Predictive factors for central lymph node and lateral cervical lymph node metastases in papillary thyroid carcinoma

Risk factors analysis of lateral cervical lymph node metastasis in papillary thyroid carcinoma: a retrospective study of 830 patients

OBJECTIVE

The aim of this study is to investigate the risk factors for lateral cervical lymph node metastasis in papillary thyroid carcinoma (PTC).

METHODS

Clinicopathological data (age, gender, Hashimoto's thyroiditis, preoperative circulating tumor cells (CTCs), multifocal, maximum lesion diameter, invaded capsule, T stage, and lymph node metastasis) of 830 PTC patients diagnosed and treated in Meizhou People's Hospital from June 2021 to April 2023 were collected. The related factors of lateral cervical lymph node metastasis were analyzed.

RESULTS

There were 334 (40.2%), and 103 (12.4%) PTC patients with central lymph node metastasis, and lateral cervical lymph node metastasis, respectively. Compared with patients without lateral cervical lymph node metastasis, PTC patients with lateral cervical lymph node metastasis had a higher proportion of multifocal, maximum lesion diameter > 1 cm, invaded capsule, T3-T4 stage. Regression logistic analysis showed that male (odds ratio (OR): 2.196, 95% confidence interval (CI): 1.279-3.769, p = 0.004), age < 55 years old (OR: 2.057, 95% CI: 1.062-3.988, p = 0.033), multifocal (OR: 2.759, 95% CI: 1.708-4.458, p < 0.001), maximum lesion diameter > 1 cm (OR: 5.408, 95% CI: 3.233-9.046, p < 0.001), T3-T4 stage (OR: 2.396, 95% CI: 1.241-4.626, p = 0.009), and invaded capsule (OR: 2.051, 95% CI: 1.208-3.480, p = 0.008) were associated with lateral cervical lymph node metastasis.

CONCLUSIONS

Male, age < 55 years old, multifocal, maximum lesion diameter > 1 cm, T3-T4 stage, and invaded capsule were independent risk factors for lateral cervical lymph node metastasis in PTC.

Prognostic factors and treatment responses among patients with gross residual disease in differentiated thyroid cancer

BACKGROUND

Various postoperative staging systems were developed to assess the outcome of differentiated thyroid cancer from initial risk after surgery to dynamic changing prognosis during follow-up. The objective of our retrospective cohort study was to identify risk factors contributing to macroscopic positive surgical margin (R2 resection) and parameters in discriminating the treatment responses and prognosis among R2 patients.

METHODS

In total, 242 differentiated thyroid cancer patients with extrathyroidal extension who underwent a thyroidectomy at Kaohsiung Chang Gung Memorial Hospital between January 2013 and July 2018, were included. The patients were grouped according to the presence or absence of gross residual disease (R2). The R2 patients were further classified into two categories according to their treatment response into excellent and nonexcellent groups. The parameters and treatment outcomes were compared between these groups.

RESULTS

The mean follow-up time was 45.3 months. Two hundred seven (85.5%) patients had either surgery-free or microscopic margins (R0/R1), while 35 (14.5%) had R2 resection. In the R2 group (n = 35), 15 (42.9%) patients achieved an excellent response, while 20 (57.1%) achieved a nonexcellent response. Statistically significant differences were observed in the extent of neck dissection, TSH-Tg level, post-RAI Tg level, nodal status, and recurrence between the two groups. The Kaplan-Meier curves for 5-year local and distant recurrence-free survival of R0/R1 versus R2 patients were 90.0% versus 66.3%, and 98.4% versus 90.7%, respectively ( p < 0.001). Among the R2 patients, the excellent responders had a higher local recurrence-free survival than nonexcellent responders (93.3% vs. 45.1%, p = 0.008).

CONCLUSION

There are significant disparities in recurrence-free survival among R2 patients with different treatment responses. The nodal status of papillary thyroid cancer and thyroglobulin level after thyroidectomy and RAI were factors contributing to difference in their treatment responses.

Association between different regional lymph node metastases of papillary thyroid carcinoma in adolescents and young adults

Adolescents and young adults (AYA) describe the demographic aged between 15-39 years diagnosed with cancer. This group is particularly at risk of papillary thyroid carcinoma (PTC) with a greater severity compared with other ages. Through comparative design, the present study aimed to quantify central lymph node metastasis (CLNM) risk in AYAs. A total of 463 AYA patients with PTC and 489 patients >39 years old with PTC from Ningbo Medical Center Lihuili Hospital (Ningbo, China) were enrolled. Details such as demographic data, serum indices and fine-needle aspiration from the Electronic Medical Records System were extracted and analyzed. AYA patients had significantly higher rates of ipsilateral Hashimoto thyroiditis, thyroid capsular invasion (TCI), CLNM, larger tumors and more positive central lymph nodes (CLN). Independent risk factors of CLNM in AYA patients were as follows: Male sex, presence of TCI, multifocality, bilateral disease and maximum tumor diameter (MTD) ≥1.0 cm. Independent risk factors of lateral lymph node metastasis in AYAs with CLNM were as follows: MTD ≥1.0 cm, maximum diameter of positive CLN ≥1.0 cm, and presence of ipsilateral nodular goiter. Furthermore, AYA patients with PTC displayed significantly greater aggression in primary tumor invasion and neck lymph node metastasis. Based on these findings, a treatment stratification chart was created to guide the PTC treatment approach for AYAs. The present study is registered at the Chinese Clinical Trials Registry (trial registration no. ChiCTR2200064921) in November 2022.

Safety and surgical outcomes of single-port trans-axillary robot-assisted thyroidectomy: Experience from a consecutive series of 300 patients

Since the introduction of the single-port (SP) robotic system, SP trans-axillary robot-assisted thyroidectomy (SP-TART) has been performed. We aimed to evaluate the safety and surgical outcomes of SP-TART in a consecutive series of 300 cases. We analyzed 300 patients with thyroid disease who underwent SP-TART from October 2021 to May 2023 in St. Mary's Hospital in Seoul, Korea. We analyzed the patients' clinicopathological characteristics and perioperative outcomes according to surgical extent. Of the 300 cases analyzed, 250 patients underwent less than total thyroidectomy (LTT), 31 patients underwent total thyroidectomy (TT), and 19 patients underwent TT with modified radical neck dissection (TT c mRND). The mean operative times for LTT, TT, and for TT c mRND were 69.8 ± 23.6, 104.2 ± 30.7, and 223.7 ± 72.4 min, respectively. Complications, including postoperative bleeding, transient hypoparathyroidism, and vocal cord palsy, were observed in nine, six, and six LTT, TT, and TT c mRND cases. The SP-TART method is a safe and feasible surgical option with a short operative time, good surgical outcome, and excellent cosmetic results.

Clinical features and imaging examination assessment of cervical lymph nodes for thyroid carcinoma

BACKGROUNDS

The purpose of this study is to investigate the relationship between clinical characteristics and cervical lymph node metastasis (LNM) in patients with thyroid carcinoma, as well as estimate the preoperative diagnosis values of ultrasound (US) and contrast enhanced computed tomography (CECT) examinations on the neck for detection of cervical LNM in thyroid carcinoma.

METHODS

A retrospective analysis of 3 026 patients with surgically proven thyroid carcinoma was conducted. Patients' clinical characteristics, including gender, age, tumor size, bilateral lesions, multifocality, adenomatous nodules, Hashimoto's thyroiditis (HT), and extrathyroidal extension, were collected to explore their association with cervical LNM in thyroid carcinoma. Preoperative assessments for central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) were conducted through US and CECT. The diagnostic value of US, CECT and US combined with CECT for detection of LNM located in various cervical compartments was estimated based on the pathological results.

RESULTS

The risk of cervical LNM was higher in thyroid cancer patients who were male, age < 55 years old, tumor size > 10 mm, bilateral lesions, and extrathyroidal extension, while multifocality, adenomatous nodules and HT had no significant effect on LNM. US, CECT and US combined with CECT all had a higher sensitivity to LLNM (93.1%, 57.8%, 95.4%) than to CLNM (32.3%, 29.0%, 43.4%). US and CECT had a high specificity to both CLNM and LLNM (94.3-97.8%).

CONCLUSION

Preoperative clinical characteristics and imaging examinations on patients with thyroid carcinoma are crucial to the evaluation of cervical lymph nodes and conducive to individualizing surgical treatments by clinicians. US combined with CECT are superior to single US or CECT alone in detection of CLNM and LLNM.

Ultrasonic Feature Prediction of Large-Number Central Lymph Node Metastasis in Clinically Node-Negative Solitary Papillary Thyroid Carcinoma

BACKGROUND

The purpose of this study was to investigate the preoperative prediction of large-number central lymph node metastasis (CLNM) in single thyroid papillary carcinoma (PTC) with negative clinical lymph nodes.

METHODS

A total of 634 patients with clinically lymph node-negative single PTC who underwent thyroidectomy and central lymph node dissection at the First Affiliated Hospital of Anhui Medical University and the Nanchong Central Hospital between September 2018 and September 2021 were analyzed retrospectively. According to the CLNM status, the patients were divided into two groups: small-number (≤5 metastatic lymph nodes) and large-number (>5 metastatic lymph nodes). Univariate and multivariate analyses were used to determine the independent predictors of large-number CLNM. Simultaneously, a nomogram based on risk factors was established to predict large-number CLNM.

RESULTS

The incidence of large-number CLNM was 7.7%. Univariate and multivariate analyses showed that age, tumor size, and calcification were independent risk factors for predicting large-number CLNM. The combination of the three independent predictors achieved an AUC of 0.806. Based on the identified risk factors that can predict large-number CLNM, a nomogram was developed. The analysis of the calibration map showed that the nomogram had good performance and clinical application.

CONCLUSION

In patients with single PTC with negative clinical lymph nodes large-number CLNM is related to age, size, and calcification in patients with a single PTC with negative clinical lymph nodes. Surgeons and radiologists should pay more attention to patients with these risk factors. A nomogram can help guide the surgical decision for PTC.

Analysis of the influence factors of cervical lymph node metastasis in Papillary thyroid carcinoma: A retrospective observational study

Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer, and surgery is crucial for curing PTC. PTC patients often experience lymph node metastasis (LNM) in the neck, and central lymph node metastasis (CLNM) significantly affects the recurrence rate of PTC. Therefore, the thoroughness of the surgery is particularly important for the treatment of PTC. However, there is still controversy regarding the choice of surgical approach. This study retrospectively analyzed the clinical data of 69 PTC patients treated at our hospital from December 2019 to April 2022 and clinically analyzed the high-risk factors for neck LNM. In this study, the patients aged ≤ 55 years were examined in which the number of patients with CLNM were 42 cases (80.77%), tumor diameter >2 cm were 15 cases (100%), the multifocal carcinoma were 38 cases (88.37%) and the involvement of membrane were 38 cases (80.85%), the number of patients whose had lateral cervical lymph node metastasis (LLNM), respectively 43 cases (82.69%), 14 cases (93.33%), 39 cases (90.7%) and 40 cases (85.11%),all of these factors were associated with cervical LNM (P < .05), but was not correlation with sex, double lobe carcinoma, extra glandular invasion and hashimoto (P > .05). The patient's age and number of cancers were independent risk factors for LNM in the central region of the neck (P < .05), while the patient's age, tumor size and number of cancers were significant risk factors for LNM in the lateral cervical region (P < .05). We concluded that cervical LNM was related with the high-risk factors of patient's age, tumor size, multifocal carcinoma in PTC. Especially, modified radical cervical dissection or selective cervical dissection was suggested in the PTC patients who were younger than 42.5 years old, with tumor diameter larger than 2 cm and multifocal carcinoma.

Factors of Central Lymph Node Metastasis in Papillary Thyroid Cancer Based on C-TIRADS Analysis

To study risk factors for central lymph node metastasis (CLNM) in papillary thyroid cancer (PTC) using the Chinese Thyroid Imaging Reporting and Data System (C-TIRADS). We retrospectively analysed patients who underwent PTC surgery and central lymph node dissection at First People's Hospital of Foshan City. The clinical and ultrasonic data of the patients from 1150 cases were analysed by multivariate regression to evaluate the correlation between grayscale ultrasound (US) features, C-TIRADS score, and the classification of thyroid nodules and CLNM of PTCs. The C-TIRADS score was 3.0±1.0 in the CLNM group, which was higher than that in the non-CLNM group (p<0.001). Sex (male) (OR=1.586, 95% CI 1.232-2.042, p<0.001), age (≤45 years) (OR=1.508, 95% CI 1.184-1.919, p=0.001), location of nodes (lower pole) (OR=2.193, 95% CI 1.519-3.166, p<0.001), number (multifocal) (OR=2.204, 95% CI 1.227-2.378, p<0.001), microcalcification (OR=1.610, 95% CI 2.225-4.434, p=0.002), extrathyroidal extension (OR=2.204, 95% CI 1.941-3.843, p<0.001), maximum diameter of nodule (≥20 mm) (OR=3.211, 95% CI 2.337-4.411, p<0.001), and C-TIRADS score (OR=1.356, 95% CI 1.204-1.527, p<0.001) were PTC in independent risk factors for CLNM. The C-TIRADS score of PTC combined with the location, number, size, and ultrasound features of the lesion and the patient's sex and age are important in predicting whether they present with CLNM and provide a reference basis for the clinical formulation of a reasonable surgical treatment plan.

Prediction of Cervical Lymph Node Metastasis in Clinically Node-Negative T1 and T2 Papillary Thyroid Carcinoma Using Supervised Machine Learning Approach

Papillary thyroid carcinoma (PTC) is generally considered an indolent cancer. However, patients with cervical lymph node metastasis (LNM) have a higher risk of local recurrence. This study evaluated and compared four machine learning (ML)-based classifiers to predict the presence of cervical LNM in clinically node-negative (cN0) T1 and T2 PTC patients. The algorithm was developed using clinicopathological data from 288 patients who underwent total thyroidectomy and prophylactic central neck dissection, with sentinel lymph node biopsy performed to identify lateral LNM. The final ML classifier was selected based on the highest specificity and the lowest degree of overfitting while maintaining a sensitivity of 95%. Among the models evaluated, the k-Nearest Neighbor (k-NN) classifier was found to be the best fit, with an area under the receiver operating characteristic curve of 0.72, and sensitivity, specificity, positive and negative predictive values, F1 and F2 scores of 98%, 27%, 56%, 93%, 72%, and 85%, respectively. A web application based on a sensitivity-optimized kNN classifier was also created to predict the potential of cervical LNM, allowing users to explore and potentially build upon the model. These findings suggest that ML can improve the prediction of LNM in cN0 T1 and T2 PTC patients, thereby aiding in individual treatment planning.

PTC-MAS: A Deep Learning-Based Preoperative Automatic Assessment of Lymph Node Metastasis in Primary Thyroid Cancer

BACKGROUND

Identifying cervical lymph node metastasis (LNM) in primary thyroid cancer preoperatively using ultrasound is challenging. Therefore, a non-invasive method is needed to assess LNM accurately.

PURPOSE

To address this need, we developed the Primary Thyroid Cancer Lymph Node Metastasis Assessment System (PTC-MAS), a transfer learning-based and B-mode ultrasound images-based automatic assessment system for assessing LNM in primary thyroid cancer.

METHODS

The system has two parts: YOLO Thyroid Nodule Recognition System (YOLOS) for obtaining regions of interest (ROIs) of nodules, and LMM assessment system for building the LNM assessment system using transfer learning and majority voting with extracted ROIs as input. We retained the relative size features of nodules to improve the system's performance.

RESULTS

We evaluated three transfer learning-based neural networks (DenseNet, ResNet, and GoogLeNet) and majority voting, which had the area under the curves (AUCs) of 0.802, 0.837, 0.823, and 0.858, respectively. Method III preserved relative size features and achieved higher AUCs than Method II, which fixed nodule size. YOLOS achieved high precision and sensitivity on a test set, indicating its potential for ROIs extraction.

CONCLUSIONS

Our proposed PTC-MAS system effectively assesses primary thyroid cancer LNM based on preserving nodule relative size features. It has potential for guiding treatment modalities and avoiding inaccurate ultrasound results due to tracheal interference.

Clinical and ultrasonic risk factors for high-volume central lymph node metastasis in cN0 papillary thyroid microcarcinoma: A retrospective study and meta-analysis

OBJECTIVE

Papillary thyroid microcarcinoma (PTMC) comprises more than 50% of all newly detected cases of papillary thyroid carcinoma (PTC). High-volume lymph node metastasis (involving >5 lymph nodes) (hv-LNM) is associated with PTMC recurrence. In half of the clinically node-negative (cN0) PTMC patients, central lymph node metastasis (CLNM) is pathologically present. However, clinical risk factors for high-volume CLNM (hv-CLNM) in cN0 PTMC have not been defined well. Therefore, we aimed to obtain evidence for hv-CLNM risk factors in cN0 PTMC.

DESIGN

Data on patients who visited our hospital between January 2020 and December 2021 were collected; a preoperative diagnosis of cN0 and a postoperative pathological confirmation of PTMC were obtained. After filtering by inclusion versus exclusion criteria, the obtained data (N = 2268) were included in the meta-analysis. Relevant studies published as of 10 April 2022, were identified from the Web of Science, PubMed, WANFANG, and CNKI databases. These eligible studies were included in the meta-analysis and the association between clinicopathological factors and hv-CLNM in cN0 PTMC was assessed. SPSS and MetaXL were used for statistical analyses.

RESULTS

The meta-analysis included 10 previous studies (11,734 patients) and 2268 patients enroled in our hospital for a total of 14,002 subjects. The results of which suggested that younger age (<40, odds ratio [OR] = 3.28, 95% confidence interval [CI] = 2.75-3.92, p < .001 or <45 odds ratio [OR] = 2.93, 95% CI = 2.31-3.72, p < .001), male sex (OR = 2.81, 95% CI = 2.25-3.52, p < .001), tumour size >5 mm (OR = 1.85, 95% CI = 1.39-2.47, p < .001), multifocality (OR = 1.88, 95% CI = 1.56-2.26, p < .001), extrathyroidal extension (OR = 2.58, 95% CI = 2.02-3.30, p < .001), capsule invasion (OR = 2.02, 95% CI = 1.46-2.78, p < .001), microcalcification (OR = 3.25, 95% CI = 2.42-4.36, p < .001) and rich blood flow (OR = 1.65, 95% CI = 1.21-2.25, p = .002) were the significant factors related to an elevated hv-CLNM risk in cN0 PTMC patients. Hashimoto thyroiditis (OR = 0.76, 95% CI = 0.55-1.07, p = .114), irregular margin (versus regular margin, OR = 0.96, 95% CI = 0.68-1.33, p = .787) and hypoechoic (versus nonhypoechoic, OR = 1.27, 95% CI = 0.84-1.92, p = .261) showed no significant association with hv-CLNM.

CONCLUSIONS

Younger age, tumour size >5 mm, males, extrathyroidal extension, multifocality, microcalcification, capsular invasion, and rich blood flow were the significant clinicopathological risk factors for hv-CLNM risk in cN0 PTMC patients. These predictors may compensate for the sensitivity of imaging diagnosis in the preoperative period, thus helping in the effective identification of PTMCs with an invasive phenotype.

Optimal method for detecting cervical lymph node metastasis from papillary thyroid cancer

PURPOSE

Papillary thyroid cancer (PTC) is often accompanied by cervical lymph node metastases (LNM). This study compared the diagnostic performance of fine needle aspiration (FNA), the combination of FNA and thyroglobulin measurement in the washout (FNA-Tg), and core needle biopsy(CNB) in order to determine the optimal method in detecting cervical LNM from PTC.

METHODS

PTC patients with suspicious cervical lymph nodes, who underwent ultrasonography-guided FNA, or CNB before surgery were retrospectively reviewed between January 2021 and April 2022. Patients' demographics, lymph node size, and results of FNA, FNA-Tg, CNB and surgical pathology were collected. Sensitivitity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and the area under the curves (AUC) of receiver operating characteristic were obtained.

RESULTS

FNA-Tg had a higher AUC with a threshold of 55 ng/mL than that with a threshold of 1 ng/mL (0.782 vs. 0.636, P = 0.005). The sensitivity of the combination of FNA and FNA-Tg was higher than that of FNA alone (91.3% vs. 81.0%, P = 0.01), but it was not different from that of CNB (91.3% vs. 88.0%, P > 0.05). No significant difference was found in specificity, PPV, NPV, accuracy and AUC among FNA alone, CNB alone, and the combination of FNA and FNA-Tg.

CONCLUSIONS

FNA-Tg is useful to improve the sensitivity of FNA. The diagnostic performance of the combination of FNA and FNA-Tg is better than that of FNA or FNA-Tg alone, but is not different from that of CNB in detecting LNM from PTC.

Combined Conventional Ultrasound and Contrast-Enhanced Computed Tomography for Cervical Lymph Node Metastasis Prediction in Papillary Thyroid Carcinoma

OBJECTIVES

This study aimed to evaluate conventional ultrasound (US) combined with contrast-enhanced computed tomography (CT) of the neck to predict central lymph node metastasis (CLNM) in clinical lymph-negative patients with papillary thyroid carcinoma (PTC), establish a simple preoperative risk-scoring model, and validate its effectiveness in a two-center dataset.

METHODS

A total of 423 patients with PTC preoperatively evaluated by US and contrast-enhanced CT were included in the modeling group, and 102 patients from two hospitals were enrolled in the validation group. Independent predictive factors were determined using multivariate logistic regression analysis. Diagnostic performance was evaluated using receiver operating characteristic curve analysis.

RESULTS

The independent predictive factors for CLNM were age ≤45 years (odds ratio [OR] = 3.950), nodule presence in the non-upper pole (OR = 2.385), nodule size >12.5 mm (OR = 2.130), Thyroid Imaging Reporting and Data System score ≥9 (OR = 2.857), normalized enhancement CT value ≥0.75 (OR = 3.132), central enhancement (OR = 0.222), and capsular invasion (OR = 3.478). The area under the curve (AUC) of the model was 0.790 (95% confidence interval [CI]: 0.747-0.834), and the sensitivity and specificity were 70.4% and 73.9%, respectively. The AUC in the validation group was 0.827 (95% CI: 0.747-0.907), and the sensitivity and specificity were 88.9% and 63.2%, respectively.

CONCLUSIONS

We found conventional US combined with contrast-enhanced CT of the neck to be useful in predicting CLNM preoperatively and established a simple risk-scoring model that might help surgeons with appropriate surgical plans and prognostic evaluation.

Central and lateral neck involvement in papillary thyroid carcinoma patients with or without thyroid capsular invasion: A multi-center analysis

PURPOSES

To quantitatively predict the probability of cervical lymph node metastasis for papillary thyroid carcinomas (PTC) patients with or without thyroid capsular invasion (TCI), to guide the decision-making of management strategies for neck regions.

METHODS

A total of 998 PTC patients from three medical centers were retrospectively analyzed.

RESULTS

Patients with positive TCI (TCI group) exhibited higher risks for both CLNM and LLNM than those with negative TCI (no-TCI group). Patients receiving lateral lymph node dissection showed significantly higher incidence of relatively severe postoperative complications. For no-TCI group, factors including age less than 55 years old, male, the presence of bilateral disease and multifocality, and maximum tumor diameter (MTD)>=0.5cm were confirmed to be independent risk factors for CLNM, while the presence of bilateral disease and ipsilateral nodular goiter (iNG), and maximum positive CLN diameter (MCLND)>1.0cm independent factors for LLNM. Independent risk factors of LLNM for patients within the TCI group included MCLND>1.0cm, positive CLN number>=3, and the presence of iNG. Predictive models of CLNM and LLNM were established based on the aforementioned risk factors for patients within no-TCI and TCI groups. A meticulous and comprehensive risk stratification flow chart was established for a more accurate evaluation of central neck involvement including both CLNM and LLNM risk in PTC patients.

CONCLUSIONS

A meticulous and comprehensive stratification flow chart for PTC patients for quantitatively evaluating both CLNM and LLNM was constructed.

Incorporation size of lymph node metastasis focus and pre-ablation stimulated Tg could more effectively predict clinical outcomes in differentiated thyroid cancer patients without distant metastases

BACKGROUND

The size of lymph node metastasis (LNM) and pre-ablation stimulated Tg (ps-Tg) were key predictors of clinical prognosis in differentiated thyroid cancer (DTC) patients, however, very few studies combine the above two as predictors of clinical prognosis of DTC patients.

METHODS

Persistent/recurrent disease and clinicopathologic factors were analyzed in 543 DTC patients without distant metastases who underwent LN dissection, near-total/total thyroidectomy, and radioiodine ablation.

RESULTS

In the multivariate analysis, size of LNM, ps-Tg, and the activity of ¹³¹I significantly correlated with long-term remission. The optimal cutoff size of LNM 0.4 cm-1.4 cm (intermediate-risk patients) and >1.4cm (high-risk patients) increased the recurrence risk (hazard ratio [95% CI], 4.674 [2.881-7.583] and 13.653 [8.135-22.913], respectively). Integration of ps-Tg into the reclassification risk stratification showed that ps-Tg ≤ 10.0 ng/mL was relevant to a greatly heightened possibility of long-term remission (92.2%-95.4% in low-risk patients, 67.3%-87.0% in intermediate-risk patients, and 32.3%-57.7% in high-risk patients).

CONCLUSION

The cutoff of 0.4 cm and 1.4 cm for a definition of size of LNM in DTC patients without distant metastases can reclassify risk assessment, and incorporating ps-Tg could more effectively predict clinical outcomes and modify the postoperative management plan.

Risk factors for skip metastasis in patients with papillary thyroid microcarcinoma

BACKGROUND

Lymph node metastasis (LNM) is prevalent in papillary thyroid microcarcinoma (PTMC) and is essential when determining tumor stage and prognosis. Positive lateral LNM with negative central LNM is defined as skip metastasis. Thyroid carcinoma's risk factors for skip metastasis remain controversial, especially in PTMC. This study aimed to determine the clinical features as well as the risk factors of skip metastasis among patients with PTMC.

METHODS

We conducted retrospective research among patients with PTMC who were subjected to treatment at our Hospital between January 2018 and December 2019 by reviewing their medical records. A database containing demographic characteristics, ultrasonography features, blood test outcomes, operation information, pathology details, and follow-up information was constructed. The link between skip metastasis and clinicopathological features of PTMC was evaluated using univariate as well as multivariate analyses.

RESULTS

Overall, 293 patients diagnosed with PTMC and lateral LNM were included. There were 91 men (31.1%) and 202 women (68.9%). The median age was 38 (31-47) years. Fifty patients were diagnosed with skip metastases. Levels III and II + III were the most prevalent in single-level and two-level metastasis, correspondingly. Univariate and multivariate analyses detected two independent factors linked to skip metastasis in PTMC: female sex (odds ratio = 2.609, 95% confidence interval (CI): 1.135-6.000; p = 0.024) and location of the tumor (upper portion) (odds ratio = 2.959, 95% CI: 1.552-5.639; p = 0.001).

CONCLUSIONS

Skip metastasis is prevalent in thyroid carcinoma. Female sex and tumor location (upper portion) are independently linked to skip metastasis in PTMC. Patients who have these two risk factors should undergo a meticulous preoperative and intraoperative evaluation of lymph node status.

Lateral Involvement in Different Sized Papillary Thyroid Carcinomas Patients with Central Lymph Node Metastasis: A Multi-Center Analysis

Objective: To quantitatively predict the probability of lateral lymph node metastasis (LLNM) for papillary thyroid carcinomas (PTC) patients with central lymph node metastasis (CLNM) in order to guide postoperative adjuvant treatment. Methods: Five hundred and three PTC patients with CLNM from three medical centers were retrospectively analyzed. Results: The LLNM rate for all patients was 23.9% (120 in 503), with 15.5% (45 in 291) and 35.4% (75 in 212) for patients with papillary thyroid microcarcinoma (PTMC) and large papillary thyroid carcinoma (LPTC), respectively. Patients with no fewer than five positive central lymph nodes (CLN) exhibited a higher risk of LLNM. For patients with fewer than five positive CLN, a maximum diameter of positive CLN > 0.5 cm and the presence of ipsilateral nodular goiter were identified as independent risk factors of LLNM for papillary thyroid microcarcinoma (PTMC) patients. The independent risk factors of LLNM for large papillary thyroid carcinoma (LPTC) patients included a tumor located in the upper portion of thyroid, maximum tumor diameter ≥ 2.0 cm, maximum diameter of positive CLN > 0.5 cm, and the presence of thyroid capsular invasion. Predictive nomograms were established based on these risk factors for PTMC and LPTC patients, respectively. The accuracy and validity of our newly built models were verified by C-index and calibration curves. PTMC and LPTC patients with fewer than five positive CLN were each stratified into three subgroups based on their nomogram risk scores, and a detailed risk stratification flow chart was established for a more accurate evaluation of LLNM risk in PTC patients. Conclusions: A detailed stratification flow chart for PTC patients with CLNM to quantitatively assess LLNM risk was established, which may aid in clinical decision-making for those patients.

[Risk factors of skip lateral cervical lymph node metastasis in papillary thyroid carcinoma]

Objective:To investigate the incidence and risk factors of skip lateral cervical lymph node metastasis in patients with papillary thyroid carcinoma（PTC）. Methods:The clinical and pathological data of 85 patients with PTC who underwent total thyroidectomy plus central and lateral neck dissection in the Department of Otolaryngology Head and Neck Surgery, the First Affiliated Hospital of Hebei North University from January 2018 to January 2022 were analyzed retrospectively. SPSS 26.0 software was used to process the data, and univariate and multivariate analysis were performed to assess the relationships between skip lateral cervical lymph node metastasis and clinicopathological characteristics. Results:There were 31 cases（36.5%） of skipped lateral cervical lymph node metastasis. Univariate analysis showed that the largest tumor diameter ≤5 mm（P=0.006） and the tumor located in the upper pole of the thyroid（P=0.002） were associated with the occurrence of skip lateral cervical lymph node metastasis in patients with PTC. Most of the skip metastases involved a single area（18/31, 58.1%）, of which area Ⅲ was most likely to be involved（10/31, 32.3%）, followed by area Ⅱ（5/31, 16.1%）. The results of binary logistic analysis showed that tumor diameter less than 5 mm（OR 7.800, 95%CI 1.710-21.394, P=0.005） and tumor at the upper pole of the gland（OR 4.060, 95%CI 1.468-11.235, P=0.007） were independent risk factors of skip lateral cervical lymph node metastasis in PTC patients. Conclusion:PTC patients with tumor diameter ≤5 mm and tumor located in the upper pole of the gland are more prone to skip lateral cervical lymph node metastasis. When the diameter of the tumor is less than 5 mm and the tumor is located at the upper pole of the gland, careful evaluation should be made before operation, even in the absence of central lymph node metastasis, attention should be paid to the possibility of lateral cervical lymph node metastasis.

Relationship between subgroups of central and lateral lymph node metastasis in clinically node-negative papillary thyroid carcinoma

BACKGROUND

Lymph node metastasis (LNM) of papillary thyroid carcinoma (PTC) has a certain regularity and occurs first to the central lymph node and then to the lateral lymph node. The pathway of PTC LNM can guide surgical prophylactic lymph node dissection (LND) for clinical surgeons.

AIM

To investigate the relationship between subgroups of central LNM and lateral LNM in unilateral clinically node-negative PTC (cN0-PTC).

METHODS

Data were collected for 1089 PTC patients who underwent surgical treatment at the Department of Endocrine and Breast Surgery of the First Hospital of Chongqing Medical University from January 2016 to December 2017. A total of 388 unilateral cN0-PTC patients met the inclusion criteria and were enrolled in this study. The clinical and pathological data for these 388 patients who underwent total thyroidectomy + central LND + lateral LND were retrospectively analyzed. The relationship between the central LNM and lateral LNM subgroups was investigated.

RESULTS

The coincidence rate of cN0-PTC was only 30.0%.Optimal scaling regression analysis showed that sex (57.1% vs 42.9%, P = 0.026), primary tumor size (68.8% vs 31.2%, P = 0.008), tumor location (59.7% vs 40.3%, P = 0.007), extrathyroid extension (ETE) (50.6% vs 49.9%, P = 0.046), and prelaryngeal LNM (57.1% vs 42.9%, P = 0.004) were significantly associated with ipsilateral level-II LNM. Their importance levels were 0.122, 0.213, 0.172, 0.110, and 0.227, respectively. Primary tumor size (74.6% vs 30.2%, P = 0.016), pretracheal LNM (67.5% vs 32.5%, P < 0.001), and paratracheal LNM (71.4% vs 28.6%, P < 0.001) were significantly associated with ipsilateral level-III LNM. Their importance levels were 0.120, 0.408, and 0.351, respectively. Primary tumor size (72.1% vs 27.9%, P = 0.003), ETE (70.4% vs 29.6%, P = 0.016), pretracheal LNM (68.3% vs 31.7%, P=0.001), and paratracheal LNM (80.8% vs 19.2%, P < 0.001) were significantly associated with ipsilateral level-IV LNM. Their importance levels were 0.164, 0.146, 0.216, and 0.472, respectively.

CONCLUSION

The LNM pathway of thyroid cancer has a certain regularity. For unilateral cN0-PTC patients with a tumor diameter > 2 cm and pretracheal or ipsilateral paratracheal LNM, LND at ipsilateral level III and level IV must be considered. When there is a tumor in the upper third of the thyroid with prelaryngeal LNM, LND at level II, level III and level IV must be considered.

The localization of thyroid cancers on the thyroid gland is a new risk factor for metastases of perithyroidal, peritracheal and central lymph nodes

OBJECTIVE

Lymph node metastasis is frequently detected in differentiated thyroid cancers. Central dissection is performed to the lymph nodes in patients with microscopic metastases in the intraoperative evaluation. Other indications for central dissections are tumor size and cervical lateral lymph node metastasis. We consider that the localization of thyroid cancer in the thyroid lodge may be another risk factor for central lymph node metastasis. For this reason, the purpose of the present study was to investigate the relations between thyroid cancer localization and lymph node metastasis in differentiated thyroid cancer patients who had no preoperative cervical metastases and who underwent total thyroidectomy, and peritracheal, perithyroidal, and central lymph node dissection.

METHOD

A total of 213 differentiated thyroid cancer cases followed in our general surgery and endocrinology clinic between September 2016 and May 2020 were evaluated retrospectively. Based on the data in the files, the patients who underwent total thyroidectomy, and central, perithyroidal, and peritracheal lymph node dissection were included in the study. The patients were divided into four Groups according to tumor localizations, those with tumors adjacent to the trachea (Group 1), upper thyroid pole (Group 2), thyroid middle part (Group 3), thyroid inferior (Group 4). The demographic characteristics, laboratory parameters, cancer types, and lymph node metastasis rates of the Groups were evaluated.

RESULTS

A total of 84% (179) of the cases had thyroid papillary cancer, 11.73% (25) had thyroid follicular cancer, and 4.2% (9) had poorly differentiated thyroid cancer. The mean age of all patients was found to be 49 ± 8.3 years, and the female/male ratio was 2.4. It was found that the differentiated thyroid cancers metastasized to the perithyroidal, peritracheal, and central lymph nodes at a rate of 57.74%. The distribution of these metastases according to the Groups was; 62.85% in Group 1, 11.53% in Group 2, 43.9% in Group 3, and 88.57% in Group 4. It was also found that 80.32% of the papillary cancer cases and 57.14% of the follicular cancer cases metastasized to central (level VI) lymph nodes in Group 4.

CONCLUSION

The localization of differentiated thyroid cancers is a new risk factor for perithyroidal metastases.

Preoperative Prediction of Central Cervical Lymph Node Metastasis in Fine-Needle Aspiration Reporting Suspicious Papillary Thyroid Cancer or Papillary Thyroid Cancer Without Lateral Neck Metastasis

Purpose

No non-invasive method can accurately determine the presence of central cervical lymph node (CCLN) metastasis in papillary thyroid cancer (PTC) until now. This study aimed to investigate factors significantly associated with CCLN metastasis and then develop a model to preoperatively predict CCLN metastasis in fine-needle aspiration (FNA) reporting suspicious papillary thyroid cancer (PTC) or PTC without lateral neck metastasis.

Patients and Methods

Consecutive inpatients who were diagnosed as suspicious PTC or PTC in FNA and underwent partial or total thyroidectomy and CCLN dissection between May 1^st, 2016 and June 30^th, 2018 were included. The total eligible patients were randomly divided into a training set and an internal validation set with the ratio of 7:3. Univariate analysis and multivariate analysis were conducted in the training set to investigate factors associated with CCLN metastasis. The predicting model was built with factors significantly correlated with CCLN metastasis and validated in the validation set.

Results

A total of 770 patients were eligible in this study. Among them, 268 patients had histologically confirmed CCLN metastasis, while the remaining patients did not. Factors including age, BRAF mutation, multifocality, size, and capsule involvement were found to be significantly correlated with the CCLN metastasis in univariate and multivariate analysis. A model used to predict the presence CCLN metastasis based on these factors and US CCLN status yielded AUC, sensitivity, specificity and accuracy of 0.933 (95%CI: 0.905-0.960, p < 0.001), 0.816, 0.966 and 0.914 in the training set and 0.967 (95%CI: 0.943-0.991, p < 0.001), 0.897, 0.959 and 0.936 in the internal validation set.

Conclusion

Age, BRAF mutation, multifocality, size, and capsule involvement were independent predictors of CCLN metastasis in FNA reporting suspicious PTC or PTC without lateral neck metastasis. A simple model was successfully built and showed excellent discrimination to distinguish patients with or without CCLN metastasis.

Papillary thyroid cancer: the value of bilateral diagnostic lymphadenectomy

Purpose

Papillary thyroid carcinoma (PTC) spreads early to lymph nodes (LN). However, prophylactic central (CND) and lateral neck dissection (LND) is controversially discussed in patients with clinically negative nodes (cN0). The preoperative prediction of LN metastasis is desirable as re-operation is associated with higher morbidity and poor prognosis. The study aims to analyse possible benefits of a systemic bilateral diagnostic lateral lymphadenectomy (DLL) for intraoperative LN staging.

Methods

Preoperative prediction of LN metastasis by conventional ultrasound (US) was correlated with the results of DLL and intra-/postoperative complications in 118 consecutive patients with PTC (cN0) undergoing initial thyroidectomy and bilateral CND and DLL.

Results

Lateral LNs (pN1b) were positive in 43/118 (36.4%) patients, including skip lesions (n = 6; 14.0%). Preoperative US and intraoperative DLL suspected lateral LN metastasis in 19/236 (TP: 8.1%) and 54/236 (TP: 22.9%) sides at risk, which were confirmed by histology. Sixty-seven out of 236 (FN: 28.4%) and 32/236 (FN: 13.6%) sides at risk with negative preoperative US and intraoperative DLL lateral LN metastasis were documented. DLL was significantly superior compared to US regarding sensitivity (62.8% vs 22.1%; p < 0.002), positive predictive value (100% vs 76.0%), negative predictive value (82.4% vs 68.2%), and accuracy (86.4% vs 69.1%), but not specificity (100% vs 96.0%; p = 0.039). DLL-related complications (haematoma) occurred in 6/236 [2.5%] sides at risk, including chylous fistula in 2/118 [1.7%] patients.

Conclusion

DLL can be recommended for LN staging during initial surgery in patients with PTC to detect occult lateral LN metastasis not suspected by US in order to plan lateral LN dissection.

Contrast-enhanced ultrasound characteristics of preoperative central cervical lymph node metastasis in papillary thyroid carcinoma

This study evaluated the preoperative diagnostic value of lymph node ultrasonography in distinguishing between benign and malignant central cervical lymph nodes (CCLNs) in patients with papillary thyroid carcinoma (PTC). A total of 176 patients who had PTC with 216 CCLNs (49 benign and 155 malignant) were enrolled in this study and preoperatively imaged by ultrasonography, including conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS). We evaluated the ultrasonography parameters for each lymph node. Binary logistic regression analysis indicated that multifocality of PTC and the absence of Hashimoto's thyroiditis are independent clinical features related to patients with PTC who also have malignant CCLNs. For preoperative ultrasonography features, heterogeneous enhancement and centripetal perfusion are independent ultrasonographic features to identify malignant and benign CCLNs. This study demonstrated that preoperative CEUS characteristics help to distinguish malignant CCLNs from benign CCLNs.

Ultrasonic Characteristics Improve Prediction of Central Lymph Node Metastasis in cN0 Unifocal Papillary Thyroid Cancer

BACKGROUND

Prediction of central lymph node metastasis (CLNM) is vital for clinical decision-making processes in clinically N0 (cN0) unifocal papillary thyroid carcinoma (PTC), but the sensitivity of preoperative detection of CLNM is limited. The aim of the present study was to determine whether there are ultrasonic (US) characteristics associated with CLNM.

METHODS

In total, 1657 PTC patients (514 men and 1143 women) were enrolled in the present study between January 2018 and May 2021. The patients met the following inclusion criteria based on preoperative detection: suspected nodule confirmed as PTC by biopsy; the nodule was unifocal and less than 4 cm in diameter; no prior neck radiation exposure; no extrathyroidal extension; and no CLNM or distant metastases on imaging. All the enrolled patients underwent total thyroidectomy with prophylactic central lymph node dissection (CLND). A postoperative pathological diagnosis was made.

RESULTS

CLNM was found in 58.4% of male patients and 36.9% of female patients. In univariate analysis, size, adjacent anterior capsule, distance to the lower pole and color Doppler flow imaging (CDFI) were considered risk factors for the male and female groups (p < 0.05). In multivariate analyses, size, adjacent anterior capsule, distance to the lower pole and CDFI were independent risk factors for male patients. For females, the independent risk factors included size, adjacent anterior capsule, distance to the lower pole and CDFI.

CONCLUSION

In the present cohort, US imaging characteristics, including size, adjacent anterior capsule, distance to the lower pole and CDFI, were identified to be potentially beneficial in preoperative clinical decision-making processes for cN0 unifocal PTC patients.

A comparative analysis of eight machine learning models for the prediction of lateral lymph node metastasis in patients with papillary thyroid carcinoma

BACKGROUND

Lateral lymph node metastasis (LLNM) is a contributor for poor prognosis in papillary thyroid cancer (PTC). We aimed to develop and validate machine learning (ML) algorithms-based models for predicting the risk of LLNM in these patients.

METHODS

This is retrospective study comprising 1236 patients who underwent initial thyroid resection at our institution between January 2019 and March 2022. All patients were randomly split into the training dataset (70%) and the validation dataset (30%). Eight ML algorithms, including the Logistic Regression, Gradient Boosting Machine, Extreme Gradient Boosting, Random Forest (RF), Decision Tree, Neural Network, Support Vector Machine and Bayesian Network were used to evaluate the risk of LLNM. The performance of ML models was evaluated by the area under curve (AUC), sensitivity, specificity, and decision curve analysis.

RESULTS

Among the eight ML algorithms, RF had the highest AUC (0.975), with sensitivity and specificity of 0.903 and 0.959, respectively. It was therefore used to develop as prediction model. The diagnostic performance of RF algorithm was dependent on the following nine top-rank variables: central lymph node ratio, size, central lymph node metastasis, number of foci, location, body mass index, aspect ratio, sex and extrathyroidal extension.

CONCLUSION

By combining clinical and sonographic characteristics, ML algorithms can achieve acceptable prediction of LLNM, of which the RF model performs best. ML algorithms can help clinicians to identify the risk probability of LLNM in PTC patients.

Blood immune indexes can predict lateral lymph node metastasis of thyroid papillary carcinoma

OBJECTIVE

To explore the clinical significance of blood immune indexes in predicting lateral lymph node metastasis (LLNM) of thyroid papillary carcinoma (PTC).

METHODS

The pathological data and preoperative blood samples of 713 patients that underwent thyroid surgery at affiliated Hangzhou First People's Hospital Zhejiang University School of Medicine from January 2013 to June 2021 were collected as the model group. The pathological data and preoperative blood samples of 177 patients that underwent thyroid surgery in the same hospital from July 2021 to October 2021 were collected as the external validation group. Univariate and multivariate logistic regression analyses were used to determine the independent risk factors of LLNM in PTC patients. A predictive model for assessing LLNM in PTC patients was established and externally validated using the external data.

RESULTS

According to univariate and multivariate logistic regression analyses, tumor diameter (P < 0.001, odds ratios (OR): 1.205, 95% confidence interval (CI): 1.162-1.249) and the preoperative systemic immune-inflammation index (SII) (P = 0.032, OR: 1.001, 95% CI: 1.000-1.002) were independent risk factors for distinguishing LLNM in PTC patients. When the Youden index was the highest, the area under the curve (AUC) was 0.860 (P < 0.001, 95% CI: 0.821-0.898). The externally validated AUC was 0.827 (P < 0.001, 95% CI: 0.724-0.929), the specificity was 86.4%, and the sensitivity was 69.6%. The calibration curve and the decision curve indicated that the model had good diagnostic value.

CONCLUSION

Blood immune indexes can reflect the occurrence of LLNM and the biological behavior of PTC. The predictive model established in combination with SII and tumor diameter can effectively predict the occurrence of LLNM in PTC patients.

Male Gender Is Associated with Lymph Node Metastasis but Not with Recurrence in Papillary Thyroid Carcinoma

BACKGROUND

The incidence of papillary thyroid carcinoma (PTC) is higher in females than in males, but it remains unclear whether gender is associated with the aggressiveness of this disease. We aimed to clarify the influence of gender on the risk of developing lymph node metastasis (LNM) and on the prognosis of PTC patients. Study Design. Retrospective cohort study. Setting. Academic tertiary care center.

METHODS

Clinical data of PTC patients who were admitted to the Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, between January 2013 and December 2018 were retrospectively reviewed. The differences in clinical features and outcomes between female and male patients were compared. Univariate and multivariate logistic regression analyses were conducted to assess the impact of gender on LNM. Kaplan-Meier curves were used to estimate recurrence-free survival (RFS).

RESULTS

A total of consecutive 2536 patients were enrolled in this study. Males accounted for 25.2% (639 cases) of all patients. Central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) rates were 52.5% (1346/2536) and 22.0% (558/2536), respectively. Male presented with higher LNM rates than female patients (65.7% vs. 51.2%; P < 0.001). Male gender was independently associated with LNM (OR = 1.93, 95% CI: 1.59-2.35; P < 0.001). After full adjustment, male gender still remained significantly associated with CLNM in all subgroups; however, subgroup analyses indicated no significant relationship between gender and LLNM. In addition, after a median follow-up period of 30 months, no significant difference was found in RFS between female and male patients (P=0.15).

CONCLUSIONS

This observational cohort study revealed that male gender was significantly associated with CLNM; whereas, LLNM was not different between female and male PTC patients in southwestern China. Moreover, currently, there is insufficient evidence to justify that male gender is an independent prognostic factor for recurrence.

Central Compartment Lymph Nodes Have Distinct Metastatic Patterns in Different Age Groups

BACKGROUND AND PURPOSE

Central compartment lymph node metastasis (CLNM) is a manifestation of tumor aggressiveness and an indicator of tumor prognosis. The purpose of this study was to construct a nomogram for evaluating CLNM patterns in papillary thyroid carcinoma (PTC) in different age groups.

METHOD

A total of 907 patients diagnosed with PTC from August 2014 to December 2018 were enrolled. A nomogram illustrating CLNM was generated using the results of multivariate logistic regression analysis.

RESULTS

According to the best Youden index, we set the cut-off age at 45 years. Multivariate logistic regression analysis showed that in patients aged <45 years, large tumor size (P<0.05), extra-thyroid extension (P<0.05) and thyroglobulin level >40 ng/ml (OR=2.985, 95% CI 1.379-6.462; P<0.05) were independent risk factors; meanwhile, Hashimoto's thyroiditis (OR=0.532, 95% CI 0.324-0.874; P<0.05) was a protective factor of CLNM. In the subgroup with age ≥45 years, large tumor size (P<0.05), extra-thyroid extension (P<0.05), unclear margin (OR=1.604, 95% CI 1.065-2.416; P<0.05), male gender (OR=2.009, 95% CI 1.257-3.212; P<0.05) were independent risk factors for CLNM. In the subgroup with age <45 years, an area under the curve (AUC) of 0.729 (95% CI 0.680-0.777); P<0.05) was obtained. In the ≥45 years subgroup, the AUC was 0.668 (95% CI 0.619-0.716; P<0.05).

CONCLUSION

CLNM of PTC in different age groups may have distinct patterns. Based on the potential risk factors for CLNM in patients with different age stratification, a user-friendly predictive model was established.

Vascular invasion predicts advanced tumor characteristics in papillary thyroid carcinoma

BACKGROUND

The clinical impact of vascular invasion in Papillary Thyroid Carcinoma (PTC) is not well understood. Our aim was to determine if there was an association between vascular invasion and other tumor characteristics and patient outcomes in PTC.

METHODS

A retrospective chart review was performed of 536 patients with PTC between January 2007-December 2011. Patient demographics, comorbidities, tumor characteristics, and outcomes were collected.

RESULTS

Vascular invasion was associated with lymphatic invasion, capsular invasion, extrathyroidal extension, and the presence of positive lymph nodes. Logistic regression revealed that tumor size was a predictor of vascular invasion. Vascular invasion in PTC tumors was associated with higher tumor recurrence rates, but there were no differences in mortality.

CONCLUSION

This study indicates that vascular invasion in PTC is associated with other aggressive pathologic features and an increased recurrence rate. For these reasons, vascular invasion should be an important tumor characteristic when determining extent of treatment.

Association of sonographic features and clinicopathologic factors of papillary thyroid microcarcinoma for prevalence of lymph node metastasis: a retrospective analysis

OBJECTIVE

The objective of the study was to develop an association between clinicopathologic and sonographic features of patients with papillary thyroid microcarcinoma and the prevalence of lymph node metastasis.

METHODS

Clinicopathologic and sonographic features of 415 patients of papillary thyroid microcarcinoma with (n = 102) or without (n = 313) lymph node metastasis were retrospectively reviewed. The thickness of the lymph node ≥ 6 mm with intra-lymph nodal occupying lesions considered lymph node metastasis. Also, it was considered metastasis if lymph node perfusion or blood flow defect was found with any thickness size. Univariate following multivariate analysis was performed for the prediction of sonographic features and clinicopathologic factors for the prevalence of lymph node metastasis.

RESULTS

Male gender (p = 0.041), age < 45 years (p = 0.042), preoperative calcitonin > 65 pg/ mL (p = 0.039), nodule size > 5 mm in diameter (p = 0.038), bilaterality (p = 0.038), tumor capsular invasion (p = 0.048), cystic change (p = 0.047), and hyper vascularity (p = 0.049) of thyroid nodules were associated with lymph node metastasis. Also, thyroid nodules 5 mm and more in diameter may have high aggressiveness.

CONCLUSION

These data helped the surgeon for individualized treatment in thyroid carcinoma and avoid unnecessary prophylactic surgery of the lymph node.

A Comparative Analysis of Six Machine Learning Models Based on Ultrasound to Distinguish the Possibility of Central Cervical Lymph Node Metastasis in Patients With Papillary Thyroid Carcinoma

Current approaches to predict central cervical lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) have failed to identify patients who would benefit from preventive treatment. Machine learning has offered the opportunity to improve accuracy by comparing the different algorithms. We assessed which machine learning algorithm can best improve CLNM prediction. This retrospective study used routine ultrasound data of 1,364 PTC patients. Six machine learning algorithms were compared to predict the possibility of CLNM. Predictive accuracy was assessed by sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve (AUC). The patients were randomly split into the training (70%), validation (15%), and test (15%) data sets. Random forest (RF) led to the best diagnostic model in the test cohort (AUC 0.731 ± 0.036, 95% confidence interval: 0.664–0.791). The diagnostic performance of the RF algorithm was most dependent on the following five top-rank features: extrathyroidal extension (27.597), age (17.275), T stage (15.058), shape (13.474), and multifocality (12.929). In conclusion, this study demonstrated promise for integrating machine learning methods into clinical decision-making processes, though these would need to be tested prospectively.

Dynamic Nomogram for Predicting Lateral Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

OBJECTIVE

To establish a dynamic nomogram based on preoperative clinical data for prediction of lateral lymph node metastasis (LLNM) of papillary thyroid carcinoma.

STUDY DESIGN

Retrospective study.

SETTING

The Sixth Affiliated Hospital of Sun Yat-Sen University.

METHODS

The data of 477 patients from 2 centers formed the training group and validation group and were retrospectively reviewed. Preoperative clinical factors influencing LLNM were identified by univariable and multivariable analysis and were to construct a predictive dynamic nomogram for LLNM. Receiver operating characteristic analysis and calibration curves were used to evaluate the predictive power of the nomogram.

RESULTS

The following were identified as independent risk factors for LLNM: male sex (odds ratio [OR] = 4.6, P = .04), tumor size ≥10.5 mm (OR = 7.9, P = .008), thyroid nodules (OR = 6.1, P = .013), irregular tumor shape (OR = 24.6, P = .001), rich lymph node vascularity (OR = 9.7, P = .004), and lymph node location. The dynamic nomogram constructed with these factors is available at https://zxh1119.shinyapps.io/DynNomapp/. The nomogram showed good performance, with an area under the curve of 0.956 (95% CI, 0.925-0.986), a sensitivity of 0.87, and a specificity of 0.91, if high-risk patients were defined as those with a predicted probability ≥0.3 or total score ≥200. The nomogram performed well in the external validation cohort (area under the curve, 0.915; 95% CI, 0.862-0.967).

CONCLUSIONS

The dynamic nomogram for preoperative prediction of LLNM in papillary thyroid carcinoma can help surgeons identify high-risk patients and develop individualized treatment plans.

Value of Pyruvate Carboxylase in Thyroid Fine-Needle Aspiration Wash-Out Fluid for Predicting Papillary Thyroid Cancer Lymph Node Metastasis

The incidence of papillary thyroid carcinoma (PTC) is increasing. Lymph node metastatic status of PTC is a major factor for decision marking of surgery and surgical extend, however, no reliable tool exists for prediction of PTC nodal metastasis, for example, ultrasound cannot qualitatively diagnose and effectively detect central lymph node metastasis (CLNM). Therefore, the development of a new diagnostic biomarker is crucial for CLNM. Metabolic dysregulation is an important factor associated with malignancy and metastasis of tumors. Pyruvate carboxylase (PC) is a major anaplerotic enzyme that catalyzes the carboxylation of pyruvate to form oxaloacetate, which has been suggested to be involved in the tumorigenesis of several cancers, including PTC. This study aimed to explore the role of PC expression in thyroid fine-needle aspiration (FNA) wash-out fluid for predicting CLNM in PTC, and to explore how PC is involved in PTC development. The expression levels of PC in PTC tissues and normal thyroid tissues were first compared based on bioinformatics analysis of public databases, including the Gene Expression Profiling (GEPIA), Oncomine and Gene Expression Omnibus (GEO) databases. Then, the PC mRNA and protein expression levels were measured by RT-PCR and Immunohistochemistry (IHC) in surgical tissues from a total of 42 patients with surgically confirmed PTC, and compared in patients with and without CLNM. Further, to assess PC expression in diagnostic biopsies, a total of 71 thyroid nodule patients with ultrasound-guided FNA wash-out fluid samples and cytological diagnosis were prospectively enrolled in the study. Then, we analyzed the mechanism of PC-mediated PTC progression in vitro. This study showed that PC expression was higher in PTC tissues and thyroid FNA wash-out fluid samples from patients with CLNM than those from patients without CLNM, and that PC-induced PTC metastasis may occur through the TGF-β/Smad-regulated epithelial-mesenchymal transition (EMT) pathway.

Value of Combining Clinical Factors, Conventional Ultrasound, and Contrast-Enhanced Ultrasound Features in Preoperative Prediction of Central Lymph Node Metastases of Different Sized Papillary Thyroid Carcinomas

Purpose

Early and accurate preoperative diagnosis of central lymph node metastasis (CLNM) is crucial to improve surgical management of patients with clinical lymph node-negative papillary thyroid carcinoma (PTC). Towards improving diagnosis of CLNM, we assessed the value of combining preoperative clinical characteristics, conventional ultrasound, and contrast-enhanced ultrasound (CEUS) in preoperative prediction of CLNM of different sized PTCs.

Patients and Methods

Patients were divided according to tumor size: a PTC group (>10 mm) and a papillary thyroid microcarcinoma (PTMC) group (≤10 mm). We retrospectively analyzed the clinical and ultrasonographic features of 120 PTC patients and 165 PTMC patients. Multivariate logistic regression analysis was used to screen independent risk factors and establish prediction models. Receiver operating characteristic curves were used to determine the best cut-off values for continuous variables and assess the performance of prediction models.

Results

Independent risk predictors of CLNM for the PTC group were extrathyroidal extension in CEUS (OR=7.923), tumor size >14 mm (OR=5.491), and multifocality (OR=3.235). For the PTMC group, the independent risk factors were the distance from the thyroid capsule =0 mm (OR=4.629), male (OR=3.315), tumor size >5 mm (OR=3.304), and microcalcification (OR=2.560). The predictive model of combined method had better performance in predicting CLNM of PTC compared with models based on CEUS and conventional ultrasound alone (area under the curve: 0.832 vs 0.739, P=0.0011; 0.832 vs 0.678, P=0.0012). For PTMC, comparing with CEUS, the combined method and conventional ultrasound performed better than CEUS alone in predicting CLNM (area under the curve: 0.783 vs 0.636, P=0.0016; 0.738 vs 0.636, P=0.0196).

Conclusion

The predictive models of combined method obtained from significant preoperative clinical and ultrasonographic features can potentially improve the preoperative diagnosis and individual treatment of CLNM in patients with PTC and PTMC. CEUS may be helpful in predicting CLNM of PTC, but CEUS would be ineffective in predicting CLNM of PTMC.

The impact of thyroid tumor features on lymph node metastasis in papillary thyroid carcinoma patients in head and neck department at KAMC: A retrospective cross-sectional study

Papillary thyroid carcinoma (PTC) is the most prevalent type of thyroid cancer. It is one of the most common types of malignancy of the thyroid that spreads to cervical lymph nodes. Lymph node metastasis (LNM) is an important factor when determining recurrence risk, and determining the extent of lymph node involvement can guide treatment. Our main objective is to evaluate the association between the size of the tumor and the number of lymph node metastases in patients with PTC. Methods: We conducted an electronic retrospective chart review of 125 patients with PTC followed in the Head and Neck Department at KAMC from 2009 to 2020. Twenty-two patients included in our study were pathologically and clinically diagnosed and confirmed to have LNM of PTC. Results: The study included 22 PTC patients who had undergone lymph node dissections. Patients had a median age of 38.8 years (IQR = 32.2–54.5), and the median tumor size was 20.5 mm. The most commonly affected level of the neck was IV (76.2%). Distant metastasis M1 was seen in only two patients (9.1%). Tumors sizes >30mm (75%) had ≥5 LNM. Most cases were the classic subtype PTC. For the site of the tumor, the site had a significant impact on the number of LNM (p = 0.004). Multifocality had a high impact on LNM (p = 0.019). Conclusions: This study showed no association between the size of PTC and the number of LNMs. The bilaterality of PTC was significantly associated with a high number of LNMs.

•

Lymph nodes in level IV were the most common metastasis site for PTC.

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Bilateral and multifocal PTC were significantly associated with a higher number of lymph nodes metastasis.

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The size of the tumor was not significantly related to the number of lymph node metastasis.

Enemy Beyond the Wall: Clinicopathological Features of Intrathyroidal Papillary Thyroid Carcinoma (T1-T3a) That Metastasize to Lymph Nodes Without Extrathyroidal Extension

The aim of this study was to determine the clinicopathological features of papillary thyroid carcinomas (PTC) without extrathyroidal extension (ETE) and with lymph node metastasis (LNM). PTC > 1 cm increased the risk of LNM by 2.161 times compared to papillary thyroid microcarcinoma. The risk increased by 3.774 times in males and 1.553 times in the presence of multifocality. Presence of vascular invasion (VI) increased the risk of LNM by 3.093 times in patients without capsular invasion (CI). Clinicians should be careful about possible LNM in patients with large primary tumor diameter, multifocal tumors, CI and VI.

Occult contralateral central neck metastasis in papillary thyroid carcinoma with preoperatively documented ipsilateral lateral neck metastasis

BACKGROUND

This study was conducted to evaluate risk factors and long-term prognosis of contralateral central neck metastasis (CCNM) in papillary thyroid cancer (PTC) patients with ipsilateral lateral neck metastasis. We present clinical evidence to aid in surgical decision-making regarding the extent of central neck dissection (CND), focusing on separation between ipsilateral and contralateral sides.

METHODS

A total of 379 PTC patients who underwent total thyroidectomy and concomitant bilateral central neck dissection with ipsilateral lateral neck dissection (LND) at a single institution was retrospectively included between January 1997 and December 2015.

RESULTS

The median follow-up time was 83.2 months, the mean age was 44.3 years, and the mean tumor size was 1.5 cm. Among the study sample, 266 patients were female (70.2%) and 113 (29.8%) were male. Of 379 patients, CCNM was present in 34.6%. In multivariate analysis, male sex (adjusted OR = 2.46, p = 0.002), bilaterality (adjusted OR = 2.58, p = 0.004), number of metastatic ipsilateral central lymph nodes (adjusted OR = 1.15, p = 0.002), number of metastatic lateral lymph nodes (adjusted OR = 1.48, p < 0.001), and three-level metastasis (adjusted OR = 2.46, p = 0.012) were identified as risk factors of CCNM. Overall recurrence occurred in 6.0% and 11.5% of patients in the CCNM (-) group and CCNM (+) group, respectively. In addition, contralateral recurrence was observed in 1.2% patients and 0.8% patients in the CCNM (-) group and CCNM (+) group, respectively. However, CCNM did not significantly increase risk of recurrence (adjusted HR = 1.01, p = 0.981).

CONCLUSIONS

Although the probability of pathological CCNM is not negligible, CCNM was not associated with higher risk of recurrence. This study suggest that central neck dissection may be limited to the ipsilateral side, and the result regarding prognosis of CCNM may help to avoid bilateral CND so that it could have potential to minimize unnecessary surgery-related complications such as recurrent laryngeal nerve(RLN) injury or hypoparathyroidism.

Therapeutic Strategy in Low-Risk Papillary Thyroid Carcinoma - Long-Term Results of the First Single-Center Prospective Non-Randomized Trial Between 2011 and 2015

Optimal therapeutic strategy in low advanced papillary thyroid carcinoma (PTC) is still a matter of debate. The management differs depending on the country. A prospective non-randomized study was performed to evaluate whether less extensive surgery could be a safe, acceptable, and sufficient therapeutic option in PTC cT1N0M0 patients. The present paper summarizes the results of over a 5-year follow-up.

MATERIAL

Our prospective group (PG) treated between 2011 and 2015 consisted of 139 patients with cT1aN0M0 PTC who underwent lobectomy (LT) as initial surgical treatment (PGcT1aN0M0 group) and 102 cT1bN0M0 patients in whom total thyroidectomy (TT) with unilateral central neck dissection (CND) was performed (PGcT1bN0M0). PG was compared with the retrospective group (RG) of patients who underwent TT with bilateral CND between 2004 and 2006: 103 cT1aN0M0 patients (RGcT1aN0M0) and 91cT1bN0M0 (RGcT1bN0M0). The risks of reoperation, cancer relapse and postoperative complications were analyzed.

RESULTS

Only 12 cT1aN0M0 patients (7.6%) withdrew from the trial and underwent TT with bilateral CND. Over 90% of patients accepted less extensive surgery. In 4 cT1aN0M0 cases, TT with CND was performed due to lymph node metastases found intraoperatively. The initial clinical stage according to the TNM/AJCC 7^th edition was confirmed histologically in 77% of cases in PGT1aN0M0 and in 72% in PGT1bN0M0, respectively. 24 PGcT1aN0M0 patients were reoperated on. In this group, cancer lesions in the postoperative histological specimens were found in 8 cases (32%). Five-year disease-free survival (DFS) was excellent. However, no statistically significant differences were found between PG and RG groups (99.3% in PGcT1aN0M0 and 99.0%, in RGcT1aN0M0; p = 0.41 and 98%, in PGcT1bN0M0 and 94.4% in RGcT1bN0M0; p=0.19). No significant differences were observed in the incidence of early paresis of the recurrent laryngeal nerves between PG and RG. However, as predicted, LT completely eliminated the risk of postoperative hypoparathyroidism.

SUMMARY

The results of the prospective clinical trial confirm that less extensive surgery in adequately selected low-advanced PTC patients is both safe and sufficient.

Clinical Study of Ultrasonographic Risk Factors for Central Lymph Node Metastasis of Papillary Thyroid Carcinoma

BACKGROUND

Thyroid cancer is the most common malignancy of the endocrine system worldwide. Papillary thyroid cancer (PTC) is the most common pathologic type. The preoperative diagnosis of PTC and central lymph node metastasis (CLNM) or metastatic tendency is of great clinical significance to the diagnosis, treatment and prognosis of these patients. This study was conducted to investigate the correlation between ultrasound features and central CLNM of PTC.

METHODS

This study retrospectively analyzed patients who underwent PTC surgery and central lymph node dissection in the Department of Surgery, Beijing Tiantan Hospital, from January 2019 to February 2020. According to the inclusion and exclusion criteria, data from 136 patients were ultimately included, and the clinical and ultrasonic data of the patients were analyzed by multivariate regression to evaluate the correlation among grayscale ultrasound (US), superb microvascular imaging (SMI) and contrast-enhanced ultrasound (CEUS) features of thyroid nodules and CLNM of PTCs.

RESULTS

The multivariate analysis showed that tumor size, multifocality, microcalcification characteristics, SMI vascularization, and CEUS evaluation of contact with the adjacent capsule were correlated with PTC metastasis (P=0.008, P=0.001, P=0.028, P=0.041, and P< 0.001, respectively). Comparisons of the area under the ROC curves revealed that the area under the ROC curve of the degree of nodular invasion into the thyroid capsule was the largest (AUC: 0.754). The sensitivity and specificity for evaluating CLNM of PTC were 67.7% and 83.1%, respectively.

CONCLUSIONS

Ultrasound characteristics of the following features are associated with a high risk of lymph node metastasis in PTCs: maximum diameter of nodules ≥1 cm, multifocality, ≥5 microcalcifications, abundant blood flow of SMI in nodules and nodule contact with the thyroid capsule ≥25% under CEUS. Ultrasound has clinical value in the preoperative evaluation of CLNM of PTCs.

Clinical Relevance and Management of Recurrent Laryngeal Nerve Inlet Zone Lymph Nodes Metastasis in Papillary Thyroid Cancer

BACKGROUND

Recurrent nodal disease often occurs in recurrent laryngeal nerve inlet zone (RLNIZ), leading to difficult surgical management.

METHODS

Medical records of 947 patients with PTC and 33 patients with recurrent PTC were retrospectively reviewed. Totally 169 sides of RLNIZ dissection in 152 patients (17 cases were bilateral and 135 cases were unilateral) with primary surgery and 4 patients with structural recurrent disease were included for the analysis.

RESULTS

The rate of lymph node metastasis in RLNIZ was 31.3% (47/150). The incidence of transient hypoparathyroidism was 5.9% and no RLN injury and permanent hypoparathyroidism occurred. RLNIZ lymph nodes metastasis (LNM) was significantly associated with age <45 years, larger tumor size, number of CNLNM, and lateral node metastasis. CNLNM and lateral node metastasis were independent risk factors for RLNIZ LNM. Recurrent nodal disease in RLNIZ was identified in four of 33 patients and permanent recurrent laryngeal nerve (RLN) injury was observed in one of four patients.

CONCLUSION

Lymph nodes in RLNIZ are usually involved in patients with heavy tumor burden and can be removed safely at initial surgery. Once central or lateral LNM was confirmed preoperatively or intraoperatively, RLNIZ lymph node dissection should be carefully performed to reduce the rate of structural recurrence in the central compartment.

Risk Factors That Influence Surgical Decision-Making for Patients with Low-Risk Differentiated Thyroid Cancer with Tumor Diameters of 1-4 cm

Background

There are several controversies between thyroid lobectomy and total thyroidectomy for surgical management of low-risk differentiated thyroid cancer (DTC) with a tumor diameter of 1–4 cm.

Patients and Methods

In this study, we explore the factors related to selection of type of surgical procedure for 103 low-risk DTC patients with a tumor diameter of 1–4 cm.

Results

Among 103 low-risk DTC patients with tumor diameters of 1–4 cm, 43 patients underwent total thyroidectomy and 60 patients underwent thyroid lobectomy based on postoperative pathology. A ROC curve showed that the optimal diagnostic threshold for selecting surgical modality was a tumor diameter of 2.15 cm. For these low-risk DTC patients, the sensitivity and specificity for predicting thyroid lobectomy when tumor diameter <2.15 cm while total thyroidectomy when tumor diameter ≥2.15 cm are 46.5% and 78.3%, respectively. There were significant differences between the selection of type of surgical procedure in patient groups with 1) tumors with multiple foci group vs a single focus (P<0.05), and 2) tumor diameter of ≥2.15 cm vs <2.15 cm (P<0.05). There was no significant difference between gender and age groups (P>0.05). Multivariate analysis confirmed that tumors with multiple foci and diameter ≥2.15 cm were the primary risk factors for implementation of total thyroidectomy (P<0.05).

Conclusion

The diameter and multifocal nature of low-risk DTC tumors are the primary factors related to preferred surgical modality. This study revealed that thyroid lobectomy is more applicable to patients with tumor diameter <2.15 cm and a single focus, whereas, total thyroidectomy was preferred in patients with tumor diameter ≥2.15 cm and/or multiple foci.

Completion Total Thyroidectomy Is Not Necessary for Papillary Thyroid Microcarcinoma with Occult Central Lymph Node Metastasis: A Long-Term Serial Follow-Up

Simple Summary

The necessity of completion total thyroidectomy is unclear in patients with papillary thyroid microcarcinoma (PTMC) with only pathological central lymph node metastasis (pCLNM). The aim of our study was to determine the necessity of completion total thyroidectomy after an initial surgery by comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We retrospectively compared the pathological central lymph node (pCLN)-positive group of 165 patients who underwent thyroid lobectomy with the pCLN-negative group of 711 patients and found no difference between the two groups in the recurrence rate and disease-free survival rates. Therefore, PTMC patients who underwent thyroid lobectomy with prophylactic central compartment neck dissection and were diagnosed with pCLNM after surgery do not require completion total thyroidectomy.

Abstract

The necessity of completion total thyroidectomy in patients with papillary thyroid microcarcinoma (PTMC) and pathological central lymph node metastasis (pCLNM) who underwent thyroid lobectomy with central compartment neck dissection (CCND) is unclear. We determined the necessity of completion total thyroidectomy by retrospectively comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We enrolled 876 patients with PTMC who underwent thyroid lobectomy with prophylactic CCND from January 1986 to December 2009. Patients were divided according to central lymph node (CLN) metastasis: 165 (18.8%) and 711 (81.2%) in the CLN-positive and CLN-negative groups, respectively. Medical records were reviewed retrospectively, and clinicopathologic characteristics and recurrence rates were analyzed. The CLN-positive group was associated with male sex (p = 0.001), larger tumor size (p < 0.001), and more microscopic capsular invasion (p < 0.001) compared with the CLN-negative group. There was no significant difference between the two groups’ recurrence (p = 0.133) or disease-free (p = 0.065) survival rates. Univariate and multivariate analyses showed no factors associated with tumor recurrence except male sex (hazard ratio = 3.043, confidence interval 1.117–8.288, p = 0.030). Patients who were diagnosed with pCLNM after undergoing thyroid lobectomy with prophylactic CCND do not require completion total thyroidectomy; however, frequent follow-up is necessary for patients with PTMC and pCLNM.

An Ultrasound Radiomics Nomogram for Preoperative Prediction of Central Neck Lymph Node Metastasis in Papillary Thyroid Carcinoma

Purpose: This study aimed to establish and validate an ultrasound radiomics nomogram for the preoperative prediction of central lymph node (LN) metastasis in patients with papillary thyroid carcinoma (PTC).

Patients and Methods: The prediction model was developed in 609 patients with clinicopathologically confirmed unifocal PTC who received ultrasonography between Jan 2018 and June 2018. Radiomic features were extracted after the ultrasonography of PTC. Lasso regression model was used for data dimensionality reduction, feature selection, and radiomics signature building. The predicting model was established based on the multivariable logistic regression analysis in which the radiomics signature, ultrasonography-reported LN status, and independent clinicopathologic risk factors were incorporated, and finally a radiomics nomogram was established. The performance of the nomogram was assessed with respect to the discrimination and consistence. An independent validation was performed in 326 consecutive patients from July 2018 to Sep 2018.

Results: The radiomics signature consisted of 23 selected features and was significantly associated with LN status in both primary and validation cohorts. The independent predictors in the radiomics nomogram included the radiomics signature, age, TG level, TPOAB level, and ultrasonography-reported LN status. The model showed good discrimination and consistence in both cohorts: C-index of 0.816 (95% CI, 0.808–0.824) in the primary cohort and 0.858 (95% CI, 0.849–0.867) in the validation cohort. The area under receiver operating curve was 0.858. In the validation cohort, the accuracy, sensitivity, specificity and AUC of this model were 0.812, 0.816, 0.810, and 0.858 (95% CI, 0.785–0.930), respectively. Decision curve analysis indicated the radiomics nomogram was clinically useful.

Conclusion: This study presents a convenient, clinically useful ultrasound radiomics nomogram that can be used for the pre-operative individualized prediction of central LN metastasis in patients with PTC.

Predictive factors of lateral lymph node metastasis in conventional papillary thyroid carcinoma

BACKGROUND

Lymph node metastasis (LNM) has been a significant predictor for local recurrence and distant metastasis in papillary thyroid carcinoma (PTC). However, the clinical predictors for conventional papillary thyroid carcinoma (CPTC) with lateral lymph node metastasis (LLNM) have yet to be established. Our work aimed to effectively identify the risk factors of LLNM in CPTC, helping surgeons to devise better individualized therapy strategies.

METHODS

We retrospectively analyzed 652 patients who were diagnosed with CPTC in the Department of General Surgery at Guangdong Provincial People's Hospital between October 2015 and June 2019. Univariate and multivariate logistic regression was used to analyze the correlation between clinicopathological characteristics and the LLNM of CPTC.

RESULTS

The incidence of LLNM in CPTC was 29.75% (194 of 652 patients). Univariate analysis found that LLNM was significantly associated with gender, age, number of central lymph nodes (CLNs), primary tumor location, multifocality, maximum tumor diameter, and BRAF V600E mutation. Independent risk factors for LLNM were multifocality (P=0.017, OR =4.325, 95% CI: 1.298-14.408), maximum tumor diameter (P<0.001, OR =4.076, 95% CI: 1.945-8.540), primary tumor location (P=0.037, OR =2.127, 95% CI: 1.046-4.328), number of CLNs (P<0.001, OR =8.604, 95% CI: 3.630-20.390), and BRAF V600E mutation (P=0.001, OR =3.913, 95% CI: 1.803-8.496) by multivariate analysis.

CONCLUSIONS

LLNM in CPTC was related to the large volume of central lymph node metastasis (CLNM), tumor located in the upper lobe, multifocality, tumor diameter >2 cm, and BRAF V600E mutation-negative, which should be considered when examining patients with suspected metastasis in the lateral compartment.

Papillary thyroid carcinoma: an ultrasound-based nomogram improves the prediction of lymph node metastases in the central compartment

OBJECTIVES

To develop a nomogram based on postoperative clinical and ultrasound findings to quantify the probability of central compartment lymph node metastases (CLNM).

METHODS

A total of 952 patients with histologically confirmed papillary thyroid carcinoma (PTC) were included in this retrospective study and assigned to three groups based on sex and age. The strongest predictors for CLNM were selected according to ultrasound imaging features, and an ultrasound (US) signature was constructed. By incorporating clinical characteristics, a predictive model presented as a nomogram was developed, and its performance was assessed with respect to calibration, discrimination and clinical usefulness.

RESULTS

Predictors contained in the nomogram included US signature, US-reported LN status and age. The US signature was constructed with tumour size and microcalcification. The nomogram showed excellent calibration in the training dataset, with an AUC of 0.826 (95% CI, 0.765-0.887) for male patients, 0.818 (95% CI, 0.746-0.890) for young females and 0.808 (95% CI, 0.757-0.859) for elder females. For male and young female patients, application of the nomogram to the validation cohort revealed good discrimination, with AUCs of 0.813 (95% CI, 0.722-0.904) and 0.814 (95% CI, 0.712-0.915), respectively. Conversely, for elderly female patients, the nomogram failed to show good performance with an AUC of 0.742 (95% CI, 0.661-0.823).

CONCLUSION

This ultrasound-based nomogram may serve as a useful clinical tool to provide valuable information for treatment decisions, especially for male and younger female patients.

KEY POINTS

• Age, gender, US-reported LN status and US signature were the strongest predictors of CLNM in PTC patients and informed the development of a predictive nomogram. • Microcalcification was the strongest predictor in the US signature, as CLMN was identified in approximately 92% of patients characterised by diffuse microcalcification. • Stratified by sex and age, this nomogram achieved good performance in predicting CLNM, especially in male and young female patients. This prediction tool may be useful as an imaging marker for identifying CLNM preoperatively in PTC patients and as a guide for personalised treatment.

Factors affecting online health community participation behavior in patients with thyroid cancer

Globally, cancer patients obtain much of their disease information online. Online health communities allow patients to share questions and information about diseases. However, there have been few studies on the factors affecting online health community participation behavior in cancer patients. Online social networking is associated with mental health problems, and patients with thyroid cancer experience high levels of distress, anxiety and depression. The purpose of this study was to investigate factors associated with use of online health communities by patients with thyroid cancer to understand the characteristics of patients participating in such online communities. A questionnaire survey was completed by 114 thyroid cancer patients admitted for surgery at a general hospital in Seoul, Korea. General characteristics, clinical characteristics, attitude toward cancer, distress, and anxiety and depression scores of patients who joined an online health community (user group) and patients who did not (non-user group) were compared. The factors affecting online health community participation were education (p = 0.049), tumor size (p = 0.010), attitude toward cancer (p = 0.022), and anxiety and depression (p = 0.021). The average score of satisfaction with the online health community was 4.25 of 5. The user group had larger tumors, a high awareness of the risk of thyroid cancer, and high levels of anxiety and depression. Patients who actively used the online health community have relatively larger cancer size and had higher levels of mental stress. As such patients are often very anxious and depend heavily on the gathered information, the quality of this information is important. Healthcare professionals need to develop appropriate interventions for patients participating in the online health community.

Impact of Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features on Revised Bethesda System Malignancy Rates at a Single Institution

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) standardizes thyroid cytopathology reporting in six tier diagnostic categories. In recent years, noninvasive encapsulated follicular variant of papillary thyroid carcinoma was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This study examines the impact of NIFTP on the BSRTC risk of malignancy (ROM).

METHODS

This was a retrospective review of prospectively collected data from 565 patients who underwent fine needle aspiration and thyroidectomy at a single institution. ROM for each Bethesda category was analyzed and calculated with NIFTP classified as a malignant and nonmalignant lesion. Absolute and relative differences between ROM were compared.

RESULTS

Of 565 patients, 19 were Bethesda I, 159 were Bethesda II, 178 were Bethesda III, 46 were Bethesda IV, 42 were Bethesda V, and 121 were Bethesda VI. ROM differences with NIFTP classified as malignant versus nonmalignant for each class were as follows: Bethesda I, no change; Bethesda II, 18%-14%; Bethesda III, 55%-48%; Bethesda IV, 50%-35%; Bethesda V, 93%-91%; and Bethesda VI, 99%-98%. Absolute ROM differences for each category were as follows: Bethesda I, 0%; Bethesda II, 4%; Bethesda III, 7%; Bethesda IV, 15%; Bethesda V, 2%; and Bethesda VI, 1%.

CONCLUSIONS

A decreasing trend in absolute and relative ROM was seen in Bethesda II, III, and IV categories; however, exclusion of NIFTP as a malignant lesion did not significantly alter the ROM of BSRTC categories. Surgeons should assess their respective institution's experiences with NIFTP and the BSRTC.

Ultrasound validation of predictive model for central cervical lymph node metastasis in papillary thyroid cancer on BRAF

Aim: To compare the value of predictive power of the models for central cervical lymph node metastasis (CLNM) in papillary thyroid carcinomas (PTCs). Patients & methods: 220 PTCs were prospectively enrolled into the study with pathological examination. We established a new risk model with univariate and multivariate analyses and receiver-operating characteristic curves were plotted. Z-test was performed to compare the area under two curves and validated the predictive model for central CLNM in PTCs. The comparison of previous and new predictive model was analyzed. Results: Microcalcification, capsule contact or involvement, internal flow and BRAF^V600E mutation were four independent risk factors for PTCs with central CLNMs. The area under the curves for the new and the previous model were 0.948 and 0.934 (p = 0.572), respectively. Conclusion: Two predictive models showed strong consistency in predicting central CLNM in PTCs. The predictive model may be helpful in selecting appropriate treatment method in PTCs.