1
|
Maniakas A, Sullivan A, Hu MI, Busaidy NL, Cabanillas ME, Dadu R, Waguespack SG, Fisher SB, Graham PH, Gross ND, Grubbs EG, Perrier ND, Wang JR, Gunn B, Garden AS, Megahed R, Navuluri S, Li X, Williams MD, Zafereo M. Decreasing utilization for postoperative radiation therapy in locoregionally advanced medullary thyroid cancer. Head Neck 2024; 46:328-335. [PMID: 38009416 DOI: 10.1002/hed.27584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/28/2023] [Accepted: 11/14/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Use of postoperative radiation therapy (PORT) in locoregionally advanced medullary thyroid cancer (MTC) remains controversial. The objective was to evaluate the effect of PORT on locoregional control (LRC) and overall survival (OS). METHODS Retrospective cohort study of 346 MTC patients separated into PORT and no-PORT cohorts. Relative indications for PORT, as well as changes in patterns of treatment, were recorded. RESULTS 49/346 (14%) received PORT. PORT was associated with worse OS; adjusted HR = 2.0 (95%CI 1.3-3.3). PORT was not associated with improved LRC, even when adjusting for advanced stage (Stage III p = 0.892; Stage IV p = 0.101). PORT and targeted therapy were not associated with improved OS compared to targeted therapy alone; adjusted HR = 1.2 (95%CI 0.3-4.1). CONCLUSIONS Use of PORT in MTC has decreased and its indications have become more selective, coinciding with the advent of effective targeted therapies. Overall, PORT was not associated with improved LRC or OS.
Collapse
Affiliation(s)
- Anastasios Maniakas
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Andrew Sullivan
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Mimi I Hu
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Naifa L Busaidy
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Maria E Cabanillas
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ramona Dadu
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Sarah B Fisher
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer R Wang
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Brandon Gunn
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Romy Megahed
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Navuluri
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Xu Li
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Michelle D Williams
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Mark Zafereo
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
2
|
Erickson TA, Shih YP, Fass J, Jang M, Tran E. T Cells Engineered to Express Immunoreceptors Targeting the Frequently Expressed Medullary Thyroid Cancer Antigens Calcitonin, CEA, and RET M918T. Thyroid 2022; 32:789-798. [PMID: 35587601 DOI: 10.1089/thy.2022.0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Medullary thyroid cancer (MTC) is a rare malignancy originating from the calcitonin-producing C cells of the thyroid. Despite recent therapeutic advances, metastatic MTC remains incurable. Adoptive cell therapy (ACT) using genetically engineered T cells targeting either tissue-restricted tumor-associated antigens or mutated neoantigens has led to durable remissions in other metastatic solid tumors. The majority of MTC express the tumor-associated antigens calcitonin and carcinoembryonic antigen (CEA), and ∼40% of MTC harbor the RET M918T oncogenic driver mutation. Methods: We developed and characterized three immunoreceptors that recognize extracellular CEA, a calcitonin epitope presented by HLA-A*24:02, or an RET M918T neoepitope restricted by HLA-DPB1*04:01/02. The chimeric antigen receptor (CAR) targeting CEA was synthetically designed, while the T cell receptors (TCRs) targeting calcitonin and RET M918T were isolated from a transgenic mouse and patient with MTC, respectively. These immunoreceptors were genetically engineered into peripheral blood T cells and tested for antigen specificity and antitumor activity. Results: T cells expressing the anti-CEA CAR or the calcitonin-reactive TCR produced effector cytokines and displayed cytotoxicity against cell lines expressing their cognate antigen in vitro. In immunodeficient mice harboring a human MTC cell line, the adoptive transfer of T cells engineered to express the anti-CEA CAR or calcitonin-reactive TCR led to complete tumor regression. T cells expressing the HLA-DPB1*04:01/02-restricted TCR targeting RET M918T, which was cloned from peripheral blood CD4+ T cells of a patient with MTC, demonstrated specific reactivity against cells pulsed with the mutated peptide and MTC tumor cells that expressed HLA-DPB1*04:01 and RET M918T. Conclusion: The preclinical data presented herein demonstrate the potential of using genetically engineered T cells targeting CEA, calcitonin, and/or RET M918T to treat metastatic MTC.
Collapse
Affiliation(s)
- Tim Andrew Erickson
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| | - Yi-Ping Shih
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| | - Joseph Fass
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| | - Myungkyu Jang
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| | - Eric Tran
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, USA
| |
Collapse
|
3
|
Angelousi A, Hayes AR, Chatzellis E, Kaltsas GA, Grossman AB. Metastatic medullary thyroid carcinoma: a new way forward. Endocr Relat Cancer 2022; 29:R85-R103. [PMID: 35521769 PMCID: PMC9175549 DOI: 10.1530/erc-21-0368] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022]
Abstract
Medullary thyroid carcinoma (MTC) is a rare malignancy comprising 1-2% of all thyroid cancers in the United States. Approximately 20% of cases are familial, secondary to a germline RET mutation, while the remaining 80% are sporadic and also harbour a somatic RET mutation in more than half of all cases. Up to 15-20% of patients will present with distant metastatic disease, and retrospective series report a 10-year survival of 10-40% from time of first metastasis. Historically, systemic therapies for metastatic MTC have been limited, and cytotoxic chemotherapy has demonstrated poor objective response rates. However, in the last decade, targeted therapies, particularly multitargeted tyrosine kinase inhibitors (TKIs), have demonstrated prolonged progression-free survival in advanced and progressive MTC. Both cabozantinib and vandetanib have been approved as first-line treatment options in many countries; nevertheless, their use is limited by high toxicity rates and dose reductions are often necessary. New generation TKIs, such as selpercatinib or pralsetinib, that exhibit selective activity against RET, have recently been approved as a second-line treatment option, and they exhibit a more favourable side-effect profile. Peptide receptor radionuclide therapy or immune checkpoint inhibitors may also constitute potential therapeutic options in specific clinical settings. In this review, we aim to present all current therapeutic options available for patients with progressive MTC, as well as new or as yet experimental treatments.
Collapse
Affiliation(s)
- Anna Angelousi
- Unit of Endocrinology, First Department of Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Correspondence should be addressed to A Angelousi or A B Grossman: or
| | - Aimee R Hayes
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - Eleftherios Chatzellis
- Endocrinology Diabetes and Metabolism Department, 251 Hellenic Air Force and VA General Hospital, Athens, Greece
| | - Gregory A Kaltsas
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Ashley B Grossman
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
- Green Templeton College, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
- Correspondence should be addressed to A Angelousi or A B Grossman: or
| |
Collapse
|
4
|
Indications of external beams radiation for thyroid cancer. Curr Opin Otolaryngol Head Neck Surg 2022; 30:137-144. [DOI: 10.1097/moo.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
5
|
Huang S, Zhong J, Zhang Z, Chen R, Li J, Sun J, Chen H. Prognosis of radiotherapy in medullary thyroid carcinoma patients without distant metastasis. Transl Cancer Res 2022; 10:4714-4726. [PMID: 35116326 PMCID: PMC8798267 DOI: 10.21037/tcr-21-1179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
Background Medullary thyroid carcinoma (MTC) is an advanced disease with a poor prognosis. Although radiotherapy is widely utilized to treat MTC, it is still controversial. MTC patients without distant metastases have not been investigated to explore indications for adjuvant radiotherapy. This study aims to investigate the impact of radiotherapy on the survival of MTC patients without distant metastases. Methods Data of MTC patients without distant metastasis who underwent total thyroidectomy between 2010 and 2015 were obtained from the Surveillance, Epidemiology and End Results (SEER) database. Propensity score matching was performed to analyze the relationship between radiotherapy and cancer-specific survival (CSS). Results Seventy-four of 718 MTC patients without distant metastases received radiotherapy and underwent total thyroidectomy. A total of 148 patients were screened via propensity score matching analysis. Multivariate Cox regression indicated that factors including age, sex, radiotherapy and chemotherapy were independent predictors of CSS. Based on these factors, MTC patients without distant metastasis were classified into two risk groups using a nomogram and risk classification system. The C-index of the nomogram was 0.791. The calibration curves showed good consistency of CSS between the actual observation and the nomogram prediction, and decision curve analysis (DCA) showed great clinical usefulness of the nomogram. The three-year CSS of the radiotherapy group was 85.3%, and that of the surgery group was 95%. Particularly, compared with the surgery group, the three-year CSS of subgroups of the radiotherapy group, including male patients and those aged >48 years, was decreased. Conclusions Radiotherapy results in worse CSS for MTC patients without distant metastases. To maximize benefits, decisions about individual radiotherapy should weigh its advantages and disadvantages.
Collapse
Affiliation(s)
- Shaojun Huang
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jiana Zhong
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhen Zhang
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Rongping Chen
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jitong Li
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jia Sun
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Chen
- Department of Endocrinology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
6
|
Ow TJ, Mehta V, Kim S, Vakil M, Friedmann P, In H. Evaluation of Survival and Postoperative Radiation Among Patients with Advanced Medullary Thyroid Carcinoma: An Analysis of the National Cancer Database. Ann Surg Oncol 2022; 29:2582-2591. [PMID: 35067791 PMCID: PMC8940671 DOI: 10.1245/s10434-021-11158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/15/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND This study compared survival between patients who had medullary thyroid cancer (MTC) treated with surgery alone and patients who underwent surgery and radiation (SRT). METHODS Patients from the National Cancer Database (NCDB) with a diagnosis of stage 3 or 4 MTC, lymph node disease, and no distant metastases between 2008 and 2016 were studied. Kaplan-Meier analyses and log-rank statistics were used to estimate and compare overall survival between patients treated with surgery alone and those treated with SRT. Mutlivariable Cox proportional hazards models and propensity-matching were used to adjust for confounding and selection bias. RESULTS Among 1370 patients, 1112 (81%) received surgery alone, and 258 (19%) received SRT. The hazard ratio for mortality in the SRT group was 1.784 (95% confidence interval [CI] 1.313-2.43) after multivariable adjustment for confounding variables. Furthermore, SRT remained associated with a higher mortality rate (p < 0.008) after propensity-matching in an effort to adjust for selection bias. CONCLUSIONS This analysis of NCDB patients showed that SRT is associated with a significantly higher mortality rate among patients treated for stage 3 or 4 IV MTC with positive lymph node disease. Although this observation can be attributed to unmeasured confounders or selection bias, the cause for the profound survival differences deserves prospective evaluation, especially as adjuvant therapies for this disease continue to evolve.
Collapse
Affiliation(s)
- Thomas J Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Pathology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Seokhwa Kim
- Gangdong Hana ENT Clinic, Hana ENT Hospital, Seoul, South Korea
| | - Mayand Vakil
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Patricia Friedmann
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Haejin In
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
7
|
Green K, Hintze J, O'Neill JP. Surgical aspects and controversies in the management of medullary thyroid cancer. Ir J Med Sci 2022; 191:2461-2466. [PMID: 35064534 DOI: 10.1007/s11845-021-02886-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/07/2021] [Indexed: 01/02/2023]
Abstract
Medullary thyroid cancer (MTC) accounts for only 4% of thyroid carcinomas but 15% of thyroid cancer deaths. MTC is a tumour of the calcitonin secreting parafollicular C cells in the thyroid which can occur sporadically or be hereditary in multiple endocrine neoplasias type 2 syndromes due to germline RET mutations. Sporadic forms of MTC can also be caused by mutations in the RET protooncogene. MTC commonly presents in a late stage, with 70% of patients presenting with local nodal metastasis. Currently, the only curative treatment for MTC is surgical removal. The aim of this paper is to describe the current guidelines and progressions of the surgical management of MTC and to highlight up-and-coming chemotherapies. A database literature review was completed utilizing PubMed to cumulate the extant literature, screening for most recent guidelines and publications regarding the management of MTC. Current guidelines were described by the American Thyroid Association in 2015. Controversial publications continue to present supporting evidence for varying degrees of thyroidectomy and neck dissections. Recently, researchers have been exploring non-surgical options including external beam radiotherapy and multikinase inhibitors such as vandetanib and cabozantinib for the treatment of MTC. Surgical management of MTC remains controversial and varies significantly dependent on the extent of disease. Chemotherapeutic options have undetermined effects on survival to date.
Collapse
Affiliation(s)
| | - Justin Hintze
- Department of Otolaryngology, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Paul O'Neill
- Department of Otolaryngology, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
8
|
Puerto M, Borson-Chazot F, Tabarin A. Updates on therapy for medullary thyroid cancer in 2021. ANNALES D'ENDOCRINOLOGIE 2021; 83:114-118. [PMID: 34921811 DOI: 10.1016/j.ando.2021.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
Medullary thyroid cancer (MTC) is a rare form of thyroid cancer, frequently linked to a germline or somatic mutation in the RET proto-oncogene. MTC has a good prognosis at the localized stage but prognosis is worse in case of metastases, although there is considerable heterogeneity in progression even in advanced stages. Classical chemotherapy shows little efficacy in this type of cancer. Over the last decade, new effective anti-cancer therapies, in particular multi-targeted tyrosine kinase inhibitors and selective anti-RET tyrosine kinase inhibitors, have changed the management of patients with advanced MTC. The aim of this review is to report the results of studies of these new treatments, and to update the state of knowledge from ongoing studies of treatments such as vectorized internal radiotherapy. In chronic forms, which are incurable but with slow progression, the development of new lines of treatment that can reduce the phenomena of acquired resistance is a major issue.
Collapse
Affiliation(s)
- Marie Puerto
- Hôpital Haut-Lévêque - CHU de Bordeaux, Endocrinology Department, 33600 Pessac, France
| | | | - Antoine Tabarin
- Hôpital Haut-Lévêque - CHU de Bordeaux, Endocrinology Department, 33600 Pessac, France
| |
Collapse
|
9
|
Jin M, Megwalu UC, Noel JE. External Beam Radiotherapy for Medullary Thyroid Cancer Following Total or Near-Total Thyroidectomy. Otolaryngol Head Neck Surg 2020; 164:97-103. [PMID: 32746731 DOI: 10.1177/0194599820947696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Medullary thyroid carcinoma (MTC) often presents with advanced disease and takes an aggressive course as compared with more well-differentiated thyroid cancers. The role of adjuvant therapy, specifically external beam radiotherapy (EBRT), remains disputed. This study investigated the impact of EBRT on survival in MTC. STUDY DESIGN Cross-sectional analysis of a national database. SETTING Patients with MTC were identified from the SEER program (Surveillance, Epidemiology, and End Results). METHODS Collected variables included age, sex, race, T and N stages, lymph node yield, and use of EBRT. Propensity score matching was performed to determine the association of EBRT with overall and disease-specific survival. RESULTS A total of 2046 patients with locoregional MTC were identified. Of these, 152 received EBRT. Patients receiving EBRT were older and had more advanced disease. EBRT was not associated with differences in overall survival (hazard ratio, 1.12; 95% CI, 0.76-1.65) or disease-specific survival (1.66; 0.93-2.95), as well as in subset analysis of age and disease extent. Long-term overall survival was similar, with 77.3% (95% CI, 70.1%-85.3%) and 58.3% (48.2%-70.5%) of patients without EBRT alive at 5 and 10 years, respectively (vs 70.7% [63.2%-79.1%] and 52.3% [43.3%-63.2%] of patients with EBRT). There were no differences in 5- and 10-year disease-specific survival. CONCLUSION EBRT was not associated with improved overall or disease-specific survival in patients with MTC. Decisions regarding EBRT must be made with consideration of morbidity relative to benefit for individual patients.
Collapse
Affiliation(s)
- Michael Jin
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University Stanford, California, USA
| | - Uchechukwu C Megwalu
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University Stanford, California, USA
| | - Julia E Noel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University Stanford, California, USA
| |
Collapse
|
10
|
The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
Collapse
|
11
|
Groen AH, Beckham TH, Links TP, Goldman DA, Sherman EJ, Tuttle MM, Bijl HP, Wong RJ, Plukker JT, Lee NY. Outcomes of surgery and postoperative radiation therapy in managing medullary thyroid carcinoma. J Surg Oncol 2020; 121:234-243. [PMID: 31733124 PMCID: PMC8011335 DOI: 10.1002/jso.25761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/02/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES We evaluated the outcomes of surgery with or without postoperative radiation therapy (PORT) in the management of medullary thyroid carcinoma (MTC). METHODS From two tertiary cancer centers, 297 consecutive patients with MTC treated with PORT (n = 46) between 1990 and 2016 or surgery alone (n = 251) between 2000 and 2016 were reviewed. RESULTS Ten-year cumulative incidences of locoregional and distant failure were 30.2% and 24.9% in the surgery cohort, and 16.9% and 55.2% in the PORT cohort. In the surgery alone cohort, T4 disease, extrathyroidal extension, N1 disease, extranodal extension (ENE), and residual disease after surgery were associated with local failure. The PORT cohort had significantly higher proportions of patients with T4 disease, N1 disease, ENE, and residual disease. CONCLUSIONS High-risk clinical features can help identify patients with MTC at high-risk for local failure after surgery alone. Patients with high-risk clinical features had effective locoregional control after PORT.
Collapse
Affiliation(s)
- Andries H. Groen
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Thomas H. Beckham
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Thera P. Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Debra A. Goldman
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Eric J. Sherman
- Department of Medicine, Endocrine Service; Memorial Sloan Kettering Cancer Center, New York, United States
| | - Michael M. Tuttle
- Department of Medicine, Endocrine Service; Memorial Sloan Kettering Cancer Center, New York, United States
| | - Hendrik P. Bijl
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Richard J. Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, United States
| | - John Th.M. Plukker
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States,Corresponding author: Nancy Y. Lee, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, telephone: 212-639-3341, fax: 212-639-2417,
| | | |
Collapse
|
12
|
Kukulska A, Krajewska J, Kolosza Z, Paliczka-Cieslik E, Kropinska A, Pawlaczek A, Puch Z, Ficek K, Lisik T, Sygula D, Wygoda Z, Roskosz J, Wydmanski J, Jarzab B. The role of postoperative adjuvant radiotherapy in the local control in medullary thyroid carcinoma. Endocr Connect 2019; 9:EC-19-0387.R1. [PMID: 31778360 PMCID: PMC6933828 DOI: 10.1530/ec-19-0387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 11/28/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The value of postoperative radiotherapy in the treatment of medullary thyroid carcinoma (MTC) has not been unequivocally demonstrated. Therefore our study aimed to answer the question of whether adjuvant radiotherapy showed any impact on the risk of local recurrence and whether there were any differences in response to radiotherapy between hereditary and sporadic MTC. METHODS A retrospective analysis involved 254 MTC patients, among them 73 patients with a hereditary disease. Two hundred and twenty-four patients, including 43 persons at high risk of local relapse, underwent only initial surgery, 18 other patients were operated due to MTC recurrences, whereas the remaining 12 patients had cytoreductive procedure or were not amenable for surgery. Radiotherapy was carried out in 132 patients. One hundred and twenty patients underwent adjuvant radiotherapy, among them 102 patients after initial surgery. The median follow up was 10 years (range 0.5-29 years). RESULTS Local recurrence occurred in 107/254 patients, among them in 63 subjects after prior radiotherapy. The frequency of relapse showed significant, increasing trend toward higher MTC stages (p<0.001). More relapses were noticed in patients with lymph node metastases at diagnosis. Adjuvant radiotherapy was associated with a lower risk of nodal recurrence only in high-risk patients, particularly if lymph node metastases were present at MTC diagnosis. The differences between hereditary and sporadic subgroups were not significant. CONCLUSIONS Adjuvant radiotherapy has a limited importance in MTC treatment. It should be considered in high-risk MTC patients. The presence of RET mutation does not influence the response to radiation.
Collapse
Affiliation(s)
- Aleksandra Kukulska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
- Radiotherapy Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Jolanta Krajewska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Zofia Kolosza
- Department of Epidemiology and Silesia Cancer Registry, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Ewa Paliczka-Cieslik
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Aleksandra Kropinska
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Agnieszka Pawlaczek
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Zbigniew Puch
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Kornelia Ficek
- Radiotherapy Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Teresa Lisik
- Radiotherapy Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Dorota Sygula
- Radiotherapy Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Zbigniew Wygoda
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Jozef Roskosz
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Jerzy Wydmanski
- Radiotherapy Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Barbara Jarzab
- Nuclear Medicine and Endocrine Oncology Department, M. Sklodowska-Curie Institute – Oncology Center, Gliwice Branch, Gliwice, Poland
| |
Collapse
|
13
|
Rowell N. The role of external beam radiotherapy in the management of medullary carcinoma of the thyroid: A systematic review. Radiother Oncol 2019; 136:113-120. [DOI: 10.1016/j.radonc.2019.03.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/09/2019] [Accepted: 03/29/2019] [Indexed: 11/30/2022]
|
14
|
Abstract
Medullary thyroid cancer (MTC) is rare but aggressive. It can be cured only if intrathyroid at diagnosis. MTC can be sporadic (75%) or familial (25%) and the 2 forms are distinguished by RET mutations analysis. Calcitonin is the specific serum marker; its doubling time is the most important prognostic factor for survival and progression; 30% of MTC patients have distant metastases at diagnosis and, when progressing, systemic therapy with vandetanib or cabozantinib should be considered. Before starting this treatment, the possibility of using a local treatment should be evaluated to delay systemic therapy. A multidisciplinary team should care for these patients.
Collapse
Affiliation(s)
- David Viola
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, Pisa 56124, Italy
| | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, Pisa 56124, Italy.
| |
Collapse
|
15
|
Sastry R, Williams EA, Koffie R, Fehnel K, Wirth L, Nahed B. Metastatic medullary thyroid cancer to the brain: a case report and review of the literature. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2018. [DOI: 10.2217/ije-2017-0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Medullary thyroid cancer rarely metastasizes to the brain. Presentation and optimal treatment approaches vary widely. We present a 53-year-old male, diagnosed with medullary thyroid cancer 21 years prior, who was presented with at least seven metastases in his brain. He underwent two craniotomies for two large, hemorrhagic metastases followed by whole brain radiation therapy. Tumor genotyping revealed a somatic C634R mutation in the RET proto-oncogene. Subsequently, he was started on multikinase inhibitor therapy. He ultimately passed away 10 months after his surgery. Complete resection may be a reasonable approach for patients with one or more cerebral or cerebellar metastases when feasible. Further analysis is necessary to understand the specific mutations that predispose medullary thyroid cancer to central nervous system metastasis.
Collapse
Affiliation(s)
- Rahul Sastry
- Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erik A Williams
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Robert Koffie
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Katie Fehnel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Lori Wirth
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Brian Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| |
Collapse
|
16
|
Cherian AJ, Ramakant P, Pai R, Manipadam MT, Elanthenral S, Chandramohan A, Hephzibah J, Mathew D, Naik D, Paul TV, Rajaratnam S, Thomas N, Paul MJ, Abraham DT. Outcome of Treatment for Medullary Thyroid Carcinoma-a Single Centre Experience. Indian J Surg Oncol 2017; 9:52-58. [PMID: 29563735 DOI: 10.1007/s13193-017-0718-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/22/2017] [Indexed: 12/18/2022] Open
Abstract
We conducted this study to evaluate the demography, clinical presentation, management and outcomes of medullary thyroid carcinoma (MTC) from the Indian context. This was a retrospective study of patients with MTC managed between January 2008 and December 2016. All pertinent data was collected and the results were analysed using STATA (v.13.1). MTC accounted for 90/2022 (4.45%) patients managed with thyroid cancer during the study period. The mean age of presentation was 40 years (range 14-70 years) with 47 males and 43 females. The most common presentation included goitre with cervical lymphadenopathy seen in 60 patients (66.7%). There were 11 patients (12.2%) with systemic metastasis at presentation. Rearranged during transfection (RET) testing was performed in 71 patients and was positive in 25 (35.2%). The mutations among these patients were seen in the following codons: 634 (12), 804 (8), 790 (3) and 618 (2). Persistent hypercalcitoninemia (calcitonin > 50 pg/ml) was observed in 62/80 (77.5%) patients. Forty patients underwent a meta-iodo-benzyl-guanidine (MIBG) scan in the postoperative period, 10 were positive. The mean duration of follow-up was 32 months and 10 patients defaulted from follow-up. Sixteen patients developed metastasis during the period of follow-up while eight patients expired. The mean survival was 85.75 months (95% CI 78.7-92.7). MTC accounted for 4.5% of thyroid carcinomas in this cohort among which 35% were hereditary. Persistent hypercalcitoninemia following surgery is seen in more than 70% of patients but this does not affect survival. RET screening should be performed for all patients with MTC as curative surgery can be offered for mutation positive offspring.
Collapse
Affiliation(s)
- Anish Jacob Cherian
- 1Department of Endocrine Surgery, Christian Medical College and Hospital, Paul Brand building (1205), Vellore, Tamil Nadu India
| | - Pooja Ramakant
- 1Department of Endocrine Surgery, Christian Medical College and Hospital, Paul Brand building (1205), Vellore, Tamil Nadu India
| | - Rekha Pai
- 2Department of Molecular Pathology, Christian Medical College and Hospital, Vellore, India
| | | | - S Elanthenral
- 3Department of General Pathology, Christian Medical College and Hospital, Vellore, India
| | | | - Julie Hephzibah
- 5Department of Nuclear Medicine, Christian Medical College and Hospital, Vellore, India
| | - David Mathew
- 5Department of Nuclear Medicine, Christian Medical College and Hospital, Vellore, India
| | - Dhukabandhu Naik
- 6Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - Thomas V Paul
- 6Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - Simon Rajaratnam
- 6Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - Nihal Thomas
- 6Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - M J Paul
- 1Department of Endocrine Surgery, Christian Medical College and Hospital, Paul Brand building (1205), Vellore, Tamil Nadu India
| | - Deepak Thomas Abraham
- 1Department of Endocrine Surgery, Christian Medical College and Hospital, Paul Brand building (1205), Vellore, Tamil Nadu India
| |
Collapse
|
17
|
Li Y, Simonds WF. Recent advances in the management of endocrine malignancies associated with hereditary hyperparathyroidism syndromes. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017. [DOI: 10.2217/ije-2016-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hereditary hyperparathyroidism syndromes, such as multiple endocrine neoplasm type 1, type 2A and the hyperparathyroidism-jaw tumor syndrome, are associated with an increased incidence of malignancies involving the neuroendocrine tissue of the pancreas and thymus, parathyroid and thyroid glands. The natural history of these endocrine tumors can differ from nonhereditary malignancies. The surgical approach, the only potentially curative treatment option for these endocrine malignancies, has evolved considerably in recent years. Newer targeted therapies, such as small molecule kinase inhibitors, somatostatin analogs and peptide receptor radionuclide therapy, are being developed. We provide here a comprehensive review of the current standards of treatment and emerging novel therapies for the endocrine malignancies commonly associated with hereditary hyperparathyroidism syndromes.
Collapse
Affiliation(s)
- Yulong Li
- Metabolic Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, MD 20892, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, MD 20892, USA
| |
Collapse
|
18
|
Konstantinidis A, Stang M, Roman SA, Sosa JA. Surgical management of medullary thyroid carcinoma. Updates Surg 2017; 69:151-160. [DOI: 10.1007/s13304-017-0443-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/01/2017] [Indexed: 12/19/2022]
|
19
|
Fedewa SA, Jemal A, Chen AY. Trends and Predictors of Chemotherapy Use among Thyroid Cancer Patients in the National Cancer Database (2004-2013). Eur Thyroid J 2016; 5:268-276. [PMID: 28101492 PMCID: PMC5216190 DOI: 10.1159/000449379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/23/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Beginning in 2011, the Food and Drug Administration (FDA) approved the use of multikinase inhibitors (MKIs) for medullary thyroid cancers (MTCs), and in 2013 MKIs were approved for metastatic differentiated thyroid cancers (DTCs). However, little is known about the use of chemotherapy in thyroid cancer patients. Thus, the goal of our study was to describe patterns of chemotherapy use, including MKIs, among DTC and MTC patients in the National Cancer Database (NCDB). METHODS Chemotherapy use, along with other treatment types (surgery and radiation), was assessed between 2004 and 2013. The primary predictor was the year of diagnosis (2004-2010 and 2011-2013), based on the FDA's approval of chemotherapy for MTC (2011). Baseline use of MKIs in DTCs in 2013 was also examined. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% CI of receipt of chemotherapy. RESULTS Overall, 199,654 patients were included in our analytic sample with 194,667 nonmetastatic DTCs, 1,633 metastatic DTCs, and 3,354 MTCs. Among MTCs, chemotherapy use significantly increased from 3.1% in 2004-2010 to 5.0% in 2011-2013 (p = 0.018) in unadjusted and adjusted (OR = 1.54, 95% CI: 1.00, 2.36) analyses. In metastatic DTCs, 4.9% of patients received chemotherapy in 2013, which was not significantly higher than in previous years (p = 0.755). CONCLUSIONS Overall, chemotherapy use among MTCs increased marginally following the FDA's approval of MKIs in 2011, although their use remains very low. MKIs were infrequently used in metastatic DTCs in 2013. Future studies examining patterns of chemotherapy in thyroid cancer patients are warranted.
Collapse
Affiliation(s)
- Stacey A. Fedewa
- Surveillance and Health Services Research, American Cancer Society, Emory University School of Medicine, Atlanta, Ga., USA
- *Stacey A. Fedewa, MPH, Surveillance and Health Services Research, American Cancer Society, 250 Williams Street, Atlanta, GA 30303 (USA), E-Mail
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Emory University School of Medicine, Atlanta, Ga., USA
| | - Amy Y. Chen
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Ga., USA
| |
Collapse
|
20
|
External beam radiotherapy in thyroid carcinoma: clinical review and recommendations of the AIRO "Radioterapia Metabolica" Group. TUMORI JOURNAL 2016; 103:114-123. [PMID: 27647221 DOI: 10.5301/tj.5000532] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 02/07/2023]
Abstract
The therapeutic approach to thyroid carcinoma usually involves surgery as initial treatment. The use of external beam radiotherapy (EBRT) is limited to high-risk patients and depends on clinical stage and histologic type. Different behavior patterns and degrees of aggressiveness of thyroid carcinomas require different management for differentiated, medullary, and anaplastic carcinoma. However, the role of EBRT is an issue of debate. Most clinical studies are retrospective and based on single-institution experiences. In this article, we review the main literature and give recommendations for the use of EBRT in thyroid carcinoma on behalf of the "Radioterapia Metabolica" Group of the Italian Radiation Oncology Association.
Collapse
|
21
|
Chapman TR, Laramore GE, Bowen SR, Orio PF. Neutron radiation therapy for advanced thyroid cancers. Adv Radiat Oncol 2016; 1:148-156. [PMID: 28740884 PMCID: PMC5514010 DOI: 10.1016/j.adro.2016.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/15/2016] [Accepted: 05/18/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The aim of this study was to review institutional outcomes for advanced thyroid cancers treated with fast neutron radiation therapy (FNRT) and photon radiation therapy (RT). METHODS AND MATERIALS In all, 62 consecutive patients were analyzed. Fifty-nine had stage IV disease. Twenty-three were treated with FNRT and 39 with photon RT. Median follow-up was 14 months. The primary endpoint was overall survival (OS). RESULTS There was no significant difference in median OS between FNRT and photon RT (26 vs 16 months; P = .49). Patients with well-differentiated histologies had superior median OS with photon RT (17 vs 69 months; P = .04). There was a nonsignificant trend toward improved OS with FNRT for medullary and anaplastic histologies. CONCLUSIONS Outcomes in this study are in line with historical results. There is an apparent detriment in OS with FNRT for well-differentiated histologies and a trend toward improved OS with medullary and anaplastic histologies that warrants further investigation.
Collapse
Affiliation(s)
- Tobias R. Chapman
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - George E. Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - Stephen R. Bowen
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
- Department of Radiology, University of Washington Medical Center, Seattle, Washington
| | - Peter F. Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
22
|
Kasaian K, Wiseman SM, Walker BA, Schein JE, Hirst M, Moore RA, Mungall AJ, Marra MA, Jones SJM. Putative BRAF activating fusion in a medullary thyroid cancer. Cold Spring Harb Mol Case Stud 2016; 2:a000729. [PMID: 27148585 PMCID: PMC4849853 DOI: 10.1101/mcs.a000729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Medullary thyroid cancer (MTC) is a malignancy of the calcitonin-producing parafollicular cells of the thyroid gland. Surgery is the only curative treatment for this cancer. External beam radiation therapy is reserved for adjuvant treatment of MTC with aggressive features. Targeted therapeutics vandetanib and cabozantinib are approved for the treatment of aggressive and metastatic tumors that are not amenable to surgery. The use of these multikinase inhibitors are supported by the observed overactivation of the RET oncoprotein in a large subpopulation of MTCs. However, not all patients carry oncogenic alterations of this kinase. Hence, there is still a need for comprehensive molecular characterization of MTC utilizing whole-genome and transcriptome-sequencing methodologies with the aim of identifying targetable mutations. Here, we describe the genomic profiles of two medullary thyroid cancers and report the presence of a putative oncogenic BRAF fusion in one. Such alterations, previously observed in other malignancies and known targets of available drugs, can benefit patients who currently have no treatment options.
Collapse
Affiliation(s)
- Katayoon Kasaian
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Blair A Walker
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Jacqueline E Schein
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada
| | - Martin Hirst
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada
| | - Richard A Moore
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada
| | - Andrew J Mungall
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada
| | - Marco A Marra
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada;; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Steven J M Jones
- Canada's Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia V5Z 4S6, Canada;; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada;; Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| |
Collapse
|
23
|
Munoz‐Bendix C, Santacroce A, Gierga K, Floeth FW, Steiger H, Penalonzo MA, Eicker SO. Recurrent spinal metastasis of a sporadic medullary carcinoma of the thyroid after radiation therapy: a case report and review of the literature. Clin Case Rep 2016; 4:9-18. [PMID: 26783427 PMCID: PMC4706409 DOI: 10.1002/ccr3.409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/17/2015] [Accepted: 08/16/2015] [Indexed: 01/28/2023] Open
Abstract
Sporadic Medullary Carcinoma of the Thyroid is a relatively uncommon entity and at the time of diagnosis, most already present loco-regional metastasis. Therapy should be aggressive to reduce recurrence and mortality. Follow-up period should continue lifelong and should also include calcium/pentagastrin infusion test, as well as 6-month interval diagnostic imaging.
Collapse
Affiliation(s)
| | - Antonio Santacroce
- Department of Radiation OncologyHeinrich Heine UniversityDüsseldorfGermany
| | - Kristin Gierga
- Department of NeuropathologyHeinrich Heine UniversityDüsseldorfGermany
| | - Frank W Floeth
- Department of NeurosurgeryHeinrich Heine UniversityDüsseldorfGermany
| | | | | | - Sven Oliver Eicker
- Department of NeurosurgeryHeinrich Heine UniversityDüsseldorfGermany
- Department of NeurosurgeryUniversity Hospital Hamburg‐EppendorfHamburgGermany
| |
Collapse
|
24
|
Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, Lee N, Machens A, Moley JF, Pacini F, Raue F, Frank-Raue K, Robinson B, Rosenthal MS, Santoro M, Schlumberger M, Shah M, Waguespack SG. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015; 25:567-610. [PMID: 25810047 PMCID: PMC4490627 DOI: 10.1089/thy.2014.0335] [Citation(s) in RCA: 1259] [Impact Index Per Article: 139.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The American Thyroid Association appointed a Task Force of experts to revise the original Medullary Thyroid Carcinoma: Management Guidelines of the American Thyroid Association. METHODS The Task Force identified relevant articles using a systematic PubMed search, supplemented with additional published materials, and then created evidence-based recommendations, which were set in categories using criteria adapted from the United States Preventive Services Task Force Agency for Healthcare Research and Quality. The original guidelines provided abundant source material and an excellent organizational structure that served as the basis for the current revised document. RESULTS The revised guidelines are focused primarily on the diagnosis and treatment of patients with sporadic medullary thyroid carcinoma (MTC) and hereditary MTC. CONCLUSIONS The Task Force developed 67 evidence-based recommendations to assist clinicians in the care of patients with MTC. The Task Force considers the recommendations to represent current, rational, and optimal medical practice.
Collapse
Affiliation(s)
- Samuel A. Wells
- Genetics Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sylvia L. Asa
- Department of Pathology, University Health Network, and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Henning Dralle
- Department of General, Visceral, and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Rossella Elisei
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - Douglas B. Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert F. Gagel
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andreas Machens
- Department of General, Visceral, and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Jeffrey F. Moley
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Furio Pacini
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Endocrinology and Metabolism and Biochemistry, University of Siena, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Friedhelm Raue
- Endocrine Practice, Moleculargenetic Laboratory, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Karin Frank-Raue
- Endocrine Practice, Moleculargenetic Laboratory, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Bruce Robinson
- University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - M. Sara Rosenthal
- Departments of Internal Medicine, Pediatrics and Behavioral Science, University of Kentucky, Lexington, Kentucky
| | - Massimo Santoro
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Universita' di Napoli “Federico II,” Napoli, Italy
| | - Martin Schlumberger
- Institut Gustave Roussy, Service de Medecine Nucleaire, Université of Paris-Sud, Villejuif, France
| | - Manisha Shah
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
25
|
Abstract
After surgery, patients with medullary thyroid carcinoma (MTC) should be assessed regarding the presence of residual disease, the localization of metastases, and the identification of progressive disease. Postoperatively, patients with MTC are staged to separate those at low risk from those at high risk of recurrence. The TNM staging system is based on tumor size, extra-thyroidal invasion, nodal metastasis, and distant spread of cancer. In addition, the number of lymph-node metastases, the number of compartments involved, and the postoperative calcitonin (CTN) and carcinoembryonic antigen (CEA) levels should be documented. The postoperative normalization of the serum CTN level is associated with a favorable outcome. When patients have basal serum CTN levels less than 150 pg/ml after a thyroidectomy, any persistent or recurrent disease is nearly always confined to lymph nodes in the neck. When the postoperative serum CTN level exceeds 150 pg/ml, patients should be evaluated with imaging procedures, including computed tomography (CT) of the neck and chest, contrast-enhanced magnetic resonance imaging (MRI) and ultrasound (US) of the liver, bone scintigraphy, MRI of the bone, and positron emission tomography (PET)/CT. One can estimate the growth rate of MTC metastases by quantifying increases in tumor size over time from sequential imaging studies analyzed with response evaluation criteria in solid tumors (RECIST), and by determining the tumor marker doubling time from sequential measures of serum CTN or CEA levels over multiple time points. One of the main challenges remains to find effective adjuvant and palliative options for patients with metastatic disease. Patients with persistent or recurrent MTC localized to the neck following thyroidectomy are candidates for neck operations, depending on the tumor extension. Once metastases appear, the clinician must decide which patients require therapy. This requires a balance between the (often) slow rate of tumor progression, which is associated with a good quality of life, and the limited efficacy and potential toxicities of local and systemic therapies. Considering that metastatic MTC is incurable, the management goals are to provide loco-regional disease control, palliate symptoms of hormonal excess, such as diarrhea, palliate symptomatic metastases, like pain or bone fracture, and control metastases that threaten life, such as bronchial obstruction or spinal cord compression. This can be achieved with palliative surgery, external beam radiation therapy (EBRT), or systemic therapy with tyrosine kinase inhibitor (TKI).
Collapse
Affiliation(s)
- Friedhelm Raue
- Endokrinologische Gemeinschaftspraxis, Brückenstr. 21, 69120, Heidelberg, Germany.
| | - Karin Frank-Raue
- Endokrinologische Gemeinschaftspraxis, Brückenstr. 21, 69120, Heidelberg, Germany
| |
Collapse
|
26
|
Abstract
Medullary thyroid carcinoma is uncommon but accounts for approximately 4 to 5 per cent of all thyroid cancers. Although most cases are sporadic, close to one-fourth of cases result from germline mutations in the RET proto-oncogene. These mutations are clinically important because they predict the earliest age of medullary thyroid cancer diagnosis and clinical aggressiveness, which guide individualized management. This review covers the presentation, diagnosis, workup, current management, and future directions of the management of medullary thyroid carcinoma. Today's chance for cure depends on early and appropriate surgical resection. Further investigation of the cellular signaling pathways shown to be essential for the growth and spread of medullary thyroid carcinoma remains an active field with hope for providing targeted systemic therapy for patients with progressive disease.
Collapse
Affiliation(s)
- Faris K. Azar
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland; the
| | - Stephanie L. Lee
- Department of Medicine, Boston University, Boston, Massachusetts; and the
| | - Jennifer E. Rosen
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
27
|
Abstract
PURPOSE OF REVIEW The role of external beam radiation therapy (EBRT) in the management of thyroid cancer is not clearly defined. In the absence of randomized studies, the review aims to identify any recent literature that helps define the role. RECENT FINDINGS In differentiated thyroid cancer, single institutional studies report durable locoregional disease control in patients considered to be at high risk of local relapse after EBRT and recent guidelines are consistent in their recommendations. In medullary thyroid cancer, the evidence is more limited but again there is benefit in selected cases. In anaplastic thyroid cancer, multimodality therapy is superior to surgery alone in achieving local control and possibly survival but the benefit must be weighed against the toxicity. Newer radiation techniques may help reduce toxicity. SUMMARY Although surgery is the main treatment for thyroid carcinoma, EBRT has a role in the adjuvant setting following surgery in high-risk patients and in unresectable cancer. Advances in the delivery of external beam radiotherapy, including intensity-modulated radiotherapy reduces toxicity.
Collapse
|
28
|
Maxwell JE, Sherman SK, O'Dorisio TM, Howe JR. Medical management of metastatic medullary thyroid cancer. Cancer 2014; 120:3287-301. [PMID: 24942936 DOI: 10.1002/cncr.28858] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/02/2014] [Accepted: 05/07/2014] [Indexed: 12/21/2022]
Abstract
Medullary thyroid cancer (MTC) is an aggressive form of thyroid cancer that occurs in both heritable and sporadic forms. Discovery that mutations in the rearranged during transfection (RET) proto-oncogene predispose to familial cases of this disease has allowed for presymptomatic identification of gene carriers and prophylactic surgery to improve the prognosis of these patients. A significant number of patients with the sporadic type of MTC and even those with familial disease still present with lymph node or distant metastases, making surgical cure difficult. Over the past several decades, many different types of therapy for metastatic disease have been attempted with limited success. Improved understanding of the molecular defects and pathways involved in both familial and sporadic MTC has resulted in new hope for these patients with the development of drugs targeting the specific alterations responsible. This new era of targeted therapy with kinase inhibitors represents a significant step forward from previous trials of chemotherapy, radiotherapy, and hormone therapy. Although much progress has been made, additional agents and strategies are needed to achieve durable, long-term responses in patients with metastatic MTC. This article reviews the history and results of medical management for metastatic MTC from the early 1970s up until the present day.
Collapse
Affiliation(s)
- Jessica E Maxwell
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | | |
Collapse
|
29
|
Colombo JR, Wein RO. Cabozantinib for progressive metastatic medullary thyroid cancer: a review. Ther Clin Risk Manag 2014; 10:395-404. [PMID: 24920914 PMCID: PMC4043815 DOI: 10.2147/tcrm.s46041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Medullary thyroid cancer is uncommon and patients typically present with advanced disease. Treatment options for patients with progressive, metastatic medullary thyroid cancer had been limited until recently. Tyrosine kinase inhibitors have garnered increasing interest in this subset of patients. The US Food and Drug Administration recently approved cabozantinib, a tyrosine kinase inhibitor, after promising results were shown in a large Phase III clinical trial. This review summarizes the clinical pharmacology, clinical trials, and safety data for cabozantinib and concludes with a discussion of possible future directions for the treatment of medullary thyroid cancer.
Collapse
Affiliation(s)
- Joshua R Colombo
- Department of Otolaryngology, Head and Neck Surgery, Tufts Medical Center, Boston, MA, USA
| | - Richard O Wein
- Department of Otolaryngology, Head and Neck Surgery, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
30
|
Sokouti M, Montazeri V, Fakhrjou A, Samankan S, Goldust M. Thyroid cancer, clinical and hystopathological study on patients under 25 years in Tabriz, Iran (2000-2012). Pak J Biol Sci 2014; 16:2003-8. [PMID: 24517019 DOI: 10.3923/pjbs.2013.2003.2008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thyroid cancer comprises a broad spectrum of diseases with variable prognoses. The aim of this study was to assess thyroid cancer in young population using the surveillance, epidemiology and end results database and whether radioactive fallout from the Chernobyl accident in 1986 influenced thyroid cancer incidence among children and adolescents in Tabriz, Iran. Patients aged 5-25 in Tabriz from April 2000 to April 2012 were studied. Using the surveillance and end results database, the study examined the overall incidence of thyroid cancer with variations based on tumor pathology, size and stage, as well as the current surgical therapy of thyroid carcinoma. This study demonstrated a positive correlation between thyroid carcinoma tumor size and stage of disease. Mortality rates were higher among men than women. Recurrence rates are also higher in men. Compared with women, men have greater likelihood ofloco regional lymph node involvement and more than twice the rate of distant metastases. Operative treatment for thyroid cancer also has shifted with Radical dissection+Total thyroidectomy replacing partial thyroidectomy as the most common surgical procedure. Our data indicate that the increasing incidence of thyroid cancer cannot be accounted for fully by an increased detection of small neoplasms. This study show the increasing in thyroid cancer incidence related to exposure to radiation from the Chernobyl accident.
Collapse
|
31
|
Jin J, Phitayakorn R, Wilhelm SM, McHenry CR. Advances in management of thyroid cancer. Curr Probl Surg 2013; 50:241-89. [DOI: 10.1067/j.cpsurg.2013.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
32
|
Indications of external beam radiation therapy in non-anaplastic thyroid cancer and impact of innovative radiation techniques. Crit Rev Oncol Hematol 2013; 86:52-68. [DOI: 10.1016/j.critrevonc.2012.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 08/13/2012] [Accepted: 09/25/2012] [Indexed: 11/23/2022] Open
|
33
|
Strosberg JR. Update on the Management of Unusual Neuroendocrine Tumors: Pheochromocytoma and Paraganglioma, Medullary Thyroid Cancer and Adrenocortical Carcinoma. Semin Oncol 2013; 40:120-33. [DOI: 10.1053/j.seminoncol.2012.11.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
34
|
Abstract
INTRODUCTION Patients with advanced medullary thyroid cancer (MTC) have poor prognoses and limited treatment options. Improved knowledge about molecular aberrations associated with MTC and the availability of novel targeted tyrosine kinase inhibitors (TKIs) have led to new potential treatment modalities. Cabozantinib is an oral multitargeted TKI with activity against multiple receptors including RET, vascular endothelial growth factor receptor type 2 (VEGFR2), and MET that has been evaluated in MTC in the preclinical and clinical arenas. METHODS This article reviews unmet clinical needs in advanced MTC. The authors consider novel agents that have been studied in MTC, with a focus on the investigational agent cabozantinib. Up-to-date clinical data of cabozantinib in MTC are discussed. RESULTS Recent clinical evaluation suggests that cabozantinib is the first agent to prolong progression-free survival in patients with progressive MTC. These findings indicate that cabozantinib may be an effective therapy in advanced MTC. No improvement in overall survival has been demonstrated but data are not mature. CONCLUSION Cabozantinib may be an effective treatment option for patients with advanced MTC and is worthy of further evaluation.
Collapse
|
35
|
Medullary Thyroid Cancer—Current Treatment Strategy, Novel Therapies and Perspectives for the Future. Discov Oncol 2012; 3:218-26. [DOI: 10.1007/s12672-012-0119-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/16/2012] [Indexed: 02/06/2023] Open
|
36
|
Park HS, Gross CP, Makarov DV, Yu JB. Immortal Time Bias: A Frequently Unrecognized Threat to Validity in the Evaluation of Postoperative Radiotherapy. Int J Radiat Oncol Biol Phys 2012; 83:1365-73. [DOI: 10.1016/j.ijrobp.2011.10.025] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 10/09/2011] [Accepted: 10/10/2011] [Indexed: 12/23/2022]
|
37
|
How has the management of medullary thyroid carcinoma changed with the advent of 18F-FDG and non-18F-FDG PET radiopharmaceuticals. Nucl Med Commun 2012; 33:679-88. [DOI: 10.1097/mnm.0b013e3283529bf7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
38
|
|
39
|
Current world literature. Curr Opin Endocrinol Diabetes Obes 2011; 18:336-8. [PMID: 21878756 DOI: 10.1097/med.0b013e32834ba6ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
40
|
Abstract
Surgery is the mainstay of treatment for thyroid cancer. The role for external beam radiotherapy (EBRT) as an adjuvant to surgery or as the primary therapy is established in anaplastic thyroid cancer but is controversial in differentiated thyroid cancer and uncertain in medullary thyroid cancer. This update reviews the recent reported success of combining EBRT with taxanes in anaplastic thyroid cancer. Also discussed are the recent reports from large single institutions that support the recommendations of the American and British Thyroid Associations on the use of EBRT in high-risk differentiated thyroid cancer. Further evidence on the role of EBRT in MTC is discussed. The important advances in the delivery of EBRT using intensity-modulated radiation and image-guided radiation that result in more accurate and potentially more effective radiation therapy with less toxicity are also discussed.
Collapse
Affiliation(s)
- James D Brierley
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada.
| |
Collapse
|