The management of advanced thyroid cancer

Stereotactic Radiosurgery for Patients with Spinal Metastases from Thyroid Cancer: A 20-Year Experience

OBJECTIVE

Primary thyroid cancer metastasizing to the spine portends poor survival and low quality of life. Current management strategies continue to evolve. This single-institution retrospective study analyzes outcomes after spinal stereotactic radiosurgery for patients with spinal metastases from thyroid cancer.

METHODS

Nineteen patients (median age: 64.5 years) were treated with stereotactic radiosurgery (SRS) for spinal primary thyroid metastases (40 metastases, 47 vertebral levels) between 2003 and 2023. Nineteen (47.5%) lesions had epidural involvement and 20 (50%) lesions were classified as potentially unstable or unstable via the Spinal Instability Neoplastic Score. The median tumor volume per lesion was 33 cc (range: 1.5-153). The median single fraction prescription dose was 20 Gy (range: 12-23.5).

RESULTS

The median follow-up period was 15 months (range: 2-40). Five (12.8%) lesions locally progressed at a median of 9 months (range: 4-26) after SRS. The 1-, 2-, and 3-year local tumor control rates per lesion were 90.4%, 83.5%, and 75.9%, respectively. On univariate analysis, age at SRS >70 years (P = 0.05, hazard ratio: 6.86, 95% confidence interval: 1.01-46.7) was significantly correlated with lower rates of local tumor control. The median overall survival was 35 months (range: 2-141). The 1-, 2-, and 3-year overall survival rates were 73.7%, 50.4%, and 43.2%, respectively. For 33 lesions initially associated with pain, patients reported pain improvement (22 lesions, 66.7%), stability (10 lesions, 30.3%), and worsening (1 lesion, 3.0%) after SRS. One patient developed dysphagia 4 months after SRS treatment.

CONCLUSIONS

SRS can be utilized as an effective and safe primary and adjuvant treatment option for primary thyroid metastases to the spine.

Case of papillary thyroid cancer presenting with an inoperable cervical mass successfully treated with high-dose radiation therapy

External-beam radiation therapy (EBRT) for differentiated thyroid cancer has been controversial. Palliative irradiation is usually recommended for patients with treatment-resistant relapse and/or distant metastases, but high-dose EBRT is not often indicated in this situation. A 50-year-old man had treatment-resistant recurrence of an inoperable cervical mass and multiple lung metastases after total thyroidectomy and neck dissection. Because the patient had good performance status and no other life-threatening metastases, he received high-dose intensity-modulated radiation therapy (IMRT). Remarkably, the tumour shrank during treatment. After 3 months, he had bleeding from the internal carotid artery. The bleeding was outside the high-dose irradiation site and was likely due to infection; emergency interventional radiology was performed. The post-EBRT clinical course was favourable and the cervical mass almost disappeared. The patient remained alive for 3 years post treatment. It is possible to extend the indication of high-dose intensity-IMRT in selected patients with differentiated thyroid cancer.

Non-Coding RNAs: Uncharted Mediators of Thyroid Cancer Pathogenesis

Thyroid cancer is the most prevalent malignancy of the endocrine system and the ninth most common cancer globally. Despite the advances in the management of thyroid cancer, there are critical issues with the diagnosis and treatment of thyroid cancer that result in the poor overall survival of undifferentiated and metastatic thyroid cancer patients. Recent studies have revealed the role of different non-coding RNAs (ncRNAs), such as microRNAs (miRNAs), long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs) that are dysregulated during thyroid cancer development or the acquisition of resistance to therapeutics, and may play key roles in treatment failure and poor prognosis of the thyroid cancer patients. Here, we systematically review the emerging roles and molecular mechanisms of ncRNAs that regulate thyroid tumorigenesis and drug response. We then propose the potential clinical implications of ncRNAs as novel diagnostic and prognostic biomarkers for thyroid cancer.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Expression of the DNA-dependent protein kinase catalytic subunit is associated with the radiosensitivity of human thyroid cancer cell lines

The prognosis and treatment of thyroid cancer depends on the type and stage of the disease. Radiosensitivity differs among cancer cells owing to their varying capacity for repair after irradiation. Radioactive iodine can be used to destroy thyroid cancer cells. However, patient prognosis and improvement after irradiation varies. Therefore, predictive measures are important for avoiding unnecessary exposure to radiation. We describe a new method for predicting the effects of radiation in individual cases of thyroid cancer based on the DNA-dependent protein kinase (DNA-PK) activity level in cancer cells. The radiation sensitivity, DNA-PK activity, and cellular levels of DNA-PK complex subunits in five human thyroid cancer cell lines were analyzed in vitro. A positive correlation was observed between the D10 value (radiation dose that led to 10% survival) of cells and DNA-PK activity. This correlation was not observed after treatment with NU7441, a DNA-PK-specific inhibitor. A significant correlation was also observed between DNA-PK activity and expression levels of the DNA-PK catalytic subunit (DNA-PKcs). Cells expressing low DNA-PKcs levels were radiation-sensitive, and cells expressing high DNA-PKcs levels were radiation-resistant. Our results indicate that radiosensitivity depends on the expression level of DNA-PKcs in thyroid cancer cell lines. Thus, the DNA-PKcs expression level is a potential predictive marker of the success of radiation therapy for thyroid tumors.

Dysadherin specific drug conjugates for the treatment of thyroid cancers with aggressive phenotypes

Background

EDC1 is a novel type of antibody-drug conjugate which binds and inhibits the Na,K-ATPase on the surface of cancer cells expressing dysadherin. The purpose of this study was to determine the expression of dysadherin in different types of thyroid carcinoma, and evaluate the therapeutic potential of EDC1 for thyroid carcinomas.

Methods

Thyroid tissues from 158 patients were examined for dysadherin expression and correlation with clinicopathological features. Thyroid cancer cell lines were examined for the expression of dysadherin and effective dose range of EDC1.

RESULTS

One in 53 benign thyroid tissues and 62% of thyroid cancers expressed dysadherin. All anaplastic and a majority of papillary thyroid cancers overexpressed dysadherin, while 25% of follicular thyroid cancers was found to be positive for dysadherin. Dysadherin expression significantly correlated with extrathyroidal extension and lymph node metastases in papillary thyroid cancer. Five of six human thyroid cancer cell lines analyzed expressed high levels of dysadherin. Of those cells lines sensitive to EDC1, half maximal effective concentrations (EC50) were observed to be between 0.125 nM and 1 nM.

Conclusions

EDC1 showed selective inhibition of growth in thyroid cancer cells with moderate to high expression of dysadherin, thus could be a specific and effective treatment.

Initial clinical presentation of single soft tissue metastasis of medullary thyroid carcinoma without primary tumor in the thyroid gland

Background

Single soft tissue metastasis of medullary thyroid carcinoma is extremely rare. In addition, several occult medullary thyroid carcinomas with distant metastasis were reported, but undetectable primary lesion at diagnosis was also extremely rare.

Case presentation

A 74-year-old man was admitted to our hospital because of a painful nodule in his left buttock for over 1 year. Needle biopsy was performed, and the histological findings revealed adenocarcinoma positive for thyroid transcription factor-1. No evidence of a primary tumor, including the lung and thyroid gland, could be found elsewhere despite detailed examinations, including thyroid echography, chest computed tomography, and fluorodeoxyglucose-positron emission tomography. The soft tissue tumor was resected with a wide margin. Immunohistochemical analysis showed the tumor cells to be positive for cytokeratin-AE1/3, cytokeratin 7, synaptophysin, chromogranin A, calcitonin, and carcinoembryonic antigen, but negative for cytokeratin 20, Napsin A, Pax8, and p40, resulting in a diagnosis of metastasis of medullary thyroid carcinoma.

Conclusion

Initial presentation with a single metastasis to soft tissue and undetectable primary tumor in the thyroid gland is an extremely rare clinical manifestation in patients with medullary thyroid carcinoma.

Pycnodysostosis with novel gene mutation and sporadic medullary thyroid carcinoma: A case report

RATIONALE

Pycnodysostosis is a rare autosomal recessive skeletal dysplasia caused by a mutation in the cathepsin K encoded by cathepsin K gene (CTSK). Medullary thyroid carcinoma (MTC) is also a relatively rare type of primary thyroid carcinoma.

PATIENT CONCERNS

A 31-year-old woman presenting a short stature and a palpable nodule in the front of her neck that had gradually increased in size during the last 2 years was referred to our department. She has experienced multiple fractures at lower limbs in the last 2 decades.

DIAGNOSES

The patient's clinical examination revealed short stature, underweight, a prominent forehead, stubby fingers, and a fixed nodule in the right thyroid lobe. Intraoral examination revealed multiple clinically malposed and missing teeth, as well as chronic periodontitis with a narrow and grooved palate. Radiographic examination revealed typical widely separated cranial sutures and an open anterior/posterior fontanel with an obtuse gonial angle, acroosteolysis, and osteosclerosis with narrowed medullary cavities. Ultrasonography of the thyroid gland showed a marked hypoechoic solid nodule in the right lobe in which tumor cell clusters were confirmed by ultrasound-guided fine needle aspiration biopsy and was suspected to be MTC. Laboratory tests revealed dramatically elevated serum calcitonin >2000 pg/L (reference range: 0-5 pg/L) and carcinoembryonic antigen (CEA) 134.37 ng/mL (reference range: 0-5 ng/mL). Genotypic screening revealed compound heterozygous mutations in the CTSK gene (c.158delA, P.Asn53Thr/c.C830T, P.Ala277Val) but no mutation associated with the familial forms of MTC.

INTERVENTIONS

The patient underwent a total thyroidectomy with right-sided functional neck dissection.

OUTCOMES

CEA and serum calcitonin decreased significantly postthyroidectomy, and no further fracture has been reported by the patient so far.

LESSONS

The present study is the first to report a rare case of the coexistence of pycnodysostosis with a compound CTSK gene mutation and sporadic MTC. Radiological techniques and gene analysis play key roles in the definitive diagnosis.

Recurrent spinal metastasis of a sporadic medullary carcinoma of the thyroid after radiation therapy: a case report and review of the literature

Sporadic Medullary Carcinoma of the Thyroid is a relatively uncommon entity and at the time of diagnosis, most already present loco-regional metastasis. Therapy should be aggressive to reduce recurrence and mortality. Follow-up period should continue lifelong and should also include calcium/pentagastrin infusion test, as well as 6-month interval diagnostic imaging.

Surgery and survival outcomes of 22 patients with epidural spinal cord compression caused by thyroid tumor spinal metastases

PURPOSE

The aim of this study was to discuss the clinical presentation, imaging findings, treatments received, and outcome of therapies for patients with epidural spinal cord compression caused by thyroid spinal metastases, with the goal of emphasizing the importance of surgery in this setting and discussing therapeutic plan for treating these patients.

METHODS

A total of 22 patients with spinal cord compression due to thyroid tumor spinal metastases who received surgery in our department were identified from 2004 to 2011. The series of 22 patients collected from our institution over the past 7 years was used to discuss treatment options for thyroid cancer spinal metastases on the basis of literature review and our own extensive experience.

RESULTS

The mean age of the patients in this study was 57 years (range 37-78 years). The duration of the preoperative symptoms was 1-24 months, with an average of approximately 6 months. All patients attained improvement of at least one level of the Frankel classification after surgery. Two patients received more than one operation at our institution. Two patients died during follow-up, two patients had stable disease, and all other patients maintained a disease-free status during follow-up.

CONCLUSIONS

As thyroid tumor spinal metastases have a favorable prognosis, a radical therapeutic attitude should be considered in decision-making. Dorsal spinal decompression through curettage and stabilization can preserve or restore neurological function for most patients. For patients who have more than one metastatic lesion of the spine, surgeries can be sequentially performed based on the urgency of the case. In addition to treatment of primary disease, surgery and bisphosphonate treatment are the most important therapies for these patients.

Spinal metastasis in thyroid cancer

BACKGROUND

Thyroid carcinoma generally responds well to treatment and spinal metastasis is an uncommon feature. Many studies have looked at the management of spinal metastasis and proposed treatments, plans and algorithms. These range from well-established methods to potentially novel alternatives including bisphosphonates and vascular endothelial growth factor (VEGF) therapy, amongst others.The purposes of this systematic review of the literature are twofold. Firstly we sought to analyse the proposed management options in the literature. Then, secondly, we endeavoured to make recommendations that might improve the prognosis of patients with spinal metastasis from thyroid carcinomas.

METHODS

We conducted an extensive electronic literature review regarding the management of spinal metastasis of thyroid cancer.

RESULTS

We found that there is a tangible lack of studies specifically analysing the management of spinal metastasis in thyroid cancer. Our results show that there are palliative and curative options in the management of spinal metastasis, in the forms of radioiodine ablation, surgery, selective embolisation, bisphosphonates and more recently the VEGF receptor targets.

CONCLUSIONS

The management of spinal metastasis from thyroid cancer should be multi-disciplinary. There is an absence; it seems, of a definitive protocol for treatment. Research shows increased survival with 131I avidity and complete bone metastasis resection. Early detection and treatment therefore are crucial. Studies suggest in those patients below the age of 45 years that treatment should be aggressive, and aim for cure. In those patients in whom curative treatment is not an option, palliative treatments are available.

Prognostic implications of microscopic involvement of surgical resection margin in patients with differentiated papillary thyroid cancer after high-dose radioactive iodine ablation

OBJECTIVE

To evaluate the relationship between microscopic cancerous involvement of surgical margin and recurrence in patients with differentiated papillary thyroid cancer (PTC) who underwent total thyroidectomy followed by high-dose radioactive iodine ablation (HDRIA).

METHODS

Consecutive 197 PTC patients (184 women; mean age 44.9 years) who underwent total thyroidectomy without gross residual tumor followed by HDRIA were retrospectively reviewed. Resection margin involvement was evaluated and recurrence of the disease was assessed with clinicopathologically. Recurrence detected within 12 months after HDRIA were defined as early recurrence, detected after 12 months were defined as late recurrence.

RESULTS

The mean follow-up was 85.9 ± 16.6 months. Twelve patients (6.1%) had microscopic cancerous involvement of surgical margin [margin (+) group], and 185 patients had negative surgical resection margins [margin (-) group]. Three patients (25.0%) in the margin (+) group and 11 patients (5.9%) in the margin (-) group had early recurrence. Margin (+) group showed higher incidence of early recurrence and lower incidence of disease free compared to margin (-) group (25.0 vs. 5.9%, p < 0.01; 66.7 vs. 81.1%, p < 0.01, respectively); however, there was no difference in incidence of late recurrence between the two groups (p = 1.00). There were no significant differences in the disease-free survival between the margin (+) and margin (-) groups after exclusion of early recurrence (p = 0.78).

CONCLUSIONS

After high-dose radioactive iodine ablation, PTC patients with microscopic cancerous surgical margin involvement had a higher incidence of early recurrence and no different late recurrence rate compared to patients without microscopic cancerous surgical margin involvement.

Brain metastasis from medullary thyroid carcinoma

The brain is an exceedingly rare site of metastasis in medullary thyroid carcinoma (MTC). A 50-year-old female who had a history of micro-MTC 11 years prior developed a cerebellar metastasis which was incidentally discovered. Imaging revealed a right cerebellar hemispheric mass with contrast enhancement on CT scans. Histopathologic exam demonstrated a metastatic tumour composed of nodules and sheets of large tumour cells with abundant cytoplasm. Immunohistochemistry confirmed the origin from a MTC. This case report highlights the unique features of an unusual metastatic brain tumour, which followed an indolent course for a long time despite multiple distant metastases.

Management of thyroid cancers

Thyroid cancers cover a large spectrum of disease with diametrically opposite prognosis. At one end of the spectrum we have the well differentiated cancers which carry an excellent prognosis, while at the other end there is anaplastic cancer with high mortality rates and dismal prognosis. Management of thyroid cancers still has some controversial issues due to lack of randomized controlled trials. Extent of surgery, extent of neck dissection, role of radioiodine treatment and thyroid stimulating hormone suppression are still debatable. In this review, we highlight these controversial issues and give guidelines for the management and follow up of patients with thyroid cancer.

Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines.

METHODS

Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.

CONCLUSIONS

We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

External beam radiation therapy for thyroid cancer

This article discusses the role of external beam radiotherapy (XRT) in the management of well-differentiated thyroid cancer (WDTC), medullary thyroid cancer, and anaplastic thyroid cancer. Although there are no randomized controlled studies on the use of XRT in thyroid cancer, evidence supports its use to treat gross disease after surgery or unresectable cancer and its use as an adjuvant after resection of a known high-risk disease in WDTC, and, to a lesser extent, in medullary thyroid cancer. The use of XRT for the palliation of symptomatic disease and recent advances in the technology of radiation delivery also will be discussed.

Results of a phase I clinical study using dendritic cell vaccinations for thyroid cancer

OBJECTIVE

We assessed the feasibility and efficacy of dendritic cell (DC) therapy for advanced thyroid papillary and follicular cancer.

DESIGN

Six Japanese patients (2 men and 4 women; aged 46-72 years, mean 60 years), who were diagnosed as advanced thyroid cancer with refractory distant metastases (papillary, n=5; follicular, n=1), were enrolled. Patients were first vaccinated weekly for 4 weeks with 10(7) autologous tumor lysate-pulsed monocyte-derived mature DCs followed by fortnightly vaccinations for 8 weeks (total=8 vaccinations). Lowdose (350 KIU) interleukin-2 was also administered for 3 days at each vaccination. Clinical response, adverse effects, delayed-type hypersensitivity skin testing (DTH), and IFN-( ) production by peripheral CD3(+) lymphocytes were evaluated.

MAIN OUTCOME

Of the 6 patients, disease was assessed as stable in 2 and as progressive in 4. No adverse events were observed. Results of DTH and IFN-( ) production in peripheral lymphocytes did not correlate to the clinical response.

CONCLUSIONS

DC immunotherapy could be administered to patients with thyroid papillary or follicular cancer without substantial side effects.

Prognostic factors and the effect of treatment with radioactive iodine and external beam radiation on patients with differentiated thyroid cancer seen at a single institution over 40 years

OBJECTIVES

To assess the prognostic factors and the role of radioactive iodine (RAI) and external beam radiotherapy (RT) in patients with differentiated thyroid cancer.

DESIGN

A retrospective review of 729 patients treated between 1958 and 1998. The median follow-up was 11.3 years (range 0.3-39.8 years). Primary outcomes included time to cause-specific survival and time to local-regional relapse. Baseline and treatment variables were assessed for statistical significance using the Cox proportional hazards model.

RESULTS

The 10-year cause-specific survival (CSS) was 87.3% and the 10-year local-regional relapse-free rate (LRFR) was 84.9%. In multivariate analysis there was no statistically significant improvement in CSS with more aggressive treatment (i.e. more extensive surgery, the administration of RAI and/or RT). By multivariate analysis the use of RAI resulted in a statistically significant improvement in LRFR (hazard ratio 0.5; 95% confidence interval 0.3-0.8; P = 0.007). In low-risk patients at AJCC stage I < or = 45 years, there was no apparent benefit from RAI. For patients over 60, with extrathyroid extension but no gross residual disease (n = 70), adjuvant external RT resulted in statistically significantly higher CSS (10-year CSS 81.0%vs. 64.6%, P = 0.04) and LRFR (10-year LRFR 86.4%vs. 65.7%, P = 0.01).

CONCLUSIONS

The use of RAI was associated with improved LRFR but not in low-risk patients. External beam RT improved LRFR and CSS in high-risk patients.