Association of adjuvant radioactive iodine therapy with survival in node-positive papillary thyroid cancer

Comparison of Treatment and Prognosis Between Follicular Variant Papillary Thyroid Carcinoma and Classical Papillary Thyroid Carcinoma

This cohort study evaluated the associations of different treatments with the prognosis of follicular variant papillary thyroid carcinoma (FVPTC) and classical papillary thyroid carcinoma (CPTC) patients. The data of 69034 PTC patients were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The 5-year mortality of CPTC and FVPTC patients receiving surgery, radiation and combination therapy were compared. The univariable and multivariable cox proportional risk models explored the associations between different treatments and the 5-year mortality in CPTC and FVPTC patients. The 5-year mortality of CPTC patients was 2.81% and FVPTC patients was 2.47%. Compared with CPTC receiving lobectomy and/or isthmectomy, those not receiving surgery were associated with increased risk of 5-year mortality [Hazards ratio (HR)=3.27, 95% confidence interval (CI): 2.55-4.20] while total thyroidectomy was correlated with reduced risk of 5-year mortality (HR=0.67, 95%CI: 0.55-0.80). Radioactive iodine (RAI) was linked with decreased risk of 5-year mortality in CPTC patients (HR=0.57, 95%CI: 0.50-0.65). CPTC patients undergoing both surgery and radiation were related to decreased risk of 5-year mortality compared with those receiving surgery only (HR=0.55, 95%CI: 0.48-0.63). CPTC patients receiving neither surgery nor radiation (HR=4.53, 95%CI: 3.72-5.51) or those receiving radiation (HR=1.98, 95%CI: 1.13-3.48) were correlated with elevated risk of 5-year mortality. The elevated risk of 5-year mortality in FVPTC patients was reduced in those undergoing RAI (HR=0.63, 95%CI: 0.51-0.76). In conclusion, combination therapy was associated with decreased risk of 5-year mortality in CPTC and FVPTC patients, which might provide a reference for the management of these patients.

Effect of Waiting Time for Radioactive Iodine Therapy on Outcome in N1 Stage Papillary Thyroid Cancer

CONTEXT

The waiting time for radioactive iodine therapy (WRAIT) after total thyroidectomy (TT) in patients with papillary thyroid cancer (PTC) and lymph node metastases (N1) has not been sufficiently investigated for risk of adverse outcomes.

OBJECTIVE

This work aimed to estimate the effect of WRAIT on the outcomes of disease persistence and recurrence among patients with N1 PTC and investigate factors predictive of delayed radioactive iodine therapy (RAIT).

METHODS

This retrospective cohort study was conducted in a university hospital. A total of 909 patients with N1 PTC were referred for RAIT between 2014 and 2018. WRAIT is the duration between TT and initial RAIT. The optimal WRAIT threshold determined using recursive partitioning analysis was used to define early and delayed RAIT. The primary end point was tumor persistence/recurrence. We compared the outcomes of patients with early and delayed RAIT using inverse probability weighting based on the propensity score.

RESULTS

The WRAIT threshold that optimally differentiated worse long-term remission/excellent response outcomes was greater than 88 days (51% of our cohort; n = 464). WRAIT exceeding 88 days was associated with an augmented risk of disease persistence/recurrence (odds ratio, 2.47; 95% CI, 1.60-3.82) after adjustment. Predictors of delayed RAIT included residence in lower-income areas, reoperation before the initial RAIT, TT at a nonuniversity-affiliated hospital, multifocality, extrathyroidal extension, N1b disease, and pre-RAIT-stimulated thyroglobulin level less than 1 ng/mL.

CONCLUSION

Delayed RAIT beyond 88 days after TT in patients with N1 PTC independently increased the risk of disease persistence/recurrence. Evaluation of the predictive determinants of prolonged WRAIT may help target at-risk patients and facilitate interventions.

Construction and validation of nomograms to reduce completion thyroidectomy by predicting lymph node metastasis in low-risk papillary thyroid carcinoma

CONTEXT

More than 5 central lymph nodes metastases (CLNM) or lateral lymph node metastasis (LLNM) indicates a higher risk of recurrence in low-risk papillary thyroid carcinoma (PTC) and may lead to completion thyroidectomy (CTx) in patients initially undergoing lobectomy.

OBJECTIVE

To screen potentially high-risk patients from low-risk patients by using preoperative and intraoperative clinicopathological features to predict lymph node status.

METHODS

A retrospective analysis of 8301 PTC patients in Wuhan Union Hospital database (2009-2021) was performed according to the 2015 American Thyroid Association (ATA) and 2021 National Comprehensive Cancer Network (NCCN) guidelines, respectively. Logistic regression and best subsets regression were used to identify risk factors. Nomograms were established and externally validated using the Differentiated Thyroid Cancer in China cohort.

RESULTS

More than 5 CLNM or LLNM was detected in 1648 (19.9%) patients. Two predictive models containing age, gender, maximum tumor size, free thyroxine (FT4) and palpable node (all p < 0.05) were established. The nomogram based on NCCN criteria showed better discriminative power and consistency with a specificity of 0.706 and a sensitivity of 0.725, and external validation indicated that 76% of potentially high-risk patients could achieve preoperative conversion of surgical strategy.

CONCLUSIONS

Models based on large cohorts with good predictive performance were constructed and validated. Preoperative low-risk (T1-2N0M0) patients with age younger than 40 years, male gender, large tumor size, low FT4 and palpable nodes may be at high risk of LLNM or more than 5 CLNM, and they should receive more aggressive initial therapy to reduce CTx.

Outcomes and Trends of Treatments in High-Risk Differentiated Thyroid Cancer

OBJECTIVES

To analyze the variant-specific survival benefits and usage patterns of standardized treatment combinations of surgery (S), radioactive iodine ablation (RAI), and thyroid-stimulating hormone suppression therapy (THST) for high-risk differentiated thyroid cancer.

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database.

METHODS

The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for high-risk papillary, follicular, or Hurthle cell thyroid cancer. Cox proportional hazards and Kaplan-Meier analyses assessed for treatment-associated survival.

RESULTS

Of 21,076 cases, 18,214 underwent survival analysis with a mean ± SD age of 50.6 ± 17.1 years (71.3% female). When compared with surgery alone, S + RAI was associated with reduced mortality in papillary (hazard ratio [HR], 0.574; P < .001) and follicular (HR, 0.489; P = .004) thyroid cancer. S + RAI + THST was associated with reduced mortality in papillary (HR, 0.514; P < .001), follicular (HR, 0.602; P = .016), and Hurthle cell (HR, 0.504; P = .021) thyroid cancer. In papillary thyroid cancer, S + RAI (91.3%), S + THST (89.2%), and S + RAI + THST (92.7%) were associated with higher 5-year overall survival rates than surgery (85.4%, all P < .001). Papillary thyroid cancer treatments involving THST were associated with higher 5-year overall survival rates than corresponding regimens without THST (all P < .001). In follicular thyroid cancer, S + RAI (73.9%) and S + RAI + THST (78.7%) were associated with higher 5-year overall survival rates than surgery (65.6%, all P < .05). In Hurthle cell thyroid cancer, S + RAI (66.5%) and S + RAI + THST (73.4%) were associated with higher 5-year overall survival rates than surgery (53.7%, all P < .05). On linear regression, THST usage increased by 77.5% (R² = 0.944, P < .001), while RAI usage declined by 11.3% (R² = 0.320, P = .035).

CONCLUSIONS

High-risk differentiated thyroid cancer exhibited varying susceptibilities to different treatment combinations depending on histology, with greatest responses to regimens that included RAI. Physician practices have trended toward decreased RAI and increased THST usage.

Surgery and Radioactive Iodine Therapeutic Strategy for Patients Greater Than 60 Years of Age with Differentiated Thyroid Cancer

Purpose: The purpose of the current study was to determine whether older patients with differentiated thyroid cancer (DTC) who received surgical treatment had a better cause-specific survival (CSS) than patients who were recommended surgery, but declined, and whether patients who underwent postoperative RAI-131 therapy had an impact on CSS based on TNM staging and number of lymph node metastases for all total or near-total thyroidectomy patients. Patients and Methods: This retrospective, population-based study analyzed the clinical data of 162 DTC patients from signal institution in China and 26,487 cases from the Surveillance, Epidemiology, and End Results (SEER) program registry. The patients were divided into two groups (underwent surgery and surgery recommended, but not performed) in the SEER cohort. Furthermore, patients were grouped as follows: T4; N1b; M1; T1-3N0-1a; specific number of lymph node metastases; and total or near-total thyroidectomy. Results: The 120-month cause-specific survival (CSS) rate of women and men showed a gradual declining trend from 60–64 to ≥80 years of age in the group that underwent surgery. The CSS rate of women and men showed a marked downward and irregular trend with an increase in age in the recommended, but no surgery group in the SEER cohort. Univariate analysis indicated that the surgery group had a higher 120-month CSS in women in most stages and men, compared with the no surgery group in the SEER cohort. The analysis of the SEER cohort showed that RAI-131 therapy was associated with an improved 80-month CSS in T4/N1b/M1 women (P < 0.0183) and men (P < 0.0011). However, there were no CSS differences between the RAI-131 therapy and the no-RAI-131 group for the patients with T4/N1b/M1 (AJCC 7th) thyroid cancer in the Chinese cohort. There was no CSS difference in women or men between the T1-3N0 and T1-3N1a patients in the SEER cohort. And similar findings were observed in T1-3N1a patients in the Chinese cohort. There was no statistical difference between the two subgroups. Conclusions: Surgical treatment should be recommended for elderly DTC patients because surgery can lead to a better CSS. High-risk patients achieve a higher benefit-to-risk ratio with RAI-131 therapy. To avoid the adverse effects associated with RAI-131 therapy, a multidisciplinary discussion should be arranged for intermediate- and low-risk patients.

Radioactive iodine in low- to intermediate-risk papillary thyroid cancer

It remains controversial whether papillary thyroid cancer (PTC) patients with low- to intermediate-risk disease should receive radioactive iodine (RAI) after total thyroidectomy (TT). We aim to identify those who might benefit from RAI treatment in PTC patients with cervical nodal metastasis after TT. Patients were divided into TT and TT+RAI groups from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2018). Overall survival (OS) and cancer-specific survival (CSS) were compared, and propensity score matching (PSM) was performed between groups. A total of 15,179 patients were enrolled, including 3,387 (22.3%) who underwent TT and 11,792 (77.7%) who received TT+RAI. The following characteristics were more likely to present in the TT+RAI group: multifocality, capsular extension, T3, N1b, and more metastatic cervical lymph nodes. RAI was associated with better OS in low- to intermediate-risk PTC patients in the multivariate Cox regression model. The subgroup analysis showed that RAI predicted better OS in patients ≥55 years, American Joint Committee on Cancer (AJCC) stage II, and capsular extension with a hazard ratio (HR) (95% CI) of 0.57 (0.45-0.72), 0.57 (0.45-0.72), and 0.68 (0.51-0.91), respectively. However, RAI failed to improve the prognoses of patients with age <55 years, AJCC stage I, PTC ≤1 cm, and capsular invasion. In the PSM cohort with 3,385 paired patients, TT+RAI treatment predicted better OS compared with TT alone. In addition, TT+RAI predicted better OS in patients with metastatic cervical lymph nodes ≥2, multifocality, extracapsular extension, and American Thyroid Association (ATA) intermediate risk. In conclusion, RAI was associated with better OS in low- to intermediate-risk PTC patients with age ≥55 years, multifocality, extrathyroidal extension, and ATA intermediate risk. However, the survival benefit from RAI may be limited in patients with AJCC stage I, PTC ≤1 cm, unifocality, capsular invasion, and ATA low-risk diseases; these patients even showed pathological cervical lymph node metastasis.

Cause-specific mortality after diagnosis of thyroid cancer: a large population-based study

PURPOSE

The study aimed to disclose mortality pattern and quantitatively evaluate risks for cause-specific mortality among thyroid cancer survivors.

METHODS

We included 173,710 patients from the Surveillance, Epidemiology, and End Results (SEER) database with thyroid cancer diagnosed between 1975 and 2015. Standardized mortality ratio (SMR) was calculated using general US population as the reference. Cumulative incidence function curves were constructed to elaborate crude cause-specific mortality by histology. Cox proportional hazards regression model was adopted to identify predictors for cause-specific mortality, expressed as hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

After a median follow-up of 101 months, 23,040 (13.3%) deaths occurred, of which 29.1% and 21.7% were attributable to thyroid cancer and cardiovascular disease (CVD), respectively. CVD SMRs were 1.14, 1.47, 1.21, and 5.66 in patients with follicular, Hürthle cell, medullary and anaplastic histology, respectively. The adjusted HRs of thyroid cancer-specific mortality were 1.59 (95% CI: 1.46-1.74), 1.87 (95% CI: 1.65-2.12), 3.66 (95% CI: 3.31-4.05), and 12.65 (95% CI: 11.50-13.92) for follicular, Hürthle cell, medullary, and anaplastic histology, respectively, as compared with papillary histology; HRs of CVD-specific mortality were 1.23 (95% CI: 1.12-1.34), 1.27 (95% CI: 1.11-1.46), 1.13 (95% CI: 0.96-1.33), and 1.60 (95% CI: 1.19-2.16), respectively. Older age, male sex, nonwhite race, unmarried status, and advanced stage were independent predictors of CVD-specific mortality, while receiving surgery and radiotherapy were protective against CVD-specific mortality.

CONCLUSIONS

We disclosed distinct mortality patterns by histology and identified predictors of CVD-specific mortality in thyroid cancer survivors, supporting CVD intervention for aggressive thyroid cancer.

Survival Analysis of Cancer Patients in North Eastern Nigeria from 2004 - 2017 - A Kaplan - Meier Method

BACKGROUND:

Cancer is a deadly malignant disease and is prevalent in Sub Saharan Africa. The North East part of Nigeria in particular and the country, in general, are struggling to cope with the increasing burden of cancer and other communicable and non-communicable diseases. The situation is worsened by the ongoing insurgency and terrorist activities in the area.

AIM:

The aim of this paper is to present the research findings from a cohort study aimed at the analysis of the estimation of the survivorship time of the real data of cancer patients in the North-eastern part of Nigeria and to establish if the insurgency in the region has contributed negatively to the life expectancy of its inhabitants.

MATERIAL AND METHODS:

The record of 1,090 patients from medical records departments of the University of Maiduguri Teaching Hospital (UMTH), located in Maiduguri, the capital city of Borno State in northeast Nigeria was obtained. The record showed patients that were diagnosed and died of one type of cancer or the other from 2004 to 2017. All the cancer cases included in the present study were grouped into sex, age, marital status, occupation, date admitted and date of death/discharge. Descriptive statistics and Kaplan-Meier method were used to analyse the data using SPSS version 23 while Microsoft EXCEL and Minitab 16.0 were used for data cleansing and organisation.

RESULTS:

Of the 1,090 patients analysed, 920 (84.40%) experienced the event, i.e. death, while 170 (15.60%) patients were censored. The data were analysed based on the ages and sex of the patients. 50.20% of the patients were of ages 21-50 years. The proportions of patients in this age bracket surviving past 7 days are 75%, while those between ages 80 years and above is 12 days. Others are of survival time of 5 days (ages 0-20 years) and 7 days (51-79 years). Using sex, 75% of the patients’ survival time is 7 days in the case of male and 6 days for females. It is safe to say that the survival time for cancer patients of the university the Maiduguri is 6 days and the result reflects the Northeastern part of Nigeria. This is because the hospital is one of few tertiary healthcare facilities in that area and consequently, cancer cases are often referred there.

CONCLUSION:

Cancer incidence is high, and the probability of survival reduces as the survival time increases. This is a dire situation in need of urgent intervention from the government, groups and individuals to tackle the scourge of cancer, thereby improving on the life expectancy battered by the ongoing Boko Haram insurgency in that region.