Lateral neck recurrence from papillary thyroid carcinoma: Predictive factors and prognostic significance

The frequency of risk pathological characteristics in clinically low-risk papillary thyroid microcarcinoma suitable for active surveillance

PURPOSE

Active surveillance has emerged as an initial management strategy for patients with low-risk papillary thyroid microcarcinoma (PTMC). The main objective of this research was to investigate the frequency of risk pathological characteristics among patients with clinically low-risk PTMC who are suitable for Active Surveillance.

METHODS

A retrospective review was conducted on patients who underwent lobectomy for PTMC between January 2013 and December 2018. Patients with bilateral tumors, macroscopic multifocal tumors, macroscopic extrathyroidal extension (ETE), clinical lymph node metastases, macroscopic extranodal extension (ENE), distant metastases, a history of neck radiation or familial thyroid cancer were excluded. Pathological characteristics were collected from the postoperative pathological results. Aggressive variants, multifocality, ETE, lymphovascular invasion (LVI), perineural invasion (PNI), metastatic lymph nodes (LNs) ≥ 5, and ENE were defined as risk characteristics.

RESULTS

The study included 4923 patients, of whom 1229 (25.0%) were male. The mean age was 43 years. A total of 2250 patients (45.7%) exhibited risk characteristics. Among them, 15 patients presented with aggressive variants, and 1813 patients (36.8%) had ETE. Multifocality, LVI, and PNI were observed in 551 (11.2%), 21 (0.4%), and 40 (0.8%) patients, respectively. A total of 139 patients (2.8%) had five or more metastatic LNs, and ENE was identified in 140 patients. Notably, 172 patients (3.5%) fulfilled the criteria for completion thyroidectomy, as they had aggressive variants, LVI, or five or more metastatic LNs.

CONCLUSIONS

Nearly half of the patients diagnosed with clinically low-risk PTMC exhibited risk pathological characteristics, and a small proportion of patients met the criteria for completion thyroidectomy.

In search of new stratification strategies: tissue proteomic profiling of papillary thyroid microcarcinoma in patients with localized disease and lateral neck metastases

INTRODUCTION

Papillary thyroid carcinomas (PTC) are the most common thyroid malignancies that are often diagnosed as microcarcinomas when the tumor is less than one centimetre in diameter. Currently, there are no valid stratification strategies that would reliably assess the risk of lateral neck metastases and optimize surgical treatment.

MATERIALS AND METHODS

Aiming to find potential tissue biomarkers of metastatic potential, we conducted a cross-sectional proteomic pilot study on formalin-fixed paraffin-embedded tissues of metastatic (N = 10) and non-metastatic (N = 10) papillary thyroid microcarcinoma patients. Samples were analysed individually using liquid chromatography/mass spectrometry, and the differentially expressed proteins (DEP) were functionally annotated.

RESULTS

We identified five overexpressed DEPs in the metastatic group (EPB41L2, CSE1L, GLIPR2, FGA and FGG) with a known association to tumour biology. Using bioinformatic-based tools, we found markedly different profiles of significantly enriched biological processes between the two groups.

CONCLUSIONS

The identified DEPs might have a role as potential tissue biomarkers for PTC metastases. However, further prospective research is needed to confirm our findings.

Risk factors and predictive model for recurrence in papillary thyroid carcinoma: a single-center retrospective cohort study based on 955 cases

Background

The 2015 American Thyroid Association guidelines proposed recurrence risk stratification of differentiated thyroid carcinoma, including papillary thyroid carcinoma (PTC), but this stratification excluded non-initial treatment patients with worse outcomes. This study aimed to explore the potential risk factors for recurrence in PTC and develop a predictive model for both initial and non-initial treatment of patients with PTC.

Methods

A total of 955 patients were included in this study. Differences between the recurrence (-) and recurrence (+) groups were compared. The 955 patients were randomized into two groups: the training group (671 cases) and the validation group (284 cases). All variables were selected using the LASSO regression analysis. A nomogram was developed based on the results of the univariate and multivariate logistic regression analyses. The nomogram performance was evaluated using discrimination and calibration.

Results

Patients aged ≥55 years, extranodal extension (ENE), metastatic LN ratio (LNR) >0.5, and non-initial treatment were identified as potential risk factors for recurrence through LASSO regression and univariate and multivariate analyses. The receiver operating characteristic curve (ROC curve) showed high efficiency, with an area under the ROC curve (AUC) of 0.819 (95% confidence interval [CI], 0.729-0.909) and 0.818 (95% CI, 0.670-0.909) in the training and validation groups, respectively. The calibration curve indicated that the nomogram had a good consistency.

Conclusion

In patients with PTC, age ≥55 years, ENE, LNR >0.5, and non-initial treatment are potential risk factors for recurrence. The predictive model of recurrence was confirmed to be a practical and convenient tool for clinicians to accurately predict PTC recurrence.

Study to Evaluate the Pattern of Nodal Distribution in Papillary Thyroid Cancer

Among the thyroid cancers, papillary thyroid cancer (PTC) is the most common with lymphatic metastasis. It has the propensity to spread to the level II-VI lymph nodes in a predictable manner. We evaluated the pattern of nodal distribution at different levels of neck in papillary thyroid cancer in this Observational Prospective study. Total 41 patients of PTC (Papillary thyroid cancer) were included in the study. 36 out of them were diagnosed as PTC by FNAC and underwent total thyroidectomy and central neck dissection, while 5 patients were histologically confirmed cases of PTC on previous hemithyroidectomy and underwent completion thyroidectomy and central neck dissection .Patients with T3/T4 stage or N1 underwent lateral neck dissection also. Clinicopathological factors such as age, sex, tumor stage, nodal metastasis and extracapsular invasion, were evaluated. Lymph node metastasis was noted in 21 patients (51.2%) and all these patients had central (level VI) lymph node involvement. Among 21 patients, pathological ipsilateral lateral neck metastasis was noted in 6 patients (28.57%) at level II, 10 patients (47.62%) at level III and 8 patients (38.10%) at level IV. Only 5 patients (23.81%) had metastasis at level V. Extracapsular invasion was observed in 10 (24.4%) patients. We concluded that patients with PTC show higher rates of metastasis at central neck (level VI) and are not easily detected on clinical examination or by USG due to low sensitivity but are sensitive and specific for lateral neck nodes in late stages . Thus, ipsilateral selective neck dissection should be considered with total thyroidectomy and central neck dissection in presence of clinically or radiologically evident lateral lymph nodes (preoperatively) and in T3, T4 stage (late stages) tumors.

A retrospective study of factors affecting contralateral central-neck lymph node metastasis in unilateral papillary thyroid carcinoma

BACKGROUND

In 30-40% of papillary thyroid cancer patients, central neck lymph node metastasis occurs. As a result, prophylactic central neck lymph node dissection is performed. The extent of lymph node dissection and prophylactic central neck lymph node dissection is still debatable. The incidence of central neck lymph node metastasis and related factors were investigated in this study, and also the necessity of both central neck lymph node dissections.

METHODS

Between December 2017 and December 2019, 482 patients had thyroidectomy at Pusan National University Yangsan Hospital. A retrospective study of 186 patients who had a thyroidectomy with bilateral central neck lymph node dissection for unilateral thyroid carcinoma was done.

RESULTS

Ipsilateral and contralateral central neck lymph node metastasis were identified in 40.9% (76/186) and 19.3% (36/186), respectively. Male (p < 0.001), tumor size >1 cm (p = 0.047), extrathyroidal extension (p = 0.002), central neck lymph node metastases >5 (p < 0.001), lateral neck lymph node metastasis (p = 0.012), and ipsilateral central neck lymph node metastasis (p < 0.001) were associated with the contralateral central neck lymph node metastasis in univariate analysis. In a multivariate analysis, extrathyroidal extension (OR, 3.664), more than 5 central neck lymph node metastases (OR, 29.667), ipsilateral central neck lymph node metastasis (OR, 3.911), and male (OR, 5.890) were related to contralateral central neck lymph node metastasis.

CONCLUSION

Male, extrathyroidal extension, and ipsilateral central neck lymph node metastasis may be considered for contralateral prophylactic central neck lymph node dissection. In the future, it is thought that more research on the recurrence rate will be required.

A nomogram for predicting lateral lymph node metastasis in cN0 unifocal papillary thyroid microcarcinoma

BACKGROUND

Identifying risk factors for occult lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC) can provide valuable insights into the necessity of lateral neck dissection (LND). The objective of this study was to develop a nomogram for predicting the probability of LLNM in patients with cN0 unifocal PTMC.

METHODS

We conducted a retrospective analyzed a total of 4872 patients with cN0 unifocal PTMC who were treated at our center from January 2013 to June 2018. Logistic regression analysis was used to determine the risk factors for LLNM, and a nomogram was constructed based on these risk factors.

RESULTS

The rate of LLNM was 3.2%. Tumors located in the upper lobe(odds ratio [OR] = 2.56, 95% confidence interval [CI] 1.80-3.62; p < 0.001) and size greater than 7 mm (OR = 2.59, 95% CI 1.85-3.62; p < 0.001) had a significantly higher risk of LLNM compared to tumors in the lower or middle lobe and size less than or equal to 7 mm. Tumors with extrathyroidal extension (ETE) had a significantly higher risk of LLNM (OR = 1.41, 95% CI 1.01-1.99; p = 0.044). The presence of three or more central lymph node metastases (CLNMs) (OR = 5.84, 95% CI 3.83-8.93; p < 0.001) or one or two CLNMs (OR = 2.91, 95% CI 1.93-4.42; p < 0.001) also increased the risk of LLNM compared to having no CLNMs. A nomogram incorporating these risk factors was developed, and the receiver operating characteristic (ROC) curve demonstrated an area under the curve (AUC) of 0.777, indicating a high degree of predictive accuracy.

CONCLUSION

Tumor location in the upper lobe, greater than 7 mm in size, ETE, and CLNMs, especially three or more, were independent risk factors for LLNM in cN0 unifocal PTMC. The nomogram based on these factors exhibited favorable predictive value and consistency.

Risk stratification of lateral neck recurrence for patients with pN1a papillary thyroid cancer

BACKGROUND

Lateral neck is not recommended for dissection in patients with pN1a papillary thyroid cancer (PTC), but its recurrence risk has not been well stratified. We aimed to develop a risk stratification system for lateral neck recurrence in patients with pN1a PTC.

METHODS

Patients with pN1a PTC who underwent thyroidectomy and unilateral central compartment dissection from 2000-2016 were enrolled. The association between number of central lymph node metastases (CLNMs) and lateral neck recurrence was comprehensively assessed using a Cox proportional hazards model with restricted cubic spline. Stratification was then performed based on CLNMs and other significant risk factors selected by multivariate analysis. Lateral neck recurrent-free survival (LRFS) rate of each stratification was estimated with Kaplan-Meier curve and comparison was performed using log-rank test.

RESULTS

Ninety-six (3.8%) lateral neck recurrences were identified during a median follow-up of 62 months among a total of 2500 admitted cases. An increasing number of CLNMs was associated with compromised LRFS for up to 6 CLNMs (P < 0.001), and CLNMs > 3 indicated significantly worse 5-year LRFS than that of CLNM ≤ 3 (90.6% vs. 98.1%, P < 0.001). When stratification with CLNMs and primary tumor size (selected by multivariate analysis, HR (95%CI) = 4.225(2.460-7.256), P < 0.001), 5-year LRFS rates of high- (CLNMs > 3 and primary tumor size > 2 cm), intermediate- (CLNMs > 3 and primary tumor size 1-2 cm) and low-risk (primary tumor size ≤ 1 cm or CLNMs ≤ 3) groups were 78.5%, 90.0% and 97.9%, respectively (P < 0.05).

CONCLUSIONS

The number of CLNMs combined with primary tumor size seems to effectively stratify lateral neck recurrence risk for patients with pN1a PTC.

LINC00958/miR-627 signal axis regulates the proliferation, migration, and invasion of thyroid papillary carcinoma cells by TRIM44

Papillary thyroid cancer (PTC) has attracted much attention due to its high morbidity and severe metastasis. Long noncoding RNA ENST00000504230 (LncRNA ENST00000504230, known as LINC00958) was overexpressed in many cancers and associated with cancer development. However, its underlying mechanism in PTC remains unclear. PTC tissues and corresponding adjacent tissues were collected for measuring the expression of LINC00958 and miR-627. MiR-627 and TRIM44 expressions were measured in in vitro cultured PTC cell lines (B-cpap and IHH4 cells) transfected with sh-LINC00958 or miR-627 mimic using RT-qPCR and western blot. Cell proliferation, migration, and invasion were measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) and Transwell assays, respectively. Dual-luciferase reporter assay was performed to evaluate the target association between miR-627 and TRIM44. LINC00958 was up-regulated in PTC tissues and cells, while the expression of miR-627 was lowly expressed. Knockdown of LINC00958 inhibited the proliferation, migration, and invasion by elevating miR-627 expression in PTC cells. TRIM44 was confirmed as a target of miR-627. Overexpression of miR-627 in PTC inhibited the proliferation, migration, and invasion by down-regulating the expression of TRIM44. LINC00958 promoted proliferation, migration, and invasion in PTC by down-regulating miR-627 and activating TRIM44, indicating the potential therapeutic effect of LINC00958 on PTC.

Combined role of lymph node ratio and serum thyroglobulin levels in predicting prognosis of papillary thyroid carcinoma

OBJECTIVES

The aim of this study was to evaluate a prognostic value of the extent of metastatic lymph node combined with TSH-stimulated serum thyroglobulin (sTg) measured just before radioactive iodine (RAI) therapy in patients with papillary thyroid cancer (PTC).

METHODS

The retrospective study included 468 patients with PTC who underwent total thyroidectomy with neck dissection and postoperative RAI therapy. The extent of metastatic lymph node was evaluated with the lymph node ratio (LNR) which was defined as the number of metastatic lymph nodes out of the number of total removed lymph nodes. We investigated which factors could significantly predict persistent or recurrent disease (PRD).

RESULTS

LNR ≥0.4 (P = 0.002) and sTg ≥6.0 ng/mL (P < 0.001) were associated with PRD in univariate analysis. In multivariate analysis, only male [hazard ratio: 2.35, 95% confidence interval (CI): 1.18-4.66, P = 0.014] and sTg (hazard ratio: 9.35, 95% CI: 4.44-19.67, P < 0.001) were associated with PRD prediction. When we divided patients into two groups (patients with sTg level < 6.0 ng/mL and those with sTg level ≥ 6.0 ng/mL), LNR (≥0.4) was a significant predictor of PRD in patients with sTg <6.0 ng/mL (hazard ratio: 4.38, 95% CI: 1.22-15.72, P = 0.024).

CONCLUSIONS

LNR ≥0.4 was a significant predictor of PRD when the sTg level was <6.0 ng/mL. LNR should be used in combination with a relatively low level of serum sTg to predict the prognosis of patients with PTC.

Blood-Rich Enhancement in Ultrasonography Predicts Worse Prognosis in Patients With Papillary Thyroid Cancer

Contrast-enhanced ultrasound (CEUS) can be used to evaluate microcirculation in cancers, which in turn is associated with the biologic features and ultimately patient prognosis. We conducted a retrospective analysis to examine potential association between CEUS parameters and prognosis in patients with papillary thyroid cancer (PTC). The analysis included 306 patients who underwent CEUS prior to thyroidectomy at our center during a period from 2012 to 2019. Subjects with excellent response (ER) were compared to the non-ER group (including indeterminate response, biochemical incomplete response and structural incomplete response). During the median follow-up of 34 months, ER was observed in 195 (63.7%) subjects. The remaining 111 (36.3%) patients developed non-ER events, with distant metastasis in five (1.6%) cases. In a multivariate COX regression, non-ER event was associated with the male sex (OR = 1.83, 95%CI: 1.21-2.76) and blood-rich enhancement in CEUS (OR = 1.69, 95%CI: 1.04-2.75). Based on this finding, we developed a predictive model: high risk for developing non-ER events was defined as having both risk factors; low risk was defined as having none or only one risk. In receiver operating characteristic (ROC) analysis, the area under the curve was 0.59 (95%CI: 0.52-0.66). The sensitivity and specificity were 17.1 and 95.4%, respectively. The positive and negative predictive values were 67.9 and 66.9%, respectively. In conclusion, blood-rich enhancement in CEUS is associated with non-ER events after thyroidectomy in patients with PTC.

De-differentiation of papillary thyroid carcinoma into squamous cell carcinoma in an elderly patient: A case report

RATIONALE

The unpredictability of thyroid cancer can be striking, as the disease may rapidly progress to death in some individuals. Herein, we reported a rare case of aggressive papillary thyroid cell carcinoma (PTC) in an elderly patient de-differentiated into squamous cell carcinoma (SCC).

PATIENT CONCERNS

We describe a case of a 79-year-old Thai woman presented with hoarseness and neck mass for 2 months and she had been diagnosed with a 3-cm papillary thyroid carcinoma (PTC) in the right side of the thyroid gland. Later on PTC de-differentiated into SCC within 3 years after initial presentation.

DIAGNOSIS

De-differentiation from papillary thyroid carcinoma to squamous cell carcinoma.

INTERVENTIONS

The patient underwent a total thyroidectomy at the initial hospital and received high dose radioactive iodine (RAI) treatment at our hospital 1 month following the surgery and then was lost to follow-up. Two years later she came back with new development of right solid-cystic neck mass which was found to be recurrent PTC. A radical neck dissection was done and another high dose RAI treatment was given. However, she developed recurrent mass with tenderness at the site above previous solid cystic mass 6 months later. Re-exploration of the neck mass revealed an inflamed midline mass 2 cm with enlarged right lateral cervical lymph nodes.

OUTCOMES

A histopathological examination of the midline neck mass showed poorly differentiated SCC with lymphatic invasion. The intermingling of two morphologically distinct tumors, a typical PTC and a poorly differentiated SCC, had been identified in 1 out of 14 excised cervical lymph nodes. The patient underwent external beam radiation without chemotherapy. She is still in stable condition at 18 months post-treatment.

LESSONS

This case clearly demonstrated that SCC transformed from a pre-existing PTC. The clinician should consider a possible transformation of papillary thyroid cancer into more aggressive histological types in elderly patients who present with rapidly progressive clinical behavior. However, some patients could have long-term survival if the tumor did not transform into anaplastic thyroid cancer.

Routine Prophylactic Central Neck Dissection May Not Obviously Reduce Lateral Neck Recurrence for Papillary Thyroid Microcarcinoma

BACKGROUND

The role of routine prophylactic central compartment neck dissection (pCCND) for papillary thyroid microcarcinoma (PTMC) remains controversial. The lateral neck recurrence-free survival (LRFS) advantages achieved by pCCND are still under investigation.

METHODS

The records of 2,074 consecutive patients with papillary thyroid carcinoma (PTC) at the time of surgery from 1996 to 2009 were retrospectively reviewed. A total of 611 consecutive patients were included in the final analyses. We used R version 3.5.1 to match patients with total thyroidectomy (TT)/lobectomy + pCCND with patients with TT/lobectomy alone and analyzed the following factors with a potential influence: age at diagnosis, sex, extrathyroid extension, and primary tumor multifocality and bilaterality. LRFS was analyzed. Moreover, the data were reanalyzed after separating the pairs of patients with pN1a from those with pN0.

RESULTS

We were able to select 159 pairs sharing the major prognostic risk factors as listed. Overall, there was no difference in the LRFS, although patients with pCCND more often had recurrence. Moreover, the central lymph node metastasis status had no significant influence on the risk of recurrence.

CONCLUSION

Routine pCCND was not a protective factor for LRFS in PTMC patients with cN0. The difference in LRFS between pN0 and pN1a was not statistically significant (p > 0.05).

Role of P53, E-cadherin and BRAF as predictors of regional nodal recurrence for papillary thyroid cancer

BACKGROUND

Regional nodal recurrence (RNR) in patients diagnosed with papillary thyroid carcinoma (PTC) has increased. Variable immunohistochemical (IHC) markers have been studied for predicting the likelihood of PTC for recurrence. We aimed to clarify the IHC expression of p53, Ecadherin and BRAF as potential markers of RNR in PTC.

METHOD

145 (73 study group and 72 control group) patients with PTC were analyzed retrospectively between January 2010 and June 2017. Further classification to a specific histological variant was done, and IHC expression of p53, Ecadherin and BRAF was analyzed both in the primary tumor and in nodal recurrence.

RESULTS

Regarding the risk of RNR, we found certain clinicopathologic features as elder age ≥55 years, tumor size >1 cm, presence of microscopic extrathyroid extension, presence of lymphovascular emboli, and conventional papillary subtype. Furthermore, IHC results for negative E-cadherin, and positive P53 and BRAF are significant risk factors, while radioactive iodine (RAI) adjuvant therapy decrease recurrence risk.

CONCLUSION

We found several risk factors for RNR in PTC diagnosed patients, all of which are easily achievable in clinical settings. In this regard, we suggested that patients with specific clinicopathologic and immunohistochemical features have strict follow up for early detection of RNR as it has a great impact on their survival.

Individual prediction of lateral neck metastasis risk in patients with unifocal papillary thyroid carcinoma

INTRODUCTION

Much controversy exists over whether to perform lateral neck dissection (LND) on patients with papillary thyroid carcinoma (PTC). This study aimed to build predictive nomograms that could individually estimate lateral neck metastasis (LNM) risk and help determine follow up intensity.

PATIENTS AND METHODS

Unifocal PTC patients who underwent LND between April 2012 and August 2014 were identified. Clinical and pathological variables were retrospectively evaluated using univariate and stepwise multivariate logistic regression analysis. Variables that had statistical significance in final multivariate logistic models were chosen to build nomograms, which were further corrected using the bootstrap resampling method.

RESULTS

In all, 505 PTC patients were eligible for analysis. Among these, 178 patients (35.2%) had lateral neck metastasis. Two nomograms were generated: nomogram (c) and nomogram (c + p). Nomogram (c) incorporated four clinical variables: age, tumor size, tumor site, and extrathyroidal extension (ETE). It had a good discriminative ability, with a C-index of 0.79 (bootstrap-corrected, 0.78). Nomogram (c + p) incorporated two clinical variables and two pathological variables: tumor size, tumor site, extranodal extension (ENE), and number of positive nodes in the central compartment. Nomogram (c + p) showed an excellent discriminative ability, with a C-index of 0.86 (bootstrap-corrected, 0.85).

CONCLUSION

Two predictive nomograms were generated. Nomogram (c) is a clinical model, whereas nomogram (c + p) is a clinicopathological model. Each nomogram incorporates only four variables and can give an accurate estimate of LNM risk in unifocal PTC patients, which may assist clinicians in patient counseling and decision making regarding LND.

Risk factors of lateral lymph node metastasis in cN0 papillary thyroid carcinoma

Background

Cervical lymph node metastasis of papillary thyroid carcinoma (PTC) is common. However, whether undergoing prophylactic central lymph node (CLN) dissection or lateral lymph node (LLN) dissections to prevent metastasis is still controversial. This study aimed to retrospectively investigate the risk factors of LLN metastasis in clinical lymph node-negative (cN0) PTC patients.

Methods

We retrospectively studied 783 lymph node-negative (cN0) PTC patients who underwent total thyroidectomy plus CLN dissection and LLN dissection.

Results

The rates of CLN and LLN metastases were 68.2 and 47.4%, respectively. Large tumor size (> 20 mm) had a fourfold higher risk of LLN metastasis compared with small tumor size (≤ 20 mm; OR = 4.082, 95% CI 2.646–6.289; P = 0.001). Patients with tumor in the upper lobe had ~ 3-fold higher risk of LLN metastasis compared with patients with tumor in other locations (OR = 2.874, 95% CI 1.916–4.310; P = 0.001). Multifocality and extrathyroidal extension indicated a twofold higher risk of LLN metastasis. Having ≥ 2 CLN metastases dramatically increased the risk of LLN metastasis, compared with those with < 2 CLN metastases (OR = 6.536, 95% CI 4.630–9.259; P = 0.001).

Conclusions

Large tumor size (> 20 mm), tumor located in the upper lobe, multifocality, extrathyroidal extension, and ≥ 2 CLN metastases may increase the risk of LLN metastasis in cN0 PTC patients.

Long-term outcomes of central neck dissection for cN0 papillary thyroid carcinoma

OBJECTIVE

The risk-benefit ratio of central neck dissection (CND) in patients affected by papillary thyroid carcinoma (PTC) without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0) is currently debated. The aim of this study was to evaluate long-term outcome of CND on locoregional recurrence, distant metastasis, survival, and postoperative complications in a large series of patients with cN0-PTC.

STUDY DESIGN

Observational retrospective controlled study.

METHODS

Clinical records of patients (n=610) surgically treated for cN0-PTC at the Otolaryngology Unit of the Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy, from January 1984 to December 2008, were retrospectively reviewed. Study population was divided into three groups according to surgical treatment: Group A, total thyroidectomy (n=205); Group B, total thyroidectomy and elective ipsilateral CND (n=281); Group C, total thyroidectomy and bilateral CND (n=124).

RESULTS

Of a total of 610 patients, 305 (50%) were classified as low-risk, 278 (45.57%) as intermediate-risk, and 27 (4.43%) as high-risk. Response to initial therapy was excellent in 567 patients (92.95%), acceptable in 21 (3.44%), and incomplete in 22 (3.61%), with no significant differences among groups. Locoregional recurrence was detected in 32 (5.2%) out of 610 patients. Distant metastasis was found in 15 patients (2.5%). Statistical analysis showed no significant differences in the rates of locoregional recurrence (p=0.890) or distant metastasis (p=0.538) among groups. Disease-specific mortality and overall survival did not significantly differ among groups (p=0.248 and 0.223, respectively). Rate of permanent hypoparathyroidism was significantly higher in Group C patients compared to those in Groups A and B.

CONCLUSION

CND does not confer any clear advantage in the treatment of low-risk patients, regardless of surgical procedure. Instead, bilateral CND may be effective in limiting disease relapse and/or progression in patients at higher prognostic risk. Our data indicate that elective CND does not confer any clear advantage in terms of locoregional recurrence and long-term survival, as demonstrated by outcomes of the study Groups, regardless of their different prognostic risk. Elective CND allows a more accurate pathologic staging of central neck lymph nodes, despite its increasing the risk of permanent hypoparathyroidism. Intraoperative pathologic staging is a valuable tool to assess the risk of controlateral lymph node metastasis in the central neck compartment and to limit more aggressive surgery only to cases, otherwise understaged, with lymph node metastasis.

Values of ultrasound features and MMP-9 of papillary thyroid carcinoma in predicting cervical lymph node metastases

Preoperative assessment of the cervical lymph node status is important in therapeutic schedule and further evaluations of prognosis for papillary thyroid carcinoma (PTC) patients. Our aim was to investigate the diagnostic values of conventional ultrasound (US), contrast-enhanced ultrasound (CEUS) features and the expression of MMP-9 of PTC in predicting the cervical lymph node metastases (LNM). In total, 156 patients with PTC confirmed by surgical pathology were included. Seventy-one patients had cervical LNM, while 85 patients had no LNM. The patients had cervical LNM (39.51 ± 13.29 years) were younger than those had no LNM (44.15 ± 10.94 years) (P = 0.02). Multivariate logistic regression results showed that tumor size ≥0.95 cm (OR = 13.47), ill-defined margin (OR = 4.31), internal heterogeneous low-enhancement (OR = 5.19) and ECE (OR = 25.25) were predictive for the presence of cervical LNM. The detection rate of ECE for the PTC with LNM by CEUS (81.48%, 44/54) was higher than by US (46.30%, 25/54). There was significant difference in MMP-9 intensity between PTC with and without cervical LNM (P = 0.000), and intense reactions (+++) were mainly found in the PTCs with LNM (80.95%, 17/21). In conclusion, the combination of conventional US, CEUS features and MMP-9 expression may serve as an effective tool for predicting the cervical LNM of PTC.

Image-guided high-dose-rate interstitial brachytherapy - a valuable salvage treatment approach for loco-regional recurrence of papillary thyroid cancer

PURPOSE

To report the treatment effect of image-guided high-dose-rate (HDR) interstitial brachytherapy for refractory recurrence of papillary thyroid cancer (PTC).

CASE REPORT

This 66-year-old female presented with recurrence 5 years after thyroidectomy for PTC. Despite external irradiation and radioactive (131)I, the lesion expanded as 3.7 × 3.0 × 2.3 cm(3) and 2.0 × 1.5 × 1.5 cm(3). The locoregional recurrent tumor was treated with image-guided HDR interstitial brachytherapy. The total dose of 30 Gy in 6 fractions were delivered on the whole recurrent tumor.

RESULTS

Removal of the recurrent tumor was securely achieved by HDR interstitial brachytherapy guided with ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) scanning. The refractory tumor in the patients healed uneventfully after HDR interstitial brachytherapy without recurrence during the 14 months of follow-up.

CONCLUSIONS

The image-guided HDR interstitial brachytherapy may be a valuable salvage treatment approach for refractory recurrence of PTC.

Clinicopathological features of recurrent papillary thyroid cancer

Background

To investigate the clinicopathological features of recurrent papillary thyroid carcinoma (PTC).

Methods

A retrospective analysis on clinical and pathological data of 34 patients with recurrent PTC was carried out. A total of 281 patients with non-recurrent PTC during the same time period were chosen as the control group.

Results

Patients were divided into three groups according to the pathological subtype. The number of patients belonging to Groups 1, 2, and 3 were 28, 154, and 133, respectively. 78 patients underwent partial or whole thyroidectomy, 151 cases underwent thyroidectomy combining neck regional lymph node dissection, and 86 patients underwent thyroidectomy combining modified or radical neck dissection. Univariate analysis showed that PTC recurrence was associated with tumor size, extrathyroid invasion, initial surgery approach, lymph node metastasis, and pathological subtype (P < 0.05). Patient age, gender, complication with Hashimoto's thyroiditis, and multifocality were unrelated to PTC recurrence (P > 0.05). Multivariate analysis showed that initial surgery approach and pathological subtype perform important functions in PTC recurrence (P < 0.001). Initial surgery approach presented a negative correlation with PTC recurrence (β = −0.320, OR = 0.726). The pathological subtype was also related to PTC recurrence (β = 0.923, OR = 2.517).

Conclusion

PTC patients without neck dissection showed greater likelihood of postoperative recurrence. Patients with the tall cell, columnar cell, diffuse sclerosing, and oncocytic variants showed a higher propensity for PTC recurrence after operation compared with those who did not. Tumor volume, extrathyroid invasion, and multiple lymph node metastases at the time of initial operation were also significantly related to postoperative recurrence. Follow-up supervision must be enhanced after initial treatment to mitigate PTC recurrence in susceptible patients. Effective and standard treatments must be adopted immediately after the discovery of recurrence.