Optimizing treatment for children and adolescents with papillary thyroid carcinoma in post-Chernobyl exposed region: The roles of lymph node dissections in the central and lateral neck compartments

Construction and validation of a nomogram for predicting lateral lymph node metastasis in pediatric and adolescent with differentiated thyroid carcinoma

BACKGROUND

Limited research has been conducted to specifically investigate the identification of risk factors and the development of prediction models for lateral lymph node metastasis (LNM) in pediatric and adolescent differentiated thyroid carcinoma (DTC) populations, despite its significant association with unfavorable prognosis.

METHODS

This study entails a retrospective analysis of the clinical characteristics exhibited by pediatric and adolescent patients who have been diagnosed with DTC. The data utilized for this analysis was sourced from the Surveillance, Epidemiology, and End Results (SEER) database, spanning the time frame from 2000 to 2020. Furthermore, the study incorporates patients who were treated at the Departments of Breast and Thyroid Surgery in the Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine, as well as The General Hospital of Western Theater Command, during the period from 2010 to 2020.

RESULTS

A cohort of 2631 patients from the SEER database, along with an additional 339 patients from our departments who met the specified inclusion criteria, were included in this study. Subsequently, four clinical variables, namely age, tumor size, multifocality, and extrathyroidal invasion, were identified as being significantly associated with lateral LNM in pediatric and adolescent DTC patients. These variables were then utilized to construct a nomogram, which demonstrated effective discrimination with a concordance index (C-index) of 0.731. Furthermore, the performance of this model was validated through both internal and external assessments, yielding C-index values of 0.721 and 0.712, respectively. Afterward, a decision curve analysis was conducted to assess the viability of this nomogram in predicting lymph node metastasis.

CONCLUSION

The current investigation has effectively constructed a nomogram model utilizing visualized multipopulationsal data. Our findings demonstrate a significant association between various clinical characteristics and lateral LNM in pediatric and adolescent DTC patients. These outcomes hold substantial significance for healthcare practitioners, as they can employ this model to inform individualized clinical judgments for the pediatric and adolescent cohorts.

Risk factors for lateral lymph node metastasis of papillary thyroid carcinoma in children

INTRODUCTION

Lateral cervical lymph node metastases (LNM) for pediatric patients with papillary thyroid cancer (PTC) is a poor prognostic factor. We aimed to identify risk factors for lateral LNM.

METHODS

This retrospective study had included 48 pediatric patients with papillary thyroid cancer underwent total thyroidectomy and central cervical lymphadenectomy at K hospital from 2016 to 2020.

RESULTS

The number of patients in each T stage was as follows: 24 (50.0%) in stage 1, 9 (18.7%) in Stage 2, 8 (16.7%) in Stage 3, and 7 (14.6%) in Stage 4. Most of the patients had LNM with N1a and N1b rates of 83.3% and 62.5%, respectively. Lung metastases were observed at presentation in three patients (6.3%). Univariate analysis revealed that age (p = 0.021), male (p = 0.011), tumor size > 10 mm (p = 0.002), multifocality (p < 0.001), extrathyroidal extension (p = 0.001) and central LNM (p < 0.001) were factors that increase the risk of metastasis to lateral LNM.

CONCLUSION

Approximately 62.5% of pediatric patients with PTC exhibited lateral LNM at the time of diagnosis. Our study confirmed that multifocality, maximum tumor diameter, extrathyroidal extension and central LNM were independent risk factors for lateral LNM in pediatric PTC.

LEVEL OF EVIDENCE

Level IV.

Papillary Thyroid Carcinoma: Current Position in Epidemiology, Genomics, and Classification

Papillary thyroid carcinoma is the most common type of thyroid malignancy both in adults and pediatric population. Since the 1980s, there are changes in criteria in labelling thyroid lesions as "papillary thyroid carcinomas." Radiation exposure is a well-established risk factor for papillary thyroid carcinoma. Other environmental risk factors include dietary iodine, obesity, hormones, and environmental pollutants. Papillary thyroid carcinomas could occur in familial settings, and 5% of these familial cases have well-studied driver germline mutations. In sporadic papillary thyroid carcinoma, BRAF mutation is common and is associated with clinicopathologic and prognostic markers. The mutation could aid in the clinical diagnosis of papillary thyroid carcinoma. Globally, thyroid cancer is among the top ten commonest cancer in females. In both adult and pediatric populations, there are variations of prevalence of thyroid cancer and rising incidence rates of thyroid cancer worldwide. The increase of thyroid cancer incidence was almost entirely due to the increase of papillary thyroid carcinoma. The reasons behind the increase are complex, multifactorial, and incompletely understood. The most obvious reasons are increased use of diagnostic entities, change in classification of thyroid neoplasms, as well as factors such as obesity, environmental risk factors, and radiation. The prognosis of the patients with papillary thyroid carcinoma is generally good after treatment. Nevertheless, cancer recurrence and comorbidity of second primary cancer may occur, and it is important to have awareness of the clinical, pathological, and molecular parameters of papillary thyroid carcinoma.

Predictive Factors for Recurrence of Papillary Thyroid Carcinoma in Children and Adolescents

Background

The incidence of papillary thyroid carcinoma (PTC) in children and adolescents has increased, but the data on long-term outcomes are limited. There are few literatures on the clinicopathological characteristics and prognosis of PTC in children and adolescents in China. Therefore, it is necessary to identify clinicopathological features to precisely predict clinical prognosis and to help choose the optimal method and perform the best therapeutic regimen.

Methods

This study was a retrospective analysis of patients undergoing thyroidectomy at Tianjin Medical University Cancer Institute and Hospital. We analyzed the factors related to the clinicopathological features and prognosis of PTC in children and adolescents.

Results

A total of 95 juvenile PTC patients who underwent thyroidectomy were enrolled. Our research found that patients with younger age (<14 years) were predominantly multifocal and have positive preoperative thyroglobulin (Tg) and higher recurrence rate, and their number of lymph node metastases (LNMs) was more than that of the older group (14–18 years). Maximal tumor size >2 cm, T stage, and multifocality were the risk factors for LNM and the number of LNM (p < 0.05). Multivariate analysis displayed the number of central LNM as the independent risk factor for lateral LNM, and multifocality was the independent risk factor for the number of central and lateral LNM. Younger age at diagnosis, positive preoperative thyroid-stimulating hormone (TSH), maximal tumor size >2 cm, lateral LNM, number of LNM, N staging, and American Thyroid Association (ATA) pediatric risk were related to poor prognosis in PTC patients (p < 0.05). Cox regression analysis found that younger age at diagnosis and positive preoperative TSH were independent risk factors for recurrence of PTC in children and adolescents.

Conclusions

Our study showed that the clinicopathological characteristics of younger age compared with older age were as follows: highly aggressive, prone to metastases, and higher recurrence rate. In our opinion, patients with characteristics such as younger age at diagnosis, positive preoperative TSH, maximal tumor size >2 cm, lateral LNM, and number of LNM >5 may be considered for prophylactic or therapeutic dissection of additional metastatic LNs by high-volume surgeons to prevent and reduce the recurrence rate of patients during long-term follow-up.

Macroscopic Examination of Surgical Specimen of Papillary Thyroid Carcinoma

Standardized pathology reporting of thyroid cancer is important for quality clinical management, research as well as education purposes. International Collaboration on Cancer Reporting (ICCR) has produced a Dataset for reporting carcinoma of thyroid. Of the 19 core elements to report, six (operative procedure, operative findings, specimen submitted, tumor focality, tumor site, tumor dimensions) depend on the proper macroscopic examination of the surgical specimen with thyroid carcinoma. The other core elements to report depend on proper and adequate sampling on macroscopic examination. Thus, proper handling, examination, dissection, and sampling of different types, the surgical specimen(s) are needed in different situations for patients with thyroid carcinomas.

Risk Factors and Prediction Model for Lateral Lymph Node Metastasis of Papillary Thyroid Carcinoma in Children and Adolescents

Purpose

Papillary thyroid carcinoma (PTC) in children and adolescents is prone to lateral lymph node metastasis (LNM), which is a high-risk factor for recurrence. However, few studies focused on identifying risk factors and establishing prediction models for lateral LNM of PTC in children and adolescents.

Patients and Methods

We retrospectively reviewed consecutive cases of children and adolescents with PTC undergoing thyroidectomy and cervical lymph node dissection between January 2009 and December 2019. The demographics and clinicopathologic features were collected and analyzed.

Results

A total of 102 children and adolescents with PTC were enrolled in our study; 51 of whom had lateral LNM (50%). After adjusting for other risk factors, the independent risk factors for lateral LNM were multifocality (odds ratio [OR]: 6.04; 95% confidence interval [CI]: 1.653–22.092; p=0.007), tumor size (OR: 1.752; 95% CI: 1.043–2.945; p=0.034), and the number of central LNM (OR: 1.23; 95% CI: 1.028–1.472; p=0.023). The formula of the combined predictor is: Multifocality + 0.31 × Tumor size + 0.115 × Number of central LNM. The area under the receiver operating characteristic curve of multifocality, tumor size, number of central LNM, and the combined predictor was 0.706, 0.762, 0.748, and 0.855, respectively. When the value of the combined predictor was ≥2.2744, lateral LNM could be predicted. The sensitivity and specificity of the predicted value were 82.4% and 74.5%, respectively.

Conclusion

The independent risk factors for lateral LNM in children and adolescents with PTC were multifocality, tumor size, and the number of central LNM. The prediction model can better predict the presence of lateral LNM.

Factors affecting the approaches and complications of surgery in childhood papillary thyroid carcinomas

BACKGROUND

The aim of the study is to analyse the factors related to permanent surgical complications in children and adolescents with papillary thyroid carcinoma treated by total thyroidectomy with central and bilateral neck dissections.

METHODS

Children and adolescents aged ≤18-year-old at presentation with papillary thyroid carcinoma during the years 1988-2010 underwent thyroid and lymph-node surgeries (with a median follow-up of 19.6 years) were analysed for post-surgical complications.

RESULTS

Permanent surgical morbidity occurred in 14% (n = 70) of patients who underwent total thyroidectomy as well as bilateral central and lateral neck dissections (n = 509). Factors associated with permanent complications included pN1 with extra-nodal extension, > 4 metastatic lymph nodes in the central neck compartment, presence of distant metastases and younger age of patients at surgery. Patients who received extensive surgery had better relapse-free survival rates (p < 0.001).

CONCLUSION

Total thyroidectomy and bilateral central as well as lateral neck dissections for children and adolescents with papillary thyroid carcinoma was associated with substantial postoperative complications. Nevertheless, it is associated with better prognosis for young patients with thyroid cancer. Prophylactic compartment-oriented lymph node dissections to these patients could be the management protocol in experienced hands.