Medullary thyroid cancer: medical management and follow-up

Do medullary thyroid carcinoma patients with high calcitonin require bilateral neck lymph node clearance? A case report

BACKGROUND

In clinical work, 85%-90% of malignant thyroid diseases are papillary thyroid cancer (PTC); thus, clinicians neglect other types of thyroid cancer, such as medullary thyroid carcinoma (MTC).

CASE SUMMARY

We report a 53-year-old female patient with a preoperative calcitonin level of 345 pg/mL. There was no definitive diagnosis of MTC by preoperative fine-needle aspiration cytology or intraoperative frozen pathology, but the presence of PTC and MTC was confirmed by postoperative paraffin pathology. The patient underwent total thyroidectomy and bilateral central lymph node dissection. Close follow-up at 1.5 years after surgery revealed no signs of recurrence or metastasis.

CONCLUSION

The issue in clinical work-up regarding types of thyroid cancer provides a novel and challenging idea for the surgical treatment of MTC. In the absence of central lymph node metastasis, it is worth addressing whether patients with high calcitonin can undergo total thyroidectomy and bilateral central lymph node dissection without bilateral lateral neck lymph node dissection.

Highly Efficient Gold Nano-Flower Optical Biosensor Doped in a Sol-Gel/PEG Matrix for the Determination of a Calcitonin Biomarker in Different Serum Samples

We developed a novel, simple, sensitive, accurate, and precise method for the determination of calcitonin in different serum samples with medullar thyroid carcinoma. The designed flower-like thin film gold nanoparticles doped in a sol-gel/polyethylene glycol mold are used as an optical biosensor for the efficient determination of calcitonin. The sensor was characterized by transmission electron microscopy, scanning electron microscopy, X-ray diffraction, energy-dispersive X-ray microanalysis, and Fourier-transform infrared spectroscopy. The efficiency of the considered bio-sensor is done using the quencher calcitonin of the emission band at 360 nm of biomarker obtained at λ_ex = 333 nm in acetonitrile solvent. The sensing mechanism was based on fluorescence resonance energy transfer. The remarkable quenching of the fluorescence intensity at 360 nm of optical sensor by various concentrations of calcitonin was successfully used as an optical biosensor for the assessment of calcitonin for different serum samples of patients with medullar thyroid carcinoma. The calibration plot was prepared for the concentration range 0.01-1000 pg/mL of calcitonin with a correlation coefficient of 0.99 and a detection limit of 0.707 pg/mL. The suggested method augments the sensitivity of calcitonin as a useful biomarker for the early diagnosis of medullar thyroid carcinoma. This method is considered as a gateway for the construction of a new prototype for the follow-up of thyroid cancer in the spinal cord during and after treatment.

One-step nucleic acid amplification testing in medullary thyroid cancer lymph nodes: a case series

INTRODUCTION

Locoregional relapse in medullary thyroid cancer (MTC) may be caused by nodal micrometastases. Medullary thyroid cancer lymph nodes have not yet been evaluated by one-step nucleic acid amplification (OSNA). Therefore, the aim of this study was to detect MTC cells by OSNA in cervical lymph nodes and compare the obtained outcomes with conventional histopathology.

MATERIAL AND METHODS

Twenty-one randomized, unenlarged lymph nodes from 5 patients with MTC were examined by histopathology and OSNA. Lymph nodes were divided into four representative blocks by a sterile, single use, special cutting device in the same way as in the clinical protocol study performed by Tsujimoto et al. Two blocks were used for histopathology and immunohistochemistry, 2 for OSNA.

RESULTS

Positive results of histopathology and OSNA were revealed in 4 patients. The outcomes of OSNA and histopathology were corresponding in 3 patients. Positive histopathology results of 2 lymph nodes from 2 patients were confirmed by OSNA. In 1 patient there were only negative results of both examinations. One-step nucleic acid amplification failed to detect metastasis in 1 lymph node in 2 patients although it did not change the TNM status in these patients. There were no false positive results in the OSNA test.

CONCLUSIONS

One-step nucleic acid amplification may be an alternative method to histopathology in detecting nodal involvement in MTC. Further studies should evaluate the sensitivity and specificity of OSNA and the impact on staging in MTC.

Phase II study of plitidepsin 3-hour infusion every 2 weeks in patients with unresectable advanced medullary thyroid carcinoma

OBJECTIVES

To evaluate the antitumor response, time-to-event efficacy endpoints and toxicity of plitidepsin (Aplidin) 5 mg/m as a 3-hour intravenous (i.v.) infusion every 2 weeks in patients with unresectable advanced medullary thyroid carcinoma (MTC).

METHODS

Sixteen patients with MTC and disease progression or large tumor burden received plitidepsin. Tumor response and time-related parameters were evaluated according to Response Evaluation Criteria in Solid Tumors. Secondary efficacy endpoints were marker response (calcitonin and carcinoembryonic antigen), clinical benefit and quality of life. Safety was assessed using the National Cancer Institute Common Toxicity Criteria.

RESULTS

A total of 141 cycles (median, 9 per patient; range, 1-24) were administered. No complete responses or partial responses (PR) were found, and 12 patients had stable disease for >8 weeks. Median follow-up was 15.0 months. Median time to progression was 5.3 months. Median overall survival could not be calculated, but 86.7% and 66.0% of patients were alive at 6 and 12 months. Marker response included 1 unconfirmed PR and 2 stabilizations for calcitonin, and 1 unconfirmed PR and 4 stabilizations for calcitonin and carcinoembryonic antigen. One patient showed clinical benefit. Quality of life scores generally decreased during the study. Most treatment-related adverse events were mild or moderate. Grade 3 lymphopenia was the only severe hematological toxicity found (2 patients). Severe nonhematological toxicities were grade 3 creatine phosphokinase increase (2 patients, with no myalgia or muscular weakness) and transient grade 3 alanine aminotransferase increase (5 patients).

CONCLUSIONS

Single-agent plitidepsin given as 3-hour i.v. infusions every 2 weeks was generally well tolerated but showed limited clinical activity in patients with unresectable advanced MTC.

Medullary thyroid carcinoma and biomarkers: past, present and future

The clinical management of patients with persistent or recurrent medullary thyroid carcinoma (MTC) is still under debate, because these patients either have a long-term survival, due to an indolent course of the disease, or develop rapidly progressing disease leading to death from distant metastases. At this moment, it cannot be predicted what will happen within most individual cases. Biomarkers, indicators which can be measured objectively, can be helpful in MTC diagnosis, molecular imaging and treatment, and/or identification of MTC progression. Several MTC biomarkers are already implemented in the daily management of MTC patients. More research is being aimed at the improvement of molecular imaging techniques and the development of molecular systemic therapies. Recent discoveries, like the prognostic value of plasma calcitonin and carcino-embryonic antigen doubling-time and the presence of somatic RET mutations in MTC tissue, may be useful tools in clinical decision making in the future. In this review, we provide an overview of different MTC biomarkers and their applications in the clinical management of MTC patients.

ANXA7 expression represents hormone-relevant tumor suppression in different cancers

Tumor suppressor function of ubiquitously expressed Annexin-A7, ANXA7 (10q21) that is involved in exocytosis and membrane fusion was based on cancer prone phenotype in Anxa7(+/-) mice as well as ANXA7 role in human prostate and breast cancers. To clarify ANXA7 biomarker and tumor suppressor function, we analyzed its expression pattern in comparison to the prostate-specific biomarker NKX3.1. Immunohistochemistry-based ANXA7 and NKX3.1 protein expression was analyzed on human tissue microarrays of 4,061 specimens from a wide spectrum of the histopathologically well-characterized tumors in different stages compared to corresponding normal tissues. Decreased ANXA7 expression was mostly associated with high invasive potential in multiple tumors. Although some metastases retained relatively high ANXA7 rates compared to primary cancer tissues, the lymph node metastases from different sites (including prostate and breast) had decreased ANXA7 expression in comparison to the intact lymphatic tissues. Major ANXA7 downregulation pattern was deviated in tumors of glandular (especially neuroendocrine) origin. ANXA7 and NKX3.1 proteins were synexpressed in the male urogenital system and adrenal gland. Gene expression profiling in prostate and breast cancers (SMD) revealed distinct hormone-related profiles for NKX3.1 and ANXA7, where ANXA7 expression correlated with steroid sulfatase which has a pivotal role in steroidogenesis. Abundant protein presence in adrenal gland and its loss in hormone-refractory prostate cancer indicated that ANXA7 can be relevant to steroidogenesis and androgen sensitivity in particular. With tumor suppressor pattern validated in different tumors, ANXA7 can be an attractive diagnostic and therapeutic target associated with the hormone and/or neurotransmitter-mediated modulation of tumorigenesis.

Thyroid cancer in children

In 1996, the authors were asked to review the subject of thyroid cancer in children. Over the subsequent decade, much has been learned about the treatment and outcome of these uncommon tumors. We now recognize quantitative and perhaps qualitative differences in genetic mutations and growth factor expression patterns in childhood thyroid cancers compared with those of adults. We also know that thyroid cancers induce a robust immune response in children that might contribute to their longevity. Patients under 10 years of age probably represent a unique subset of children at particularly high risk for persistent or recurrent disease; the management of these patients is under evaluation. We remain limited in our knowledge of how to stratify children into low- and high-risk categories for appropriate long-term follow-up and in our knowledge of how to treat children who have detectable serum thyroglobulin but negative imaging studies. In this article, the authors update our understanding of thyroid cancers in children with special emphasis on how these data relate to the current guidelines for management of thyroid cancer developed by the American Thyroid Association Taskforce. The limited data regarding management of children who have detectable serum thyroglobulin but negative whole-body scans are also reviewed.