Clinicopathological Characteristics and Long-term Outcome in Patients with Distant Metastases from Differentiated Thyroid Cancer

Development and validation of a predictive model for assessing the risk of follicular carcinoma in thyroid nodules identified as suspicious by intraoperative frozen section

Introduction

Follicular thyroid carcinoma (FTC) is the second most common thyroid malignancy and is characterized by a higher risk of distant metastasis compared to papillary thyroid cancer. Intraoperative frozen section (IOFS) diagnosis of FTC is challenging due to its limited sensitivity and accuracy, leading to uncertainty in intraoperative surgical decision-making. In response, we developed a predictive model to assess the risk of follicular carcinoma in thyroid nodules identified as suspicious for follicular neoplasm by IOFS.

Methods

This model was derived from preoperative clinical and ultrasound data of 493 patients who underwent thyroid surgery at Ningbo Medical Center Lihuili Hospital. It identified five significant predictors of follicular carcinoma: nodule size, thyroglobulin (Tg) level, hypoechogenicity, lobulated or irregular margins, and thick halo.

Results

The model demonstrated robust discrimination and calibration, with an area under the curve (AUC) of 0.83 (95% CI: 0.77-0.90) in the training set and 0.78 (95% CI: 0.68-0.88) in the validation set. In addition, it achieved a sensitivity of 81.63% (95% CI: 69.39-91.84) and 68.00% (95% CI: 48.00--4.00), a specificity of 77.42% (95% CI: 72.18-82.66) and 72.51% (95% CI: 65.50-78.96), an accuracy of 78.1% (95% CI: 73.4-82.4) and 71.9% (95% CI: 65.3-78.6), a positive predictive value (PPV) of 41. 67% (95% CI: 35.65-48.84) and 26.79% (95% CI: 19.40-34.33), respectively, and a negative predictive value (NPV) of 95.61% (95% CI: 92.86-97.99) and 94.07% (95% CI: 90.44-97.08) in the training and validation sets, respectively.

Conclusion

The model can accurately rule out FTC in low-risk nodules, thereby providing surgeons with a practical tool to determine the necessary extent of surgical intervention for nodules flagged as suspicious by IOFS.

Spontaneous hepatic hemorrhage as presentation of metastasized papillary thyroid carcinoma: a case report

BACKGROUND

Spontaneous hepatic hemorrhage is a rare condition, most commonly diagnosed in patients with hepatocellular carcinoma or hepatic adenomas, and is seldom caused by metastatic disease. In this case report, we present a patient with spontaneous hepatic hemorrhage due to hepatic metastasis of papillary thyroid carcinoma, an exceptionally rare occurrence.

CASE PRESENTATION

The patient was a 77-year-old white male with a history of atrial fibrillation treated with apixaban. He presented at a local hospital with abdominal pain and nausea. A CT scan revealed a hepatic lesion in segment 3 with an adjacent hematoma. He was referred to our tertiary center and treated conservatively. Further evaluation revealed an intrathoracic goiter containing a tumorous process diagnosed as a papillary thyroid carcinoma (PTC), and the patient subsequently underwent thyroidectomy. A biopsy of the hepatic lesion confirmed it as a PTC metastasis. Due to worsening abdominal pain and anorexia, the patient underwent subacute hepatic segmental resection. Postoperatively, he developed iodine-refractory disease with disseminated metastasis and passed away 22 months after the initial admission.

CONCLUSIONS

To our knowledge, this is the first recorded case of metastasized papillary thyroid carcinoma presenting with spontaneous hepatic hemorrhage-adding to the list of rare causes for this condition.

PDLIM7 Promotes Tumor Metastasis in Papillary Thyroid Carcinoma via Stabilizing Focal Adhesion Kinase Protein

Background: As an actin cytoskeleton interactor, PDZ (postsynaptic density 65-discs large-zonula occludens 1) and LIM (abnormal cell lineage 11-isket 1-mechanosensory abnormal 3) domain protein 7 (PDLIM7) was supposed to play an essential role modulating cytoskeleton. Focal adhesions (FAs), which are located at the cytomembrane terminus of actin cytoskeleton, function as a force sensor and can transform the mechanical signal to a biochemical signal. Focal adhesion kinase (FAK) localizes to and regulates signal transduction in FAs, which play an essential role in cell polarity, migration, and invasion. However, whether PDLIM7 is involved in FAs-associated signal transduction and its role in tumor invasion and metastasis remains largely unknown. Methods: A cohort of 80 patients with papillary thyroid carcinoma (PTC) at The Second Affiliated Hospital of Guilin Medical University, as well as 512 PTC samples from The Cancer Genome Atlas thyroid cancer database was utilized to analyze the expression of PDLIM7 and its association with prognosis. Survival data were assessed using Kaplan-Meier curves, whereas clinicopathological characteristics such as age, sex, tumor size, multilocality, extrathyroidal extension, lymph metastases, Hashimoto's thyroiditis, distant metastasis, and TNM stage were considered. Functional assays were performed in vitro and in a xenograft mouse model to assess the role of PDLIM7 in PTC cell lines. The colocalization of PDLIM7 with FAK and integrin alpha V (ITGAV) was determined using immunofluorescence assay and immunoprecipitation assay. Protein expression levels in cell and tissue biopsies were measured through Western blotting and immunohistochemistry. Results: (1) The PDLIM7 protein frequently upregulated in both PTC tissues and cells, and overexpression of PDLIM7 is associated with advanced clinicopathological characteristics. (2) Knockdown of PDLIM7 effectively inhibits cell proliferation, migration, and invasion in PTC cell lines in vitro. (3) Knockdown of PDLIM7 hinders the growth and metastasis of TPC-1 xenografts in vivo. (4) PDLIM7 demonstrates colocalization with both FAK and the FA molecule ITGAV and the knockdown of PDLIM7 resulted in disassembly of FAs and proteosome-dependent degradation of FAK in PTC cell lines. Conclusions: PDLIM7 function as an oncoprotein in PTC to promote metastasis, and a novel underlying mechanism is proposed that PDLIM7 keeps FAK protein from proteosome-dependent degradation.

Tyrosine kinase inhibitors for radioiodine refractory differentiated thyroid cancer: A systematic review and meta-analysis

BACKGROUND

The poor overall prognosis of radioiodine refractory thyroid cancer is an inevitable challenge in managing this disease. A series of trials have demonstrated the antitumor activity of tyrosine kinase inhibitors (TKIs) in radioiodine refractory differentiated thyroid cancer (RAIR-DTC). However, the available evidence cannot determine the optimal choice of TKI in RAIR-DTC.

METHODS

This study searched PubMed, EMBASE, Cochrane databases, and the ClinicalTrials website. The Cochrane bias risk tool was used to assess the risk of bias, and to evaluate randomized clinical trials (RCT) of RAIR-DTC patients treated with the TKI system. Outcomes, including progression-free survival (PFS), overall survival (OS), and adverse events (AEs) were reported.

RESULTS

Seven studies involving 1310 patients with RAIR-DTC was conducted to compare the PFS and OS of various TKI monotherapies with placebo. The results showed that all TKI monotherapies had a statistically significant benefit in terms of PFS compared with placebo, with lenvatinib demonstrating the greatest benefit (hazard ratio [HR] 0.19, 95% credible interval [CrI] 0.14-0.25). In terms of OS, only apatinib (HR 0.42, 95% CrI 0.18-0.97) and anlotinib (HR 0.36, 95% CrI 0.18-0.73) showed statistically significant benefits compared with placebo. TKIs also had a higher incidence of AEs of grade 3 or higher compared with placebo. The findings suggest that lenvatinib may be the preferred TKI for the treatment of RAIR-DTC, although its high incidence of AEs should be considered. The results also indicate that TKI treatment may be similarly effective in RAIR-DTC patients with BRAF or RAS mutations and in those with papillary or follicular subtypes of the disease, regardless of prior TKI treatment.

CONCLUSIONS

The results of this meta-analysis suggest that targeted therapy with TKIs may be beneficial for patients with radioiodine-refractory advanced or metastatic differentiated thyroid cancer. Among the TKIs analyzed, lenvatinib appeared to be the most effective at improving PFS, although it also had the highest incidence of AEs. Further research through direct randomized controlled trials is needed to determine the optimal choice of TKI for treating patients with RAIR-DTC. This study is beneficial for formulating patients' treatment plans and guides clinicians' decision-making.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

Development and validation of the clinical report form for nodular thyroid pathologies

Objective

The aim of this study is to develop and validate a novel clinical report form in the format of a structured interview to enable the characterization of the Portuguese population of the Baixo Vouga region with different subtypes of nodular thyroid pathologies (NTyPs).

Materials and methods

A structured interview was developed and to the best of our knowledge, this is the first structured interview built and validated for that purpose in Portugal.

Results

This structured interview enables the identification of possible correlations between each subtype of nodular lesions and sociodemographic data, consumption habits and lifestyle, endocrine history, and family predisposition.

Conclusion

The novel structured interview will simultaneously, enable a detailed characterization of the group of patients with nodular thyroid lesions and will support future metabolomic studies.

Impact of Lung Metastasis versus Metastasis of Bone, Brain, or Liver on Overall Survival and Thyroid Cancer-Specific Survival of Thyroid Cancer Patients: A Population-Based Study

We investigate the impact of lung metastasis versus metastasis of bone, brain, or liver on overall survival (OS) and thyroid cancer-specific survival (TCSS) in patients with thyroid cancer (TC). Therefore, de-identified SEER 18 registry data of primary TC patients diagnosed between 2010 and 2016 were analyzed. The primary outcome was the prognosis of TC patients with lung metastasis compared with other sites. The secondary outcomes included the prognosis comparison between patients with and without surgery and between single and multiple metastasis sites. Isolated lung metastasis was associated with worse OS and TCSS than bone metastasis (both p < 0.05) and was associated with worse OS than liver metastasis (p = 0.0467). Surgery performed either for the primary or distant site was associated with better OS and TCSS in patients with metastasis of lung or bone (p < 0.05). Isolated lung metastasis was related to better OS and TCSS than lung−liver, lung−brain, and lung−other multiple metastases. The multivariable analysis revealed that age < 55 years, surgery to the primary site, and to the distant site(s) were associated with better outcomes, while T4 and Tx were associated with worse outcomes. Nevertheless, it revealed that the other race (i.e., any race other than white, black, or unknown) and male gender were associated with better TCSS only (p < 0.05). Isolated lung metastasis is associated with a worse prognosis in TC patients compared with bone or liver metastasis. Surgery performed either for the primary or distant site(s) is associated with better survival outcomes in TC patients with metastasis of lung or bone.

Thoracic Spinal Cord Compression Secondary to Metastatic Papillary Thyroid Carcinoma: An Unusual Oncological Phenomenon

Hematogenous spread is fairly an unusual feature for papillary thyroid carcinoma (PTC) in comparison to follicular thyroid carcinoma (FTC). Thoracic spinal metastasis with complicating cord compression is an even rarer manifestation of PTC that was reported in a limited number of cases in the literature. Herein we present a 65-year-old female with a history of PTC on current radiotherapy, status post attempted surgery due to significant tumor burden and intraoperative bleeding, presented with a one-week history of rapidly progressive bilateral lower extremities weakness. Physical examination revealed paraplegia of both lower extremities with areflexia and a sensory level equivalent to the upper thoracic vertebrae. Urgent imaging depicted destructive epidural lesions at T1-T3 vertebrae with thoracic cord compression. Emergent laminectomy and debulking of these lesions were undertaken. Histopathological examination confirmed metastatic PTC. The patient proceeded to further treatment with radiotherapy following her successful neurological recovery. Thoracic vertebral metastasis is an unusual oncological phenomenon of PTC. Metastatic PTC should be considered in patients with a current or remote history of PTC who present with thoracic cord compression. Our case demonstrates that multidisciplinary management is the key to achieving a better outcome for metastatic PTC with thoracic cord compression.

Metastatic papillary thyroid carcinoma presenting as an isolated renal mass: Case report and review of the literature

Distant metastasis of Papillary Thyroid Cancer (PTC) to the kidney(s), while rare, has been observed, with approximately 30 cases described in the literature. We present the case of a 28-year-old male who was diagnosed with metastatic PTC following resection of a solitary renal mass. Pathological analysis of the thyroid gland following subsequent thyroidectomy revealed positive regional lymph nodes consistent with metastatic PTC, however, no evidence of malignancy was identified in the thyroid gland. To our knowledge, this is the only known case of metastatic PTC involving the kidney in which no primary lesion was found in the thyroid gland.

Risk factors associated with disease-specific mortality in papillary thyroid cancer patients with distant metastases

PURPOSE

Papillary thyroid carcinoma (PTC) is among the most curable cancer types. Even though uncommon, some patients present distant metastatic disease at diagnosis or during the follow-up and most of them have long-term survival. However, there continues to be controversies regarding what clinicopathological features are associated with mortality in these patients. This paper evaluates the factors related to poor disease-specific survival (DSS) in patients with metastatic PTC.

METHODS

A retrospective cohort study included PTC patients with distant metastasis from a tertiary public oncological center. Clinicopathological features, treatment modalities, and outcome were reviewed.

RESULTS

Between 1986 and 2014, 108 patients were diagnosed with metastatic PTC. In the multivariate analysis male sex (HR = 2.65; 95%CI: 1.08-6.53; P = 0.033), radioiodine refractory disease (HR = 9.50; 95%CI: 1.23-73.38; P = 0.031) and metastasis at multiple sites (HR = 5.91; 95%CI: 1.80-19.32; P = 0.003) were independent risk factors for death in patients with metastatic PTC.

CONCLUSION

Male patients with metastatic PTC, with radioiodine refractory disease and metastasis at multiple sites have a high risk of death.

Clinicopathological Characteristics and Treatment Outcome of Patients with Metastatic Differentiated Thyroid Cancer

BACKGROUND AND OBJECTIVE

Differentiated thyroid carcinoma (DTC) is a slow-growing tumour with 20% of the cases having distant metastasis. Its prognosis can vary by its histological characteristics, extension and spread. The data on metastatic DTC patients in Pakistan is scarce; therefore, the purpose of our study was to assess the clinicopathological characteristics and treatment outcomes of metastatic DTC in our population.

METHODS

This retrospective, single-centre study was carried out on 117 patients with metastatic DTC with their age at diagnosis, gender, tumour size and extent and spread of the tumour, and its histologic characteristic recorded. The treatment they received and the outcome in terms of status, at last, follow-up were also recorded.

RESULTS

The mean age of diagnosis was found to be 46.6 ± 17.2 years with an almost equal male to female ratio. The most common site of metastasis was the lung followed by bone. Papillary carcinoma was the most common subtype with 89.7% of the cases followed by follicular carcinoma occurring in 7.7%. The overall survival in years was found to be 5.6 ± 2.6 years. Ninety-six per cent had complete surgical resection followed by radioactive iodine (RAI) in 91.5%.

CONCLUSION

Our study shows that the most significant factors in predicting the outcome in metastatic DTC are age, an extrathyroidal extension of the primary tumour and distant metastasis. However, further multicentric studies done on a much larger population will be needed to further support and strengthen our results.

The differences in distant metastatic patterns and their corresponding survival between thyroid cancer subtypes

INTRODUCTION

This study aimed to systematically elucidate the metastatic patterns and their corresponding survival of each thyroid cancer subtype at time of diagnosis.

METHODS

We accessed the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2018 to search for primary thyroid cancers with DM at presentation (M1).

RESULTS

We included 2787 M1 thyroid cancers for statistical analyses and the incidence of DM at presentation was 2.4%. Lung was the most common metastatic site for anaplastic thyroid carcinoma (ATC), poorly differentiated thyroid carcinoma (PDTC), papillary thyroid carcinoma (PTC), and oncocytic (Hurthle) cell carcinoma (HCC) whereas bone is the favorable disseminated site of follicular thyroid carcinoma (FTC) and medullary thyroid carcinoma (MTC). Patients with multi-organ metastases had the worst survival whereas bone metastases were associated with a favorable outcome (p < 0.001).

CONCLUSION

There are significant differences in DM patterns of thyroid cancer subtypes and their corresponding survival.

Metabolic Profile Characterization of Different Thyroid Nodules Using FTIR Spectroscopy: A Review

Thyroid cancer's incidence has increased in the last decades, and its diagnosis can be a challenge. Further and complementary testing based in biochemical alterations may be important to correctly identify thyroid cancer and prevent unnecessary surgery. Fourier-transform infrared (FTIR) spectroscopy is a metabolomic technique that has already shown promising results in cancer metabolome analysis of neoplastic thyroid tissue, in the identification and classification of prostate tumor tissues and of breast carcinoma, among others. This work aims to gather and discuss published information on the ability of FTIR spectroscopy to be used in metabolomic studies of the thyroid, including discriminating between benign and malignant thyroid samples and grading and classifying different types of thyroid tumors.

Preliminary Study on the Relationship of BRAF Mutations with the Outcome of the First 131I Radiotherapy and Malignant Biological Characteristics in Papillary Thyroid Carcinoma

Objective

To investigate the relationship of BRAF mutation with the outcome of the first postoperative ¹³¹I treatment and malignant biological characteristics in papillary thyroid carcinoma (PTC).

Methods

Thirty-three patients with PTC who underwent their first ¹³¹I treatment after total thyroidectomy were enrolled in this study. BRAF mutation in postoperative tumor tissue and circulating tumor DNA (ctDNA) in peripheral blood at the time of ¹³¹I treatment were detected. According to the status of BRAF mutation, all patients were divided into 2 groups in each category of tumor tissues and ctDNA, respectively: 1) BRAF mutation, 2) BRAF wild-type. The Fisher’s exact test was performed to analyze the relationship of BRAF mutation in either tumor tissue or ctDNA with the outcome of the first ¹³¹I treatment and malignant characteristics of PTC.

Results

BRAF mutation was detected in tumor tissues in 25 patients (25/33,75.8%), and all the patients had single mutation site. In ctDNA, BRAF mutation was detected in 5 patients (5/33, 15.2%), and all the patients had single mutation site. In both tumor tissues and ctDNA, BRAF mutation showed no relationship with the outcome of first ¹³¹I treatment and the malignant biological characteristics (P>0.05).

Conclusion

The value of BRAF mutation alone might be limited in predicting therapeutic outcome of the first ¹³¹I treatment in PTC. No definitive relevance was found between BRAF mutation and malignant biological features in PTC.

Loss of ZNF677 Expression Is an Independent Predictor for Distant Metastasis in Middle Eastern Papillary Thyroid Carcinoma Patients

Thyroid cancer incidence has increased in recent decades. Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Approximately 30% of PTC patients develop recurrence or distant metastasis and tend to have poor prognosis. Therefore, the identification of targetable biomarkers in this subset of patients is of great importance. Accumulating evidence indicates that zinc finger protein 677 (ZNF677), which belongs to the zinc finger protein family, is an important effector during the progression of multiple malignancies. However, its role in Middle Eastern PTC patients has not been fully illustrated. Here, we uncovered the molecular mechanism and the clinical impact of ZNF677 expression in a large cohort of more than 1200 Middle Eastern PTC and 15 metastatic tissues. We demonstrated that ZNF677 is frequently downregulated in primary PTC (13.6%, 168/1235) and showed that complete loss of expression of ZNF677 is significantly associated with aggressive clinico-pathological markers such as extrathyroidal extension (p = 0.0008) and distant metastases (p < 0.0001). We also found a significantly higher incidence of ZNF677 loss in primary tumors with distant metastases (33.3%; p < 0.0001) as well as in distant metastatic tissues (46.7%; p = 0.0002) compared to the overall cohort (13.6%). More importantly, PTC with loss of ZNF677 expression showed significantly lower metastasis-free survival (p = 0.0090). Interestingly, on multivariate logistic regression analysis, ZNF677 loss was an independent predictor of distant metastasis in PTC (Odds ratio = 2.60, 95% Confidence interval = 1.20–5.62, p = 0.0155). In addition, we found a significant association between ZNF677 loss and phospho-AKT expression (p < 0.0001). Our functional molecular results suggest that ZNF677 acts as a tumor suppressor, mediating its effect by inhibiting AKT phosphorylation. Taken together, our results highlight the pivotal role played by ZNF677 during carcinogenesis and metastasis formation in Middle Eastern PTC patients.

Clinical Indications for Treatment with Multi-Kinase Inhibitors in Patients with Radioiodine-Refractory Differentiated Thyroid Cancer

Differentiated thyroid cancer is usually a slow-growing disease, even if the patients develop distant metastasis. For recurrent or metastatic disease, radioactive iodine therapy is a standard treatment. However, the disease gradually progresses in some of the patients and can ultimately develop into life-threatening conditions. For patients with progressive radioactive iodine-refractory differentiated thyroid cancer (RR-DTC), multi-kinase inhibitors (MKIs) including sorafenib and lenvatinib prolonged progression-free survival compared with placebo in pivotal randomized phase 3 trials, although the benefit in overall survival has not been clearly confirmed, possibly because the patients who received placebo were permitted to cross-over to lenvatinib upon disease progression. Moreover, the adverse events related to MKIs were not negligible. Therefore, the optimal timing of MKI initiation has long been controversial, and physicians should consider various patient and disease factors. Herein, we comprehensively review the clinical factors that can be helpful in determining the initiation of MKIs for patients with RR-DTC.

Update on the systemic management of radioactive iodine refractory differentiated thyroid cancer (Review)

The incidence of differentiated thyroid cancer (DTC) has increased over the last few decades, though it remains to be a rare disease. The prognosis of DTC is excellent; its treatment includes surgery (near-/total thyroidectomy), which is usually followed by remnant thyroid bed ablation using radio-iodine, as well as a risk-stratified follow-ups, including hormone replacement. Treatment of patients who are non-responsive to radioactive iodine (RAI) remains a challenge. Targeted therapies for RAI refractory DTC act primarily through inhibition of cell proliferation, survival and angiogenesis. Tyrosine kinase inhibitors (TKI) have achieved prolonged responses and improved progression-free survival, thereby representing a shift in the treatment of advanced thyroid cancer. There will be number of targeted treatment options for this patient population in the near future. Evidence regarding which drug should be used first and whether there is crossover drug resistance between these drugs is still lacking. Clinicians should be able to choose precisely which patients should be treated with novel targeted therapies after taking into account the following facts: i) TKIs have still not demonstrated a survival benefit. ii) The adverse effects of long-lasting treatment with TKIs could worsen quality of life, which is mostly excellent in these patients before starting treatment with these agents.

Metastatic site discriminates survival benefit of primary tumor surgery for differentiated thyroid cancer with distant metastases: A real-world observational study

The role of primary tumor surgery in the management of differentiated thyroid cancer (DTC) with distant metastases (DM) remains controversial. We aimed to explore the survival benefit of primary tumor surgery in patients with different metastatic sites.A retrospective cohort study based on the SEER database was conducted to identify DTC patients with DM diagnosed between 2010 and 2016. Patients were divided into following 2 groups: surgery and non-surgery group. Propensity score weighting was employed to balance clinicopathologic factors between the 2 groups.Of 3537 DTC patients with DM, 956 (66.0%) patients underwent primary tumor surgery while 493 (34.0%) patients did not. There were 798 all-cause deaths and 704 DTC-specific deaths over a median follow-up of 22 months. The weighted 3-year overall survival (OS) for the surgery group was 55.2%, compared to 27.8% (P < .001) for the non-surgery group. The magnitude of the survival difference of surgery was significantly correlated with metastatic sites (Pinteraction <.001). Significant survival improvements in surgery group compared with non-surgery group were observed in patients with lung-only metastasis (adjusted HR = 0.45, P < .001), bone-only metastasis (adjusted HR = 0.40, P < .001), and liver-only metastasis (adjusted HR = 0.27, P < .001), whereas no survival improvement of surgery was found for patients with brain-only metastasis (adjusted HR = 0.57, P = .059) or multiply organ distant metastases (adjusted HR = 0.81, P = .099).The survival benefit from primary tumor surgery for DTC patients with DM varies by metastatic sites. Decisions for primary tumor surgery of DTC patients with DM should be tailored according to metastatic sites.

Independent risk factors evaluation for overall survival and cancer-specific survival in thyroid cancer patients with bone metastasis: A study for construction and validation of the predictive nomogram

Bone is a frequent site for the occurrence of metastasis of thyroid cancer (TC). TC with bone metastasis (TCBM) is associated with skeletal-related events (SREs), with poor prognosis and low overall survival (OS). Therefore, it is necessary to develop a predictive nomogram for prognostic evaluation. This study aimed to construct an effective nomogram for predicting the OS and cancer-specific survival (CSS) of TC patients with BM. Those TC patients with newly diagnosed BM were retrospectively examined over a period of 6 years from 2010 to 2016 using data from the Surveillance, Epidemiology and End Results (SEER) database. Demographics and clinicopathological data were collected for further analysis. Patients were randomly allocated into training and validation cohorts with a ratio of ∼7:3. OS and CSS were retrieved as research endpoints. Univariate and multivariate Cox regression analyses were performed for identifying independent predictors. Overall, 242 patients were enrolled in this study. Age, histologic grade, histological subtype, tumor size, radiotherapy, liver metastatic status, and lung metastatic status were determined as the independent prognostic factors for predicting the OS and CSS in TCBM patients. Based on the results, visual nomograms were separately developed and validated for predicting 1-, 2-, and 3-year OS and CSS in TCBM patients on the ground of above results. The calibration, receiver operating characteristic (ROC) curve and decision curve analysis (DCA) also demonstrated the reliability and accuracy of the clinical prediction model. Our predictive model is expected to be a personalized and easily applicable tool for evaluating the prognosis of TCBM patients, and may contribute toward making an accurate judgment in clinical practice.

Anaplastic transformation of thyroid cancer in mesentery metastases presenting as intestinal perforation: a case report

Background

Anaplastic thyroid carcinoma is a highly aggressive form of thyroid cancer associated with a very poor prognosis. Anaplastic transformation most commonly occurs in the thyroid itself or within regional lymph nodes. Here we report the case of a patient with papillary thyroid cancer, presenting with colon perforation as a result of anaplastic transformation of metastases in the mesentery tissue. There have been no previous reports of this form of anaplastic transformation.

Case presentation

A 74-year-old man was admitted to our hospital, presenting with abdominal pain that he had been experiencing for 1 week prior to admission. The patient had a history of papillary thyroid carcinoma, for which he underwent a total thyroidectomy and mediastinal lymph node dissection 6 years earlier, and subsequently received radioactive iodine therapy for postoperative recurrence in the lung 2 years later. During the present reported admission, a computed tomography scan revealed a large intra-abdominal mass infiltrating into the colon and retroperitoneum and also highlighted the pneumoperitoneum. The patient was diagnosed with generalized peritonitis as a result of colon perforation, as such, we conducted an emergency laparotomy. Intraoperative findings showed a mass affecting the ascending colon and kidney, following which, an ileostomy and biopsy were completed. Poorly differentiated spindle cells were identified in the biopsy specimens, and histopathological and immunohistochemical findings revealed the absence of thyroid carcinoma cells. The tumor was therefore believed to be a primary sarcoma. Following surgery, the patient recovered from sepsis that had arisen as a result of colon perforation, however, rapidly developed systemic metastases and died 1 month post-operation. An autopsy was performed, and the patient was diagnosed with anaplastic papillary thyroid cancer at the mesentery site of metastasis. This conclusion was reached owing to the presence of the squamous differentiation of lymph node cells, and because tumor cells were positive results for paired-box gene 8 expressions.

Conclusions

Anaplastic transformation of papillary thyroid carcinoma should be considered in the diagnosis of a large mesentery mass in patients with a history of papillary carcinoma. An appropriate biopsy and paired-box gene 8 immunostaining can be useful in confirming such a diagnosis.

Liver metastasis from papillary thyroid carcinoma treated by laparoscopic hepatectomy 43 years after resection of the primary tumor: a case report

Background

Papillary thyroid carcinoma (PTC) generally has a good prognosis, while liver metastasis from PTC is rare and difficult to diagnose.

Case presentation

A 67-year-old woman was diagnosed with PTC and underwent a left hemithyroidectomy 43 years ago. Two years ago, thoracoscopic right middle lobectomy was performed for a lung tumor, and pathology reports confirmed a metastatic lung tumor of PTC. The patient was followed up regularly with computed tomography, and a liver tumor measuring 16 mm was found in the lateral segment of the liver. Fluorodeoxyglucose positron emission tomography (FDG-PET) was negative for liver tumor. However, FDG uptake was observed at the nodule outside the right lobe of the thyroid gland, suggesting metastasis to the right supraclavicular lymph node. Laparoscopic partial S2 hepatectomy was performed without complications. The final diagnosis was metastatic liver tumor from PTC, and the surgical margins were free of tumor. Postoperatively, the patient underwent complementary thyroidectomy and right supraclavicular lymph node dissection, followed by I-131 ablation. The final diagnosis was PTC of 7 mm and 4 mm and lymph node metastasis of 9 mm. The patient is currently doing well and has had no recurrence 1 year after surgery.

Conclusions

This case demonstrates that liver metastases from PTC may be found after long-term follow-up, and liver resection might be the most appropriate treatment.

Metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma

OBJECTIVE

To investigate possible metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma (PTC) with lateral neck metastasis and to determine the reliability of preoperative ultrasound-guided fine-needle aspiration biopsy (FNAB) as a method of detecting positive lymph nodes in sublevel IIa in comparison with the finding of definitive pathohistological analysis.

DESIGN

Prospective study with patients with proven lateral neck metastases from PTC at the time of initial diagnosis. All patients had total thyroidectomy, central neck dissection (level VI) and selective neck dissection (levels II-V). Potential predictive factors for the occurrence of metastasis in sublevel IIb were analysed. Sensitivity and specificity tests were used to determine the reliability of preoperative ultrasound-guided FNAB. Patients were monitored for recurrence for at least ten years.

SETTING

Single-centre study.

PARTICIPANTS

Study included 53 patients with proven lateral neck metastases from PTC at the time of initial diagnosis.

RESULTS

Predictive factors for the occurrence of metastasis in sublevel IIb that have reached statistical significance are positive sublevel IIa, number of positive lymph nodes and positive levels IIa + III + IV + V. None of the patients who fulfilled predefined criterion for minimum 10-year follow-up had local recurrence in operated lateral levels.

CONCLUSION

Highest clinical significance has positivity of sublevel IIa. Therefore, it is necessary to prove or exclude metastasis in sublevel IIa, preoperatively or intraoperatively, to decide whether to include sublevel IIb in dissection. Preoperative ultrasound-guided FNAB is a reliable method for the detection of positive lymph nodes in sublevel IIa in comparison with the definitive histopathological analysis.

Long-Term Outcomes and Prognoses of Elderly Patients (≥65-Years-Old) With Distant Metastases From Well-Differentiated Thyroid Cancer During Radioiodine Therapy and Follow-Up

OBJECTIVE

The objective of this study was to investigate the clinicopathological characteristics, long-term outcomes, and prognostic factors of elderly patients with distant metastases at initial diagnosis from well-differentiated thyroid cancer (WDTC) during radioactive iodine (¹³¹I) treatment and follow-up.

METHODS

A retrospective review of medical records identified 183 elderly patients with DTC who underwent ¹³¹I treatment at our institution between 2006 and 2019.

RESULTS

In total, 57 elderly WDTC patients with distant metastases were enrolled in this study. After ¹³¹I treatment, 32 (56.14%) patients had ¹³¹I avidity and 25 (43.86%) had non-¹³¹I avidity; 35 (61.40%) cases were classified as radioiodine refractory (RR)-WDTC and 22 (38.60%) as non-RR-WDTC. At the end of follow-up, 25 (43.86%) patients had died and 32 (56.14%) were alive. The 5- and 10-year overall survival (OS) rates were 71.50% and 30.49%, respectively, while the 5- and 10-year disease-specific survival (DSS) rates were 76.89% and 48.71%, respectively. Multivariate analyses showed that gross extrathyroidal extension and RR-DTC were independent prognostic factors for poor OS (P=0.04 and P=0.03, respectively), while gross extrathyroidal extension, extrapulmonary distant metastases, and RR-WDTC were independent prognostic factors for poor DSS at the end of follow-up (P=0.02, P=0.03, and P=0.02, respectively).

CONCLUSIONS

WDTC with distant metastases at initial diagnosis accounted for 31.15% of all elderly patients with DTC. Gross extrathyroidal extension and RR-DTC were the major factors associated with poor OS; gross extrathyroidal extension, extrapulmonary distant metastases, and RR-DTC were independent prognostic factors for poor DSS in elderly DTC patients with distant metastases.

Clinical outcomes and prognostic factors in patients with no less than three distant organ system metastases from differentiated thyroid carcinoma

OBJECTIVES

For patients with differentiated thyroid carcinoma (DTC), distant metastases are commonly identified in the lungs and bones. However, they are relatively rare in other distant organs, such as the liver, kidneys, or brain. The aim of the current study was to describe the clinical outcomes and evaluate the prognostic factors of patients with no less than three different distant organ system metastases from DTC.

METHODS

This study retrospectively identified 717 patients diagnosed with DTC with distant metastases between January 2005 and December 2017. Patient response to radioactive iodine (RAI) therapy was monitored by changes in serum thyroglobulin levels and imaging changes. Five-year and 10-year overall survival (OS) rates were calculated by the Kaplan-Meier methods and Cox proportional hazards.

RESULTS

Among the 717 participants, 37 (5.16%) patients had no less than three different distant organ system metastases from DTC. Five-year and 10-year OS were 45.9% and 37.8% in patients with three or more distant organ system metastases while 74.5% and 64.9% in individuals with one or two distant organ system metastases, respectively. RAI avidity and RAIR-DTC were main independent prognostic factors influencing the clinical outcomes for both groups of patients. The presence of 3 or more different distant organ system metastases was the only independent prognostic factors for 10-year OS by multivariate analysis.

CONCLUSIONS

Patients with no less than three distant organ system metastases from DTC had poor prognosis. RAI avidity and RAIR-DTC were main factors influencing overall survival for patients with distant metastases from DTC in both groups.

Papillary thyroid carcinoma presenting as a primary renal tumor with multiple pulmonary and bone metastases: a case report

Background

Papillary thyroid carcinoma is the most common endocrine malignancy. Distant metastasis from differentiated thyroid carcinoma is infrequent and the metastasis rate of papillary thyroid carcinoma is lower than that of follicular thyroid carcinoma. Distant metastases from differentiated thyroid carcinoma are usually seen in the lungs and bones; however, renal metastasis is very rare.

Case presentation

Here we describe an 85-year-old Caucasian woman who presented with right flank pain 10 years ago. We describe a case of papillary thyroid carcinoma presenting as a primary renal tumor with extensive pulmonary and bone metastases. Abdominal screening with computed tomography revealed a mass on her right kidney, which was considered a primary renal cell carcinoma and she underwent a right nephrectomy. Unexpectedly, papillary thyroid carcinoma metastasis was diagnosed from demonstrative histopathological findings, such as positive immunoperoxidase staining for thyroglobulin. A total thyroidectomy was performed. Unenhanced thoracic computed tomography and skeletal scintigraphy revealed bilateral multiple nodules in her lungs and bone metastasis on T10 vertebra and right sacroiliac joint. Initially, 30 Gy radiotherapy was implemented to her T9–10 vertebrae and then she was treated with a total of 800 mCi radioactive iodine for ablation. A radioactive iodine whole body scan was performed after each 200 mCi and continuous progression was shown in each scan. After she was lost to follow-up for 3 years, she referred to our clinic again with a draining mass on her neck and we planned radiotherapy to this giant mass.

Conclusion

Our patient was surprisingly still alive after metastatic disease was diagnosed 10 years ago and she had no major complaint other than a draining mass on her neck. Our primary aim by sharing this case is to underline potential renal metastasis from papillary thyroid carcinoma. In other words, when approaching primary renal tumors, possible distant metastases of other organs need to be kept in mind for differential diagnosis. In addition, it should be noted that if managed appropriately, the long-term survival in patients with papillary thyroid carcinoma with multiple organ metastases could be encouraging.

mRNA and miRNA expression profiling of follicular variant of papillary thyroid carcinoma with and without distant metastases

Follicular Variant of Papillary Thyroid Carcinoma (FVPTC) is usually associated with a good outcome. Nevertheless, in rare cases, it develops distant metastases (1-9%). Our goal was to investigate whether mRNA and miRNA expression profiles may help distinguish between metastatic versus non-metastatic FVPTCs. Twenty-four primary FVPTCs, 12 metastatic and 12 non-metastatic, with similar clinicopathological features were selected and analyzed by nanoString nCounter technology using two distinct panels for expression analysis of 740 mRNA and 798 miRNAs. Data analysis was performed using the nanoString nSolver 3.0 software. Forty-seven mRNA and 35 miRNAs were differentially expressed between the two groups. Using these mRNA and miRNAs, metastatic and non-metastatic FVPTCs were clearly divided into two distinct clusters. Our results indicate that FVPTCs with metastatic abilities have different expression profiles compared to the non-metastatic. A prospective validation is needed to evaluate the usefulness of this molecular approach in the early identification of high-risk FVPTCs.

Unusual Metastases in Papillary Microcarcinoma of Thyroid

Papillary carcinoma thyroid is the most common type of thyroid cancer. Papillary thyroid cancer metastasizes commonly to regional lymph nodes, distant organ involvement is to lungs and bone are rare and is associated with poor prognosis. Metastases to intra-abdominal organs are extremely rare. Here, we report a case of 50-year-old female diagnosed with papillary microcarcinoma thyroid who initially treated total thyroidectomy, later presented with metastasis to liver, bone, left adrenal gland, and bilateral lungs. The functioning metastasis was diagnosed by Iodine-131 whole-body scan and later treated with radioiodine.

Nephrectomy for Metastatic Kidney Tumor in Patients with Differentiated Thyroid Cancer: A Report of Two Cases

The occurrence of renal tumors originating from thyroid cancer is extremely rare with a few effective treatments for renal metastases. Here, we report the cases of two patients with differentiated thyroid cancer who underwent nephrectomy for a metastatic kidney tumor. Case 1 was a 74-year-old man who was diagnosed with right kidney tumor 10 years after initial surgery for papillary thyroid cancer (PTC). Right nephrectomy was performed, and the pathology was metastatic PTC. Case 2 was a 68-year-old woman who was diagnosed with left kidney tumor 24 years after surgery for follicular thyroid carcinoma (FTC). Left nephrectomy was performed, and the pathology was metastatic FTC. Nephrectomy for single renal metastasis could be considered a treatment option if the patients' general condition is positive.

Clinical Status and Treatment of Liver Metastasis of Differentiated Thyroid Cancer Using Tyrosine Kinase Inhibitors

BACKGROUND

Treatment of patients with liver metastasis of differentiated thyroid carcinoma (DTC) has not been sufficiently defined, because liver metastasis of DTC has been described mostly as case reports. Additionally, such patients are considered end-of-treatment responders. A relatively new approach using tyrosine kinase inhibitors (TKIs) may provide opportunities to manage systemic metastasis. This study aims to define the clinical features of DTC patients with liver metastasis and evaluate the benefits of TKIs.

METHODS

We retrospectively analyzed clinical features of 29 patients (mean age 67.8 years) diagnosed with liver metastasis of DTC at our institution between January 1981 and May 2017.

RESULTS

All patients had distant metastasis at other organ sites upon diagnosis of liver metastasis; 41% of them developed new metastasis afterward. Management after diagnosis of liver metastasis comprised palliative care (48%), radioactive iodine therapy (28%), and TKI therapy (24%). The median survival after diagnosis of liver metastasis was only 4.8 months. Survival rates were significantly better in patients with performance statuses between 0 and 2 on the Eastern Cooperative Oncology Group scale at diagnosis of liver metastasis (n = 22, 76%) treated with TKI compared to those who were not (P = 0.017; log-rank test; hazard ratio 0.19). One-year survival rates were 71.4 and 26.7% for patients treated with or without TKI, respectively.

CONCLUSIONS

Patients with liver metastasis had poor clinical prognosis. When other distant metastases existed at diagnosis of liver metastasis, TKI therapy was considered an effective therapeutic option for patients with liver metastasis of DTC.

Hypoxia Increases Thyroid Cancer Stem Cell-Enriched Side Population

Introduction

Hypoxic stress is a feature of rapidly growing thyroid tumours. Cancer progression is thought to be driven by a small population of tumour cells possessing stem cell properties. Hypoxia-inducible factors (HIFs) are important mediators of hypoxia. Both HIF-1alpha and HIF-2alpha have been reported to be expressed in thyroid cancers. There is growing evidence that the HIF pathway plays a significant role in the maintenance of thyroid cancer stem cells (CSC).

Methodology

We have isolated thyroid CSC from a papillary thyroid cancer-derived cell line (BCPAP) and an anaplastic thyroid cancer-derived cell line (SW1736) as side population (SP) cells (a putative stem cell population) and treated them with cobalt chloride (II) to induce hypoxia.

Results and discussion

We observed an increase in the SP of cells within the thyroid cancer cell lines following induction of hypoxia.

Synchronous colon cancer with pulmonary metastasis and follicular variant of papillary thyroid cancer metastasising to kidney

Thyroid malignancies are one of the fastest growing cancers in the world, with the majority being papillary thyroid cancer. Follicular variant of papillary thyroid cancer accounts for about 10%-20% of papillary thyroid carcinomas. The usual sites for metastases of these tumours are lungs and bones with renal metastases being extremely rare. We describe a case of a 64-year-old woman who presented with abdominal pain. On subsequent imaging, she was found to have a colonic mass with metastatic lesions in the lungs and tumour involving left kidney. On biopsy and immunohistochemical staining, the renal mass showed positivity for thyroid cancer markers. Thyroid scan was noted to be negative and the patient was placed on active surveillance after undergoing chemotherapy for colonic adenocarcinoma.

False-Positive Uptake of 131I Due to Tubal Ligation in a Patient With Papillary Thyroid Cancer

A 39-year-old woman with papillary thyroid cancer underwent I therapy after thyroidectomy. Posttherapeutic I whole-body scan accidentally showed symmetric "hot spots" in the pelvic region beyond known bone metastases. SPECT/CT was immediately added and revealed metal artifacts with I accumulation in the nearby uterus. Further inquiry discovered that she underwent tubal ligation 19 years ago. Our case demonstrates that I accumulation can occur at the site of oviducts many years after tubal ligation, which should be distinguished from I-avid metastases.

Prognostic markers in well differentiated papillary and follicular thyroid cancer (WDTC)

OBJECTIVES

WDTC (papillary and follicular thyroid cancer) make up around 90% of all thyroid tumours. Overall, the prognosis in patients with WDTC is excellent. However, there are small cohorts of patients who experience a more aggressive form of disease which is often associated with certain poor prognostic factors. Identifying these patients at an early stage is imperative for guiding treatment decisions. With recent developments in this area we plan to discuss the current evidence surrounding prognostic markers.

METHODS

The literature regarding prognostic factors in WDTC was reviewed using an electronic database Medline - Pubmed. Using the MeSH search engine specific prognostic factors including age, size, grade, lymph node involvement, distant metastasis, extension/invasion, ethnic background, radioactive iodine avidity, and thyroglobulin level and their association with WDTC were evaluated. A broader search of prognostic markers in thyroid cancer was also carried out to avoid missing other pertinent markers.

RESULTS

Multiple clinical and pathologic variables have been shown to be poor prognostic factors in WDTC with statistical significance. Extensive extrathyroidal extension and age may be the most important factors when predicting clinical outcomes in WDTC, although the age threshold may be increased from 45 to 55 years in due course.

CONCLUSIONS

Management of WDTC has changed considerably over the last two years as reflected in evolving British and American Thyroid Guidelines. In all cases a combined multi-disciplinary approach, with consideration of the available guidelines and stratification systems should be utilised when planning an individualised treatment program to offer the best contemporary care to WDTC patients.

LONG-TERM OUTCOMES AND PROGNOSTIC FACTORS IN PATIENTS WITH DIFFERENTIATED THYROID CANCER AND DISTANT METASTASES

OBJECTIVE

Distant metastatic spread is the most frequent cause of thyroid cancer-related death. The objective of this study was to evaluate overall and disease-related survival of patients with differentiated thyroid cancer (DTC) and distant metastases (DM) attending a single medical center and to investigate variables predictive of better long-term outcomes.

METHODS

The Rabin Medical Center Thyroid Cancer Registry was searched for patients with DM from DTC.

RESULTS

The cohort included 138 patients (58.7% female) diagnosed at age 54.7 ± 19.5 years. Mean primary tumor size was 33.9 ± 26 mm. Most patients (57.7%) were stage T3/T4; 48.7% had extrathyroidal extension; 53.5% had lymph node metastases. Histopathology yielded papillary and follicular thyroid carcinoma in 66.7% and 13.8%, respectively, and intermediate/poorly differentiated carcinoma in 19.6%. All but 2 patients underwent total thyroidectomy, and 133/138 (96.4%) received radioactive iodine (RAI) therapy. DM were synchronous in 55.1%. The mean follow-up was 8.2 years from detection of metastases. The common sites of metastases were the lungs (85.6% of patients), bones (39.9%), brain (5.8%) and liver (3.6%). At last follow-up, resolution was documented in 24.6% of patients, improvement/stable disease in 31.6%, and structurally progressive disease in 43.4%. By the end of the study, 40.6% of patients died, 23.2% of DTC. Improved overall survival and disease progression were associated with younger age, lung-only DM, and metastatic RAI avidity.

CONCLUSION

Patients with DTC and DM treated by standard-of-care approaches frequently achieve favorable long-term outcomes. Novel therapies might be necessary in only a minority of these patients, and the reported prognostic factors can aid in their identification.

ABBREVIATIONS

CR = complete response; DM = distant metastases; DTC = differentiated thyroid cancer; ETE = extra-thyroidal extension; M0 = detected during follow-up; M1 = detected at diagnosis; MSKCC = Memorial Sloan Kettering Cancer Center; NED = no evidence of disease; OS = overall survival; PFS = progression free survival; PTC = papillary thyroid cancer; RAI = radioactive iodine; Tg = thyroglobulin.

Differentiated Thyroid Cancer-Treatment: State of the Art

Differentiated thyroid cancer (DTC) is a rare malignant disease, although its incidence has increased over the last few decades. It derives from follicular thyroid cells. Generally speaking, the prognosis is excellent. If treatment according to the current guidelines is given, cases of recurrence or persistence are rare. DTC requires special expertise by the treating physician. In recent years, new therapeutic options for these patients have become available. For this article we performed a systematic literature review with special focus on the guidelines of the American Thyroid Association, the European Association of Nuclear Medicine, and the German Society of Nuclear Medicine. For DTC, surgery and radioiodine therapy followed by levothyroxine substitution remain the established therapeutic procedures. Even metastasized tumors can be cured this way. However, in rare cases of radioiodine-refractory tumors, additional options are to be discussed. These include strict suppression of thyroid-stimulating hormone (also known as thyrotropin, TSH) and external local radiotherapy. Systemic cytostatic chemotherapy does not play a significant role. Recently, multikinase or tyrosine kinase inhibitors have been approved for the treatment of radioiodine-refractory DTC. Although a benefit for overall survival has not been shown yet, these new drugs can slow down tumor progression. However, they are frequently associated with severe side effects and should be reserved for patients with threatening symptoms only.

Renal metastases as the initial presentation of papillary thyroid carcinoma: A case report and literature review

Distant metastasis of thyroid carcinoma is rare, and it occurs particularly rarely in renal regions, which represent ~3% of all thyroid distant metastases, with fewer than 30 single case study reports existing in the literature. The present study (and subsequent literature review) of papillary thyroid carcinoma (PTC) reports the case of a 53-year-old male patient who presented with a left renal mass and who had no previous history of thyroid disease. Following renal and thyroid surgery, postoperative pathology confirmed the case to be a follicular variant of PTC, accompanied by renal metastasis. The patient exhibited brain metastasis during a later follow-up. In conclusion, thyroid metastases to the renal site are extremely rare events, particularly for men who present initially with renal neoplasms, which may easily be misdiagnosed as renal cell carcinoma. PTC tends to have a good prognosis; however, when it is accompanied by distant metastasis, the prognosis becomes less favorable.

Thyroid Hormone Receptor-β (TRβ) Mediates Runt-Related Transcription Factor 2 (Runx2) Expression in Thyroid Cancer Cells: A Novel Signaling Pathway in Thyroid Cancer

Dysregulation of the thyroid hormone receptor (TR)β is common in human cancers. Restoration of functional TRβ delays tumor progression in models of thyroid and breast cancers implicating TRβ as a tumor suppressor. Conversely, aberrant expression of the runt-related transcription factor 2 (Runx2) is established in the progression and metastasis of thyroid, breast, and other cancers. Silencing of Runx2 diminishes tumor invasive characteristics. With TRβ as a tumor suppressor and Runx2 as a tumor promoter, a compelling question is whether there is a functional relationship between these regulatory factors in thyroid tumorigenesis. Here, we demonstrated that these proteins are reciprocally expressed in normal and malignant thyroid cells; TRβ is high in normal cells, and Runx2 is high in malignant cells. T3 induced a time- and concentration-dependent decrease in Runx2 expression. Silencing of TRβ by small interfering RNA knockdown resulted in a corresponding increase in Runx2 and Runx2-regulated genes, indicating that TRβ levels directly impact Runx2 expression and associated epithelial to mesenchymal transition molecules. TRβ specifically bound to 3 putative thyroid hormone-response element motifs within the Runx2-P1 promoter ((-)105/(+)133) as detected by EMSA and chromatin immunoprecipitation. TRβ suppressed Runx2 transcriptional activities, thus confirming TRβ regulation of Runx2 at functional thyroid hormone-response elements. Significantly, these findings indicate that a ratio of the tumor-suppressor TRβ and tumor-promoting Runx2 may reflect tumor aggression and serve as biomarkers in biopsy tissues. The discovery of this TRβ-Runx2 signaling supports the emerging role of TRβ as a tumor suppressor and reveals a novel pathway for intervention.

Thyroid computed tomography imaging: pictorial review of variable pathologies

Abstract

Focal and diffuse thyroid abnormalities are commonly encountered during the interpretation of computed tomography (CT) exams performed for various clinical purposes. These findings can often lead to a diagnostic dilemma, as the CT reflects the nonspecific appearances. Ultrasound (US) examination has a superior spatial resolution and is considered the modality of choice for thyroid evaluation. Nevertheless, CT detects incidental thyroid nodules (ITNs) and plays an important role in the evaluation of thyroid cancer.

In this pictorial review, we cover a wide spectrum of common and uncommon, incidental and non-incidental thyroid findings from CT scans. We also discuss the most common incidental thyroid findings, best practices for their evaluation, and recommendations for their management. In addition, we explore the role of imaging in the assessment of thyroid carcinoma (before and after treatment) and preoperative thyroid goiter, as well as localization of ectopic and congenital thyroid tissue.

Teaching Points

• Thyroid disorders tend to have non-specific CT appearances.

• ITNs are common on neck CT.

• ITN management depends on nodule size, age, health status, lymphadenopathy, and invasion.

• CT is used in assessment of cancer extension, mass effect, invasion, and recurrence.

• CT plays a role in preoperative planning in patients with symptomatic goiter.

Primary follicular thyroid carcinoma metastasis to the kidney and widespread dissemination: A case report

Distant metastases are more common in follicular thyroid carcinoma (FC) than in papillary thyroid carcinoma. However, FC metastasis to the kidney with eggshell calcification, as observed in the present case, is rare. The current report presents a case of a 67-year-old woman exhibiting a solitary tumor in the mid pole of the left kidney. Radical nephrectomy was performed, as the tumor was diagnosed as a primary renal carcinoma using contrast-enhanced computed tomography. Once the tumor was confirmed to be FC, total thyroidectomy was performed. Following administration of an oral therapeutic dose of 100 mCi ¹³¹I, functional imaging demonstrated the presence of multifocal metastases in the chest and abdomen. Euthyrox^® was prescribed orally to aid normal thyroid function. Follow-up 6 months later using radionuclide imaging demonstrated the disappearance of the multifocal metastases in the chest and abdomen. The distant metastasis of FC may represent the initial symptom of the primary lesion, which was neglected. Ultrasound is an effective method to examine nodules located on the thyroid.

Impact of neck failure on survival in older patients with differentiated thyroid cancer

BACKGROUND

Regional recurrence of differentiated thyroid cancer (DTC) is often salvaged with neck dissection without survival penalty. It is unknown whether recurrence may be associated with inferior survival in older patients.

METHODS

Surveillance, Epidemiology, and End Results (SEER) and Medicare data were linked to identify patients age ≥65 with nonmetastatic DTC. Patients undergoing neck dissection >6 months after their initial diagnosis were considered to have regional recurrent disease. We compared overall survival (OS) and cause-specific survival (CSS) for patients with recurrent disease versus a matched cohort of patients with non-recurrent DTC.

RESULTS

Of 6235 patients, 143 had treatment-defined recurrent disease. Patients with recurrent disease had inferior OS (p < .01) and CSS (p < .01). Multivariate analysis demonstrated that recurrent disease was independently associated with inferior 10-year OS (hazard ratio [HR] = 1.75; p < .01) and CSS (HR = 3.05; p < .01).

CONCLUSION

Regional recurrence of DTC may negatively impact OS and CSS in patients ≥65 years old. © 2016 Wiley Periodicals, Inc. Head Neck 38: 919-924, 2016.

Noninferior response in BRAF(V600E) mutant nonmetastatic papillary thyroid carcinoma to radioiodine therapy

PURPOSE

As the most frequent and specific genetic alteration in papillary thyroid carcinoma (PTC), BRAF(V600E) has an intimate relationship with more invasive tumour and higher postoperative recurrence risk in PTC patients. We investigate the effect of radioactive iodine (RAI) therapy on the clinical outcome in PTC patients with the BRAF(V600E) mutation without distant metastases.

METHODS

This retrospective study included PTC 228 patients without distant metastases who underwent total or near-total thyroidectomy and RAI treatment in our hospital from January 2011 to July 2014. The BRAF(V600E) status of the primary lesions was determined and the patients were divided into two groups according to the presence of the mutation. Serological and imaging data were collected at a median follow-up of 2.34 years after RAI administration. Suppressed and stimulated thyroglobulin (Tg), Tg antibody, diagnostic whole-body scintigraphy, and other imaging examinations were used to assess clinical outcome, which was defined as excellent response, indeterminate response, biochemical incomplete response and structural incomplete response.

RESULTS

The BRAF(V600E) mutation was observed in 153 of the 228 patients (67.1 %). The clinicopathological features did not differ between the BRAF(V600E) mutatation and wild-type groups except age at diagnosis (P = 0.000), tumour size (P = 0.023) and TNM stage (P = 0.003). Older age and more advanced TNM stage were prevalent in the BRAF(V600E) mutatation group, whereas tumours were slightly larger in the BRAF(V600E) wild-type group. The response to RAI therapy was evaluated in both the entire series and the patients with a high recurrence risk, and no significant difference in response was found between the BRAF(V600E) mutatation and the wild-type groups (P = 0.881 and P = 0.851, respectively).

CONCLUSION

The clinical response to timely postsurgical RAI therapy is not inferior in BRAF(V600E) mutation PTC patients without distant metastases, which suggests that RAI therapy might improve the general clinical outcome in this patient group.

Outcomes and Prognostic Factors in Radioiodine Refractory Differentiated Thyroid Carcinomas

BACKGROUND

Outcomes vary among patients with radioiodine refractory (RR) differentiated thyroid cancer (DTC). The prognostic factors for survival are not well-known, resulting in difficulty in selecting patients for new targeted therapies. We assessed overall survival (OS) and cancer-specific survival (CSS) from RR-DTC to identify prognostic factors associated with survival.

PATIENTS AND METHODS

The data on all cases of metastatic RR-DTC treated in our center from 1990 to 2011 were retrospectively reviewed. Survival was estimated using the Kaplan-Meier method; associated prognostic factors were assessed using Cox's model.

RESULTS

Of 153 cases of metastatic DTC, 59% (n = 91) met a criterion for RR: that is, 60% (n = 55) had at least 1 metastasis without (131)I uptake; 21% (n = 19) had progressive disease (PD) despite (131)I; 19% (n = 17) had persistent disease despite a cumulative activity of (131)I of ≥600 mCi. After the diagnosis of RR, median OS was 8.9 years (95% confidence interval [CI]: 5.4-NR); median CSS was 9.6 years (95% CI: 6.01-NR). In multivariate analyses, PD despite (131)I as a criterion for RR disease and the time from initial diagnosis of DTC to diagnosis of RR <3 years were the only independent prognostic factors for poor OS and CSS. Thyroglobulin doubling time (Tg-DT) was assessed in 31 of 91 cases. Among the 11 patients with Tg-DT for <1 year or undetectable Tg, 6 deaths occurred, whereas only 3 died of 20 patients with Tg-DT >1 year or negative Tg-DT.

CONCLUSION

The identification of prognostic factors for decreased survival in RR-DTC may improve the selection of patients for targeted agents.

IMPLICATIONS FOR PRACTICE

This study shows a great heterogeneity in terms of prognosis in radioiodine refractory differentiated thyroid carcinoma. Poorer prognosis is observed in patients with tumor progression or with a diagnosis of radioiodine resistance within 3 years after the initial diagnosis of thyroid cancer. Those findings could lead to improvements in the selection of patients for targeted therapies.

[Differentiated thyroid cancer]

Thyroid carcinoma is a rare and heterogeneous disease. Initial therapy and follow-up has to be adjusted to the individual risk for an excellent vs. poor prognosis. Differentiated thyroid cancer has a very high cure rate and is treated by surgery, usually followed by radioiodine ablation. Depending on the response to initial therapy the risk for persisting or recurrent disease should be re-evaluated. Continued TSH suppressive levothyroxine therapy is only recommended in high-risk patients. In contrast, metastatic radioiodine-refractory thyroid cancers have a poor prognosis and may benefit from multidisciplinary treatment concepts including tyrosine kinase inhibitors. Due to its complexity, management of thyroid cancer patients should be performed in close collaboration with a specialized thyroid cancer team.

Detection of plasma BRAF(V600E) mutation is associated with lung metastasis in papillary thyroid carcinomas

PURPOSE

The BRAF(V600E) mutation represents a novel indicator of the progression and aggressiveness of papillary thyroid carcinoma (PTC). The purpose of this study was to determine the clinical significance of free circulating mutant BRAF(V600E) in predicting the advanced disease of PTC.

MATERIALS AND METHODS

Seventy seven matched tumor and plasma samples obtained from patients with both benign and PTC were analyzed for BRAF(V600E) mutation using a peptide nucleic acid (PNA) clamp real-time polymerase chain reaction (PCR).

RESULTS

The BRAF(V600E) mutation was absent in tumor DNA samples obtained from patients with benign follicular adenomas or adenomatous goiter. In contrast, 49 of 72 (68.1%) PTC tumors were positive for the BRAF(V600E) mutation. Among them, 3 (6.1%) patients with PTC were positive for BRAF(V600E) mutation in plasma and tumor. However, all 3 patients (100%) had lateral lymph node and lung metastasis.

CONCLUSION

These findings suggest that the BRAF(V600E) mutation can be detected using a PNA clamp real-time PCR in the blood of PTC patients with lung metastasis. Future studies are warranted to determine clinical significance of serum BRAF(V600E) mutation in large prospective studies.

Prognostic implications of radioiodine avidity and serum thyroglobulin in differentiated thyroid carcinoma with distant metastasis

BACKGROUND

Although differentiated thyroid carcinoma (DTC) rarely develops distant metastases, the present study was performed to evaluate factors that affect the survival of patients with DTC who present with distant metastasis.

METHODS

Among 4,989 patients who underwent thyroid surgery for DTC, 82 presenting with distant metastasis were analyzed. Based on radioiodine ((131)I) avidity and the thyroid-stimulating hormone-stimulated serum thyroglobulin (sTg) level at the time of metastasis, patients were divided into three groups: group 1 ((131)I uptake + sTg ≤ 215 ng/mL, n = 46), group 2 ((131)I uptake + sTg > 215 ng/mL, n = 24), group 3 (no (131)I uptake, n = 12). Disease-specific survival (DSS) was estimated using the Kaplan-Meier method. Factors predicting the outcome were evaluated using Cox proportional hazard regression analysis.

RESULTS

The age of patients (p = 0.04), frequency of follicular thyroid carcinoma (p = 0.002), tumor size (p < 0.001), and number of multiple metastatic sites (p = 0.004) differed significantly among the groups. With a median follow-up after surgery of 72 months, the 5- and 10-year DSSs for all patients were 84 and 69 %, respectively. The predictors of survival were age (p = 0.004), symptoms at the time of presentation (p = 0.045), histology (p = 0.01), sites of metastasis (p = 0.03), and (131)I avidity and sTg level at the time of metastasis (p = 0.002). In the multivariate analysis, age, histology, and (131)I avidity and sTg level at the time of metastasis remained significant factors for survival.

CONCLUSIONS

Certain DTC patients with distant metastasis demonstrate favorable outcomes dependent on age, histology, and (131)I avidity and sTg level at the time of metastasis.

Multi-organ distant metastases confer worse disease-specific survival in differentiated thyroid cancer

BACKGROUND

Differentiated thyroid cancer (DTC) is usually associated with an excellent prognosis. With appropriate management of disease in the neck, death from thyroid cancer is more commonly related to the impact of distant metastases rather than locoregional recurrence. However, many patients with distant metastases can have very long periods of progression-free survival. The aims of this study were to determine the impact of single and multi-organ distant metastases (SODM and MODM) on survival, and identify factors that predict SODM progressing to MODM.

METHODS

An institutional database of 3664 previously untreated patients with DTC who had surgery between 1986 and 2010 was reviewed. One hundred and twenty-five (3.4%) patients developed distant metastases, of whom 93 developed SODM and 32 MODM. Overall survival was determined for each group by the Kaplan-Meier method. Factors predictive of MODM were identified by univariate and multivariate analysis. Multi-organ recurrence-free survival (MORFS) is a measure of SODM progressing to MODM disease. MORFS was calculated from the time of first distant metastasis to the time of second organ involvement by distant metastases.

RESULTS

The median age was 56 years (range 5-86 years). The median follow-up was 77 and 79 months (range 2-318 months) for the SODM and MODM groups respectively. SODM patients had five-year survival of 77.6% from the time of first distant metastasis, whereas MODM patients had a significantly poorer survival of just 15.3% from the time of second organ distant metastasis to death (p<0.001). The median time from first to second distant metastasis was 14.7 months (range 1-121 months). Seventy-one (57%) patients had M1 disease at presentation. Being aged ≥ 45 years (p = 0.05) and having an unstimulated serum thyroglobulin (Tg) level of ≥ 30 ng/mL at the time of diagnosis of initial distant metastasis (p<0.001) were univariate predictors of developing MODM. Controlling for age, an unstimulated serum Tg level of ≥ 30 ng/mL conferred a hazard ratio of 5.77 ([CI 2.13-15.64]; p = 0.001) for diagnosis of MODM.

CONCLUSIONS

MODM are associated with a poorer survival compared to patients with SODM. A serum Tg level >30 ng/mL at the time of first distant metastases confers more than a fivefold risk of having MODM identified during follow-up.

[Surgical therapy of lung metastases from head and neck cancer]

Pulmonary metastasectomy is an established procedure in oncological therapeutic concepts. A systematic literature search and an analysis of all studies published since 01.01.2000 should evaluate the advantage of pulmonary metastasectomy for patients with primary head and neck cancer. Lung metastases develop in 1.9-13% of head and neck cancer patients. Following metastasectomy, patients reach a median survival of 9.5-78 months and 5-year survival rates of up to 58% are achieved. Intrathoracic recurrence occurs in 18.4-81.8% of patients, selected instances of which can be successfully treated by remetastasectomy. Patients with squamous cell carcinoma have the worst prognosis, but could also become long-term survivors (≥ 60 months). Pulmonary metastasectomy is frequently the only potentially curative therapeutic approach and offers a better long-term survival than nonsurgical therapies. Lung metastasectomy is thus the treatment of choice in selected patients with pulmonary metastases from primary head and neck cancer.