Anaplastic Thyroid Carcinoma, Thyroid Lymphoma, and Metastasis to Thyroid

Diagnosis and treatment of primary thyroid lymphoma from a surgical perspective: a multi-institutional study

PURPOSE

Surgery of primary thyroid lymphoma (PTL) has been mostly limited to diagnostic work-up. This study aimed to further study its potential role.

METHODS

This was a retrospective study from a multi-institutional registry of PTL patients. Clinical, diagnostic work-up (fine needle aspiration, FNA; core needle biopsy, CoreNB), contribution of surgery (open surgical biopsy, OpenSB; thyroidectomy), histology subtype, and outcome data were evaluated.

RESULTS

Some 54 patients were studied. Diagnostic work-up included FNA in 47 patients, CoreNB in 11, and OpenSB in 21. CoreNB yielded the best sensitivity (90.9%). Thyroidectomy was performed in 14 patients with other diagnosis (incidental PTL), in 4 for diagnosis and in 4 for elective treatment of PTL. Incidental PTL was associated with not performed FNA nor CoreNB (OR 52.5; P = 0.008), mucosa-associated lymphoid tissue (MALT) subtype (OR 24.3; P = 0.012), and Hashimoto's thyroiditis (OR 11.1; P = 0.032). Lymphoma-related death (10 cases) mostly occurred within the first year after diagnosis and was associated with diffuse large B-cell (DLBC) subtype (OR 10.3; P = 0.018) and older patients (OR 1.08 for every 1-year increase; P = 0.010). There was a trend towards lower mortality rate in patients receiving thyroidectomy (2/22 versus 8/32, P = 0.172).

CONCLUSION

Incidental PTL accounts for most of thyroid surgery cases and are associated with incomplete diagnostic work-up, Hashimoto's thyroiditis and MALT subtype. CoreNB appears to be the best tool for diagnosis. Most of PTL deaths occurred during the first year after diagnosis and mostly related to systemic treatment. Age and DLBC subtype are poor prognostic factors.

Thyroid Carcinoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

Differentiated thyroid carcinomas is associated with an excellent prognosis. The treatment of choice for differentiated thyroid carcinoma is surgery, followed by radioactive iodine ablation (iodine-131) in select patients and thyroxine therapy in most patients. Surgery is also the main treatment for medullary thyroid carcinoma, and kinase inhibitors may be appropriate for select patients with recurrent or persistent disease that is not resectable. Anaplastic thyroid carcinoma is almost uniformly lethal, and iodine-131 imaging and radioactive iodine cannot be used. When systemic therapy is indicated, targeted therapy options are preferred. This article describes NCCN recommendations regarding management of medullary thyroid carcinoma and anaplastic thyroid carcinoma, and surgical management of differentiated thyroid carcinoma (papillary, follicular, Hürthle cell carcinoma).

Precision Medicine in Oncology: A Review of Multi-Tumor Actionable Molecular Targets with an Emphasis on Non-Small Cell Lung Cancer

Precision medicine is essential for the modern care of a patient with cancer. Comprehensive molecular profiling of the tumor itself is necessary to determine the presence or absence of certain targetable abnormalities or biomarkers. In particular, lung cancer is a disease for which targetable genomic alterations will soon guide therapy in the majority of cases. In this comprehensive review of solid tumor-based biomarkers, we describe the genomic alterations for which targeted agents have been approved by the United States Food and Drug Administration (FDA). While focusing on alterations leading to approvals in a tumor-agnostic fashion (MSI-h, TMB-h, NTRK) and on those alterations with approvals in multiple malignancies (BRAF, ERBB2, RET, BRCA, PD-L1), we also describe several biomarkers or indications that are likely to lead to an approved drug in the near future (e.g., KRAS G12C, PD-L1 amplification, HER2 overexpression in colon cancer, HER2 mutations in lung cancer). Finally, we detail the current landscape of additional actionable alterations (EGFR, ALK, ROS1, MET) in lung cancer, a biomarker-rich malignancy that has greatly benefitted from the precision oncology revolution.

Anaplastic transformation of thyroid cancer in mesentery metastases presenting as intestinal perforation: a case report

Background

Anaplastic thyroid carcinoma is a highly aggressive form of thyroid cancer associated with a very poor prognosis. Anaplastic transformation most commonly occurs in the thyroid itself or within regional lymph nodes. Here we report the case of a patient with papillary thyroid cancer, presenting with colon perforation as a result of anaplastic transformation of metastases in the mesentery tissue. There have been no previous reports of this form of anaplastic transformation.

Case presentation

A 74-year-old man was admitted to our hospital, presenting with abdominal pain that he had been experiencing for 1 week prior to admission. The patient had a history of papillary thyroid carcinoma, for which he underwent a total thyroidectomy and mediastinal lymph node dissection 6 years earlier, and subsequently received radioactive iodine therapy for postoperative recurrence in the lung 2 years later. During the present reported admission, a computed tomography scan revealed a large intra-abdominal mass infiltrating into the colon and retroperitoneum and also highlighted the pneumoperitoneum. The patient was diagnosed with generalized peritonitis as a result of colon perforation, as such, we conducted an emergency laparotomy. Intraoperative findings showed a mass affecting the ascending colon and kidney, following which, an ileostomy and biopsy were completed. Poorly differentiated spindle cells were identified in the biopsy specimens, and histopathological and immunohistochemical findings revealed the absence of thyroid carcinoma cells. The tumor was therefore believed to be a primary sarcoma. Following surgery, the patient recovered from sepsis that had arisen as a result of colon perforation, however, rapidly developed systemic metastases and died 1 month post-operation. An autopsy was performed, and the patient was diagnosed with anaplastic papillary thyroid cancer at the mesentery site of metastasis. This conclusion was reached owing to the presence of the squamous differentiation of lymph node cells, and because tumor cells were positive results for paired-box gene 8 expressions.

Conclusions

Anaplastic transformation of papillary thyroid carcinoma should be considered in the diagnosis of a large mesentery mass in patients with a history of papillary carcinoma. An appropriate biopsy and paired-box gene 8 immunostaining can be useful in confirming such a diagnosis.

Prevalencia de tumores metastásicos en la glándula tiroides. Revisión sistemática y metanálisis

Introducción y objetivo: Los tumores metastásicos en la glándula tiroides complican el diagnóstico, el tratamiento y el pronóstico del paciente. El objetivo es conocer la prevalencia de las metástasis en la glándula tiroides referida en la literatura médica y los tumores primarios que con más frecuencia metastatizan en la glándula tiroides. Método: Se realizó una revisión bibliográfica sistemática en las bases de datos de PubMed, La Biblioteca Cochrane y Scopus. Los artículos seleccionados se dividieron en dos grupos, series clínicas de pacientes en los que se hallaron metástasis en tiroides (grupo A) y series de hallazgos de metástasis en tiroides en autopsias (grupo B). Se realizó metanálisis de prevalencia para cada grupo de artículos siguiendo el modelo de efectos aleatorios. Resultados: La prevalencia en cada grupo con su índice de confianza al 95% fue 0.00479 (0.002-0.007) para el grupo A y 0.0362 (0.014-0.059) para el grupo B. La prevalencia de metástasis halladas en autopsias fue 7,58 veces mayor que en los estudios clínicos. En el grupo A la edad media fue 60.82 y en el grupo B 57.20. En ambos grupos las metástasis halladas en tiroides fueron más frecuentes en el sexo femenino. La localización del tumor primario fue diferente en ambos grupos, en el grupo A fue el cáncer de riñón y en el grupo B el cáncer de mama. La variabilidad de la prevalencia de metástasis en tiroides en los diferentes artículos de ambos grupos hace que este estudio tuviese una alta heterogeneidad (índice I2 y Q). Los funnel plot de ambos grupos indicaron alto sesgo de publicación. Discusión: La diferente prevalencia entre series clínicas y autopsias puede implicar que la detección de metástasis en tiroides en la clínica está infradiagnosticada. La razón de esto podría ser que las metástasis intratiroideas se presentan de forma asintomática siendo diagnosticadas como hallazgo casual en autopsias. En otras ocasiones se presentan como un nódulo tiroideo años después del tumor primario, lo que condiciona el diagnóstico. Conclusiones: La prevalencia de metástasis en tiroides es superior en las series de autopsias que en series clínicas (hasta 6.67 veces más frecuente en nuestro estudio). Las metástasis intratiroideas probablemente están infradiagnosticadas por cursar sin clínica siendo diagnosticadas como hallazgo casual en autopsias. Los tumores primarios más frecuentes fueron el riñón (series clínicas) y la mama (series de autopsias).

Dietary iodine intake, therapy with radioiodine, and anaplastic thyroid carcinoma

Background Anaplastic thyroid cancer (ATC) is one of the most aggressive tumors. The aim of the study was to determine the correlation between a higher dietary intake of iodine, frequency of ATC and the characteristics of ATC, and to find out how often patients with ATC had a history of radioiodine (RAI) therapy. Patients and methods This retrospective study included 220 patients (152 females, 68 males; mean age 68 years) with ATC who were treated in our country from 1972 to 2017. The salt was iodinated with 10 mg of potassium iodide/ kg before 1999, and with 25 mg of potassium iodide/kg thereafter. The patients were assorted into 15-year periods: 1972-1986, 1987-2001, and 2002-2017. Results The incidence of ATC decreased after a higher iodination of salt (p = 0.04). Patients are nowadays older (p = 0.013) and have less frequent lymph node metastases (p = 0.012). The frequency of distant metastases did not change over time. The median survival of patients in the first, second, and third periods was 3, 4, and 3 months, respectively (p < 0.05). The history of RAI therapy was present in 7.7% of patients. Conclusions The number of patients with a history of RAI therapy did not change statistically over time. The incidence of ATC in Slovenia decreased probably because of higher salt iodination.

Development and Validation of a Nomogram for Predicting Survival in Patients with Thyroid Cancer

BACKGROUND The AJCC staging system is inadequate for use in patients with thyroid carcinomas. Here, we aimed to establish a nomogram for thyroid cancer, and we compare its prognostic value with the AJCC staging system in adults diagnosed with thyroid carcinoma. MATERIAL AND METHODS Patient records were obtained from the Surveillance, Epidemiology, and End Result database. The 8491 included patients were divided into a modeling cohort (n=5943) and a validation cohort (n=2548). The variables included in the modeling cohort were selected using a backward stepwise selection method with Cox regression, and the prognosis nomogram was constructed. In the validation cohort, we compared our survival model with the AJCC prognosis model using the concordance index, the area under the time-dependent receiver operating characteristic curve, the net reclassification improvement, the integrated discrimination improvement, calibration plotting, and decision curve analysis. RESULTS Twelve independent prognostic factors were identified and used to establish the nomogram. In particular, marital status was included in a survival prediction model of thyroid cancer for the first time. The concordance index, area under the time-dependent receiver operating characteristic curve, net reclassification improvement, integrated discrimination improvement, calibration plotting, and decision curve analysis for the nomogram showed better performance compared to the AJCC staging system. CONCLUSIONS We have developed and validated a highly accurate thyroid cancer prognosis nomogram. The prognostic value of the nomogram is better than that of the AJCC staging system alone.

Understanding Malignancies of the Thyroid Gland: Institutional Experience

To study the epidemiological, pathological characters and determine survival in patients diagnosed of having thyroid gland malignancies. Retrospective chart review of patients having thyroid gland malignancies, which were managed by the two senior authors at our tertiary care institute from January 2000 to December 2006, were performed and evaluated in terms of various clinical, operative and histological parameters. Patients in which follow up of at least 10 years are available were included in the study. Survival was enquired telephonically in those patients who got cured and did not consent to come for follow up. Slides were reviewed. Statistical analysis was done using SPSS statistical software. Kaplan-Meier method was used for calculating survival. A total of 182 patients were included in the study. Papillary carcinoma was the commonest malignant lesion with a frequency of 87.91% followed by follicular carcinoma (7.69%), medullary carcinoma (3.29%) and anaplastic carcinoma (1.09%). Female predominance was seen (F:M-5.06:1). The 5 year and 10 year survival rates were 89% and 73% respectively. The most common postoperative squeal was transient hypocalcaemia, seen in (27/182) 15% patients which was followed by permanent hypocalcaemia 16/182 (8.79%), transient recurrent laryngeal nerve paresis 12/182 (6.59%) and permanent recurrent laryngeal nerve palsy 8/182 (4.39%). Thyroid malignancies affect all age groups and have good long term prognosis. Management yields promising results and hence early and adequate treatment is emphasized.

A Synergistic Anti-Cancer Effect of Troglitazone and Lovastatin in a Human Anaplastic Thyroid Cancer Cell Line and in a Mouse Xenograft Model

Anaplastic thyroid cancer (ATC) is a malignant subtype of thyroid cancers and its mechanism of development remains inconclusive. Importantly, there is no effective strategy for treatment since ATC is not responsive to conventional therapies, including radioactive iodine therapy and thyroid-stimulating hormone suppression. Here, we report that a combinational approach consisting of drugs designed for targeting lipid metabolism, lovastatin (an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A reductase, HMGCR) and troglitazone (an agonist of peroxisome proliferator-activated receptor gamma, PPARγ), exhibits anti-proliferation in cell culture systems and leads to tumor regression in a mouse xenograft model. The composition contains a sub-lethal concentration of both drugs and exhibits low toxicity to certain types of normal cells. Our results support a hypothesis that the inhibitory effect of the combination is partly through a cell cycle arrest at G0/G1 phase, as evidenced by the induction of cyclin-dependent kinase inhibitors, p21^cip and p27^kip, and the reduction of hyperphosphorylated retinoblastoma protein (pp-Rb)-E2F1 signaling. Therefore, targeting two pathways involved in lipid metabolism may provide a new direction for treating ATC.

Clinical presentation, treatment and outcome of anaplastic thyroid carcinoma: results of a multicenter study in Germany

CONTEXT

Anaplastic thyroid carcinoma (ATC) is an orphan disease and confers a dismal prognosis. Standard treatment is not established.

OBJECTIVE

The aim of this study is to describe clinical characteristics, current treatment regimens and outcome of ATC and to identify clinical prognostic markers and treatment factors associated with improved prognosis.

DESIGN

Retrospective cohort study at five German tertiary care centers.

PATIENTS AND METHODS

Totally 100 ATC patients diagnosed between 2000 and 2015 were included in the analysis. Disease-specific overall survival (OS) was compared with the Kaplan-Meier method and log-rank test; Cox proportional hazard model was used to identify risk factors.

RESULTS

The 6-month, 1-year and 5-year disease-specific OS rates were 37, 28 and 5%, respectively. Stage-dependent OS at 6 months was 78, 54 and 18% for stage IVA, B and C, respectively. 29% patients survived >1 year. Multivariate analysis of OS identified age ≥70 years, incomplete local resection status and the presence of distant metastasis as significant risk factors associated with shorter survival. Radical surgery (hazard ratio [HR] 2.20, 95% confidence interval (CI) 1.19-4.09, P = 0.012), external beam radiation therapy (EBRT) ≥40 Gy (HR = 0.34, 0.15-0.76, P = 0.008) and any kind of chemotherapy (CTX) (HR = 11.64, 2.42-60.39, P = 0.003) were associated with longer survival in multivariate analyses adjusted for age and tumor stage. A multimodal treatment regimen was significantly associated with a survival benefit (HR = 1.04, 1.01-1.08, P < 0.0001) only in IVC patients.

CONCLUSION

Disease-specific OS is still poor in ATC. Treatment factors associated with improved OS provide a rationale to devise treatment pathways for routine care. Collaborative research structures should be aimed to advance treatment of ATC.

Clinical Presentation and Diagnostic Challenges of Thyroid Lymphoma: A Cohort Study

BACKGROUND

Thyroid lymphoma is a relatively rare disease often posing a diagnostic challenge. Reaching the final diagnosis can be delayed if insufficient biopsy material is obtained for immunohistochemistry analysis. The aim of this study was to evaluate the clinical, biochemical, and radiological features of thyroid lymphoma.

METHODS

A retrospective analysis was conducted of all Mayo Clinic patients evaluated between 2000 and 2014 who had a tissue biopsy positive for thyroid lymphoma.

RESULTS

Seventy-five subjects had biopsy-proven thyroid lymphoma, and 62.7% were primary thyroid lymphomas. The median age at diagnosis was 67 years (range 20-90 years). A total of 50.7% were male, and 54.7% had a history of Hashimoto's thyroiditis. Presenting symptoms included neck mass (88%), dysphagia (45.3%), and hoarseness (37.3%). The typical ultrasound appearance consisted of a solid, hypoechoic mass with increased vascularity and variable edge characteristics. Fine-needle aspiration (FNA) biopsies were abnormal in 70.7% of cases, and 42% indicated a specific lymphoma subtype. The diagnosis was confirmed in 53.3% by core biopsy, in 21.3% by thyroidectomy (partial or total), in 12% through incisional biopsy, and in 12% by lymph node biopsy. Core biopsy had a higher sensitivity compared with FNA (93% vs. 71%, p = 0.006).

CONCLUSION

A rapidly enlarging neck mass in the setting of Hashimoto's thyroiditis should raise suspicion for thyroid lymphoma. Radiologically, this usually presents as a large, unilateral, thyroid-centered mass, hypoechoic by ultrasound, and expanding into adjacent soft tissues. Core-needle biopsy should be the first diagnostic test to expedite reaching the final diagnosis and decrease patient burden of additional tests and interventions.

Anaplastic Thyroid Carcinoma, Version 2.2015

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Thyroid Carcinoma focuses on anaplastic carcinoma because substantial changes were made to the systemic therapy recommendations for the 2015 update. Dosages and frequency of administration are now provided, docetaxel/doxorubicin regimens were added, and single-agent cisplatin was deleted because it is not recommended for patients with advanced or metastatic anaplastic thyroid cancer.

Sites of metastases of anaplastic thyroid carcinoma: autopsy findings in 45 cases from a single institution

BACKGROUND

Despite surgical treatment, chemotherapy, and/or radiotherapy, the vast majority of patients with anaplastic thyroid carcinoma (ATC) have a dismal prognosis. Better knowledge of the frequency of metastases to different sites might help us to perform the appropriate diagnostic tests before treatment and during the course of the disease. The aim of this study was to determine the frequency of metastases from ATC in different sites as found at autopsy.

METHODS

Altogether, 205 patients were treated for ATC at our institute during the years 1972-2008. Autopsy was performed in 45 cases (30 females, 15 males; median age 66 years). The relative frequencies of metastases in different sites were analyzed using descriptive statistics.

RESULTS

Altogether, 41 cases (91%) had metastases at autopsy. The most common sites of metastases were the lungs (78%), intrathoracic lymph nodes (58%), neck lymph nodes (51%), pleura (29%), adrenal glands (24%), liver (20%), brain (18%), heart (18%), and retroperitoneal lymph nodes (18%). Less common sites of distant metastases were the pericardium (13%), bones (13%), kidneys (13%), mesentery or peritoneum (13%), skin (9%), pancreas (4%), stomach (4%), diaphragm (4%), pituitary gland (2%), ovary (2%), jejunum (2%), axillary lymph nodes (2%), and gingival mucosa (2%). Both distant and regional metastases were present in 23 cases, while only distant metastases were present in 18 cases. An extensive local infiltration of the primary tumor was found in 76% of the cases. The total number of the involved organs and lymph node basins were 123 and 58, respectively. The mean number of metastatic sites was 4.02±2.75. Lung metastases were present in 34 of 38 (89%) of our patients who had distant metastases found at autopsy. Of these 34 patients, 27 were known to have lung metastases when they were alive.

CONCLUSION

Two or more metastatic sites were found at autopsy in 84% of cases. The most common metastatic sites are lungs, followed by the intrathoracic and neck lymph nodes.

Prognostic factors and treatment outcomes for anaplastic thyroid carcinoma: ATC Research Consortium of Japan cohort study of 677 patients

BACKGROUND

Anaplastic thyroid carcinoma (ATC) accounts for only 1 to 2% of all thyroid carcinomas, but it is one of the most lethal neoplasms in humans. To date, most findings about ATC have been derived from single-institution studies with limited numbers of cohorts. To obtain further insights into this "orphan disease," we have established a multicenter registry, the ATC Research Consortium of Japan (ATCCJ). We analyzed prognostic factors and treatment outcomes using the large cohort database of the ATCCJ.

METHODS

Most of the Japanese centers involved in the treatment of thyroid cancer were invited to join the ATCCJ and have provided information on ATC patients treated between 1995 and 2008. The database includes 677 cases from 38 registered institutions. Survival curves were determined using Kaplan-Meier methods and were compared using the log-rank test. Cox's proportional hazards model was used for multivariate analysis.

RESULTS

Clinical varieties of ATC were classified into four types: common type (n = 547); incidental type (n = 29); anaplastic transformation at the neck (n = 95); anaplastic transformation at a distant site (n = 6). The incidental type followed by anaplastic transformation at the neck showed better outcomes than the other types. Anaplastic transformation at a distant site showed the worst outcomes. The 6-month and 1-year cause-specific survival (CSS) rates for common-type ATC were 36 and 18%, respectively. In all, 84 (15%) achieved long-term (>1 year) survival. Multivariate analysis identified age ≥70 years, presence of acute symptoms, leukocytosis (white blood cell count ≥10,000/mm(3)), large tumor >5 cm, T4b tumor, and distant metastasis as significant risk factors for lower survival. CSS rates also differed significantly depending on UICC stages, with 6-month CSSs of 60% for stage IVA, 45% for IVB, and 19% for IVC. For 36 of 69 (52%) stage IVA patients who underwent radical surgery, adjuvant therapies, including radiation therapy (RTX) and chemotherapy (CTX) did not show additional benefit statistically. Conversely, among 242 stage IVB patients, 80 (33%) underwent radical surgery. For those patients, therapies combining RTX with CTX significantly improved CSS.

CONCLUSIONS

Long-term survival is possible for selected patients with ATC. To determine the treatment strategy, UICC stage (disease extent) and other prognostic factors (e.g., biologic malignancy grade) should be considered.

Lower incidence of anaplastic carcinoma after higher iodination of salt in Slovenia

BACKGROUND

Anaplastic thyroid carcinoma (ATC) may arise de novo or from a preexistent differentiated carcinoma. It is well known that higher iodine intake in the diet causes higher frequency of papillary thyroid carcinoma, but decreases the frequency of follicular thyroid carcinoma. However, it is not known how the change in iodine intake influences the frequency of ATC. The aim of our study was to compare the incidence of ATC during the periods when the intake of potassium iodide in salt was 10 and 25 mg/kg.

METHODS

A total of 205 patients with ATC (140 women, 65 men; median, 69 years) were treated in the Republic of Slovenia between 1972 and 2008. In Slovenia, a country with a population of 2 million people, the salt was iodinated with 10 mg of potassium iodide/kg from 1972 to 1997. From 1998 to 2008 the degree of iodination of salt was increased to 25 mg of potassium iodide/kg. The frequency of ATC during the two periods and the characteristics of the patients during these periods were compared.

RESULTS

The mean incidences of ATC during 1972-1997 and 1998-2008 was 6.2 (range, 3-12) and 4 (range, 2-10) patients per year, respectively. During the period 1972-1997 and 1998-2008, the mean age of patients was 66.7 and 72.2 years (p = 0.02), and the mean tumor diameter was 9.6 and 8.6 cm (p = 0.21), respectively. However, the median survival of patients in both periods was 3 months.

CONCLUSION

The incidence of ATC decreased after higher iodination of salt. The patients with ATC during the period of higher iodination of salt were older than those from the period with lower iodination of salt.