on the definition of advanced thyroid cancer and its targeted systemic treatment.

METHODS

An expert panel was assembled, a literature review was conducted, and best practice statements were developed. The modified Delphi method was applied to assess the degree of consensus for the statements developed by the author panel.

RESULTS

A review of the current understanding of thyroid oncogenesis at a molecular level is presented and characteristics of advanced thyroid cancer are defined. Twenty statements in topics including the multidisciplinary management, molecular evaluation, and targeted systemic treatment of advanced thyroid cancer are provided.

CONCLUSIONS

With the growth in targeted treatment options for thyroid cancer, a consensus definition of advanced disease and statements regarding the utility of molecular testing and available targeted systemic therapy is warranted.

Radiofrequency ablation of recurrent thyroid cancers: anatomy-based management

Although differentiated thyroid cancer has an excellent prognosis and low mortality, its recurrence rate has been reported to be very high. While surgery is recommended as the standard treatment for recurrent thyroid cancer, reoperation may increase the incidence of complications due to fibrosis and anatomical distortion. In patients with high surgical risk or those who refuse repeated surgery, ultrasonography-guided ablation techniques including radiofrequency ablation, ethanol ablation, and laser ablation are suggested as alternative treatments. In this manuscript, we introduce an anatomy-based management concept for radiofrequency ablation for recurrent thyroid cancer, and present a review of the relevant literature, including indications, basic techniques, clinical outcomes, and complications.