Prognostic factors and the therapeutic strategy for patients with bone metastasis from differentiated thyroid carcinoma

TRPC5 expression promotes the proliferation and invasion of papillary thyroid carcinoma through the HIF-1α/Twist pathway

OBJECTIVE

This study aimed to investigate the effect of TRPC5 on PTC (papillary thyroid carcinoma) proliferation and invasion.

METHODS

Immunofluorescence and western blot were used to evaluate the expression of TRPC5 in paraffin sections and clinical tissues. Overexpression and silencing of TRPC5 to generate the cells for in vitro experiments. Wound-healing assay, transwell invasion assay, MTT assay, and in vivo tumorigenicity assay were used to determine cell proliferation and cell migration in vitro and in vivo. Real-time PCR was used to test the expression of TRPC5. Western blot was used to test the expression of downstream factors: E-cadherin, Vimentin, MMP-9, MMP-2, TRPC5, ZEB, Snail, and Twist.

RESULTS

The level of TRPC5 protein expression was higher in PTC than in adjacent normal thyroid tissue. TPC-1 cells overexpressing TRPC5 were more proliferative, had longer migration distances, and increased the number of invading cells. TPC-1 cells silenced with TRPC5 had a weaker proliferation capacity, shorter migration distances, and a reduced number of invading cells. Overexpression and silencing of TRPC5 modulated E-cadherin, Vimentin, MMP-9, MMP-2, TRPC5, and Twist, but did not affect ZEB and Snail. The results of tumor formation experiments in nude mice showed that inhibition of TRPC5 expression suppressed the volume and weight of transplanted tumors.

CONCLUSION

TRPC5 induced papillary thyroid cancer metastasis and progression via up-regulated HIF-1α signaling in vivo and in vitro. High TRPC5 expression is a biomarker for lymph node metastasis at its early stages.

A long-term retrospective cohort-based risk-benefit analysis of augmenting total cumulative I-131 activity to 37GBq in differentiated thyroid cancer patients with skeletal metastases

OBJECTIVE

Skeletal metastases in differentiated thyroid cancer (DTC) patients are associated with poor prognosis. The objective was to determine the maximum I-131 cumulative activity that could be safely administered without compromising efficacy. The secondary objective was to identify other prognostic factors affecting survival outcomes.

MATERIALS AND METHODS

This was a retrospective cohort study done at a tertiary-care institution comprising of data from January 1990-June 2020. 489 DTC patients having skeletal metastases with ≥12 months follow-up were included. Ninety-six percent of patients had thyroidectomy followed by radioiodine therapy for skeletal metastases. All patients were on oral suppressive levothyroxine tablets. External beam radiotherapy (EBRT) and oral tyrosine kinase inhibitors were used whenever indicated. The main outcome measures were overall survival (OS), progression-free survival (PFS), and adverse-events.

RESULTS

There were 347 (71%) females and 324 (66%) had follicular carcinoma thyroid. Median follow-up was 78 (interquartile range, IQR: 37-153) months. 333 patients (68%) received ≤37GBq I-131 cumulative activity (group 1) and 156 patients (32%) received >37GBq cumulative RAI activity (group 2). Overall median OS and PFS were 74 (95% confidence interval (CI): 62.2-85.8) and 48 (95%CI: 40.5-55.4) months, respectively. The 5-, 10-, 15- and 20-year estimated overall survival probabilities were 55.7%, 28.4%, 14% and 8.3%, respectively. On multivariate analysis, age(<55years) (p<0.001), female gender(p = 0.01), cumulative I-131 activity >37GBq (p<0.001) and EBRT(p = 0.001) were favourably associated with OS; no factors were significantly associated with PFS. The median OS for groups 1 & 2 were 51 versus 90 months (p<0.001) & median PFS for groups 1 & 2 were 45 versus 53 months respectively (p = 0.9). However, cumulative activity >37GBq resulted in more adverse events (2.4%), particularly bone marrow suppression (3.5%).

CONCLUSION

For better survival outcomes, cumulative I-131 activity upto 37GBq could be administered with acceptable toxicity to DTC patients with skeletal metastases.

Bilateral follicular thyroid carcinoma with large sternal metastasis: Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Follicular thyroid cancer (FTC) typically spreads hematogenously, with bone metastasis being worrisome, often appearing to be resistant to radioactive iodine (RAI) therapy. Metastasis to sternum is exceedingly rare.

CASE PRESENTATION

A 43-year-old Egyptian male presented with chest tightness, cough, and shortness of breath. He was initially treated as bronchial asthma. Later, he was referred to our thyroid surgery clinic as a case of goitre and palpable sternal mass. He looked clinically well, with enlarged anterior neck mass and visible sternal mass, no lymphadenopathy. Laboratory tests showed thyroid-stimulating hormone levels within normal (2.13 mIU/L), and mildly decreased FT4 (10.3 pmol/L). Neck/chest CT demonstrated multinodular goitre with retrosternal extension, expansile lytic lesion in the sternum, and bilateral lung metastases. Thyroid fine needle aspiration and cytology showed FLUS, and true cut biopsy from the sternal lesion showed invasive FTC.

DISCUSSION

Rare bilateral FTC presenting as slow-growing sternal metastasis. The patient underwent total thyroidectomy, followed by high dose RAI therapy, and concluded with sternectomy and reconstruction surgery repair using polymethyl methacrylate wrapped in proline mesh. On follow-up, he received further RAI ablation therapy and became RAI refractory. He then received systemic therapy (Lenvatinib). Most recent follow up showed that the disease was controlled (low volume cancer) and he was tolerating treatment well with no reported symptoms.

CONCLUSION

Bilateral FTC with sternal metastasis is rare, and can be treated with total thyroidectomy, sternectomy and reconstruction, followed by RAI therapy and systemic therapy where required, hence inferring real survival benefit.

A practical dynamic nomogram model for predicting bone metastasis in patients with thyroid cancer

PURPOSE

The aim of this study was to established a dynamic nomogram for assessing the risk of bone metastasis in patients with thyroid cancer (TC) and assist physicians to make accurate clinical decisions.

METHODS

The clinical data of patients with TC admitted to the First Affiliated hospital of Nanchang University from January 2006 to November 2016 were included in this study. Demographic and clinicopathological parameters of all patients at primary diagnosis were analyzed. Univariate and multivariate logistic regression analysis was applied to build a predictive model incorporating parameters. The discrimination, calibration, and clinical usefulness of the nomogram were evaluated using the C-index, ROC curve, calibration plot, and decision curve analysis. Internal validation was evaluated using the bootstrapping method.

RESULTS

A total of 565 patients were enrolled in this study, of whom 25 (4.21%) developed bone metastases. Based on logistic regression analysis, age (OR=1.040, P=0.019), hemoglobin (HB) (OR=0.947, P<0.001) and alkaline phosphatase (ALP) (OR=1.006, P=0.002) levels were used to construct the nomogram. The model exhibited good discrimination, with a C-index of 0.825 and good calibration. A C-index value of 0.815 was achieved on interval validation analysis. Decision curve analysis showed that the nomogram was clinically useful when intervention was decided at a bone metastases possibility threshold of 1%.

CONCLUSIONS

This dynamic nomogram, with relatively good accuracy, incorporating age, HB, and ALP, could be conveniently used to facilitate the prediction of bone metastasis risk in patients with TC.

Papillary thyroid microcarcinoma with contralateral large humerus metastasis and cervical lymph node metastasis: A case report

Introduction

Papillary thyroid microcarcinoma (PTMC) that metastasizes to bone, especially metastasizes to contralateral humerus with so large mass, is rarely reported before.

Case report

We presented a 50-year-old female patient with a large painful mass in the right humerus for 5 years, presenting with swelling of the right shoulder with limited mobility. Positron emission tomography–computed tomography (PET/CT) showed a large mass in the right humerus, bilateral lung lesions, and enlarged lymph nodes in the right supraclavicular fossa. Right humerus lesion biopsy and immunohistochemical evaluations confirmed that the lesion originated from the thyroid tissue. Then, the thyroid ultrasonography showed a hypo-echoic solid nodule with an irregular taller-than-wide shape in the upper of left thyroid lobe and enlarged lymph nodes with the absence of fatty hilum in the contralateral right IV compartment. The total thyroidectomy and cervical lymph node dissection were undertaken; the histopathology confirmed the diagnosis of PTMC with contralateral cervical lymph node metastasis.

Conclusion

We reported a case of PTMC with contralateral large humerus and cervical lymph node metastasis and demonstrated the PET/CT images of the metastatic large humerus and thyroid ultrasonographic appearances of the PTMC and enlarged cervical lymph node.

Locoregional progression-free survival of bone metastases from differentiated thyroid cancer

To evaluate the locoregional progression-free survival (LPFS) of bone metastatic lesions from differentiated thyroid cancer (DTC) after radioiodine therapy (RAIT) and to define its influencing factors, we performed a retrospective cohort analysis of 89 patients with bone metastases from DTC who received RAIT in our department over a 17-year period. The median follow-up time was calculated using the reverse Kaplan-Meier method. The log-rank test and a multivariate Cox proportional hazards regression model were performed in the analysis of prognostic indicators for LPFS. In this research, the median follow-up time for all patients was 47 (95% CI, 35.752-58.248) months, and that for patients with no progression was 42 months. The longest follow-up time was 109 months. The median LPFS time was 58 (95% CI, 32.602-83.398) months, and the 3- and 5-year LPFS probabilities were 57.8 and 45.1%, respectively. Multivariate analysis revealed bone structural changes as an independent risk factor for LPFS (P= 0.004; hazard ratio, 49.216; 95% CI, 3.558-680.704). Furthermore, the non-total-lesion uptake subgroup presented a worse LPFS than the total-lesion uptake subgroup in patients with structural bone lesions (P = 0.027). RAIT can improve the LPFS of radioiodine-avid bone metastases from DTC, especially those without bone structural changes.

The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 4: miscellaneous cancers

This article discusses relevant information for the dental sector regarding metastatic cancers beyond breast and prostate cancer. Typically, tumour sites such as lung, renal, colorectal, gastrointestinal, thyroid, hepatic and pancreatic cancers are increasingly being referred for bone-targeting agents upon evidence of bone metastases.The current article explores the presenting dental status of these tumour groups on the background of survival outcomes. In addition, the article provides insight towards the complexity in achieving 'dental fitness' and whether 'dental stability' could be an alternative to consider via palliative dentistry in certain cases.

Bone metastases from differentiated thyroid carcinoma: heterogenous tumor response to radioactive Iodine therapy and overall survival

PURPOSE

Bone metastases (BM) from differentiated thyroid carcinoma (DTC) impact negatively the quality of life and the life expectancy of patients. The aim of the study was (a) to evaluate the overall survival (OS) and prognostic factors of OS and (b) to assess predictive factors of complete BM response (C-BM-R) using radioiodine treatment (RAI) either alone or in association with focal treatment modalities.

METHODS

A total of 178 consecutive DTC patients harbouring BM, treated between 1989 and 2015, were enrolled in this retrospective study conducted in two tertiary referral centers. OS analysis was performed for the whole cohort, and only the 145 considered non-RAI refractory patients at BM diagnosis were evaluated for C-BM-R following RAI.

RESULTS

The median OS from BM diagnosis was 57 months (IQR: 24-93). In multivariate analysis, OS was significantly reduced in the case of T4 stage, ¹⁸FDG uptake by the BM and RAI refractory status. Among the 145 DTC considered non-RAI refractory patients at BM diagnosis, 46 patients (31.7%) achieved a C-BM-R following RAI treatment, either alone in 32 (18%) patients or in association with focal BM treatment modalities in 14. The absence of extra-skeletal distant metastasis and of ¹⁸FDG uptake in BM were predictive for C-BM-R.

CONCLUSIONS

In nearly one-third of DTC patients with RAI avid BM, RAI alone or in combination with BM focal treatment can induce C-BM-R. The presence of ¹⁸FDG uptake in BM is associated with an absence of C-BM-R and with a poor OS. ¹⁸FDG PET-CT should be performed when BM is suspected.

Incidence and Predictors of Synchronous Bone Metastasis in Newly Diagnosed Differentiated Thyroid Cancer: A Real-World Population-Based Study

Background

Clinical and sociodemographic characteristics of differentiated thyroid cancer (DTC) patients with synchronous bone metastasis (SBM) remain unclear. This real-world study aimed to elucidate the incidence and prognosis of DTC patients with SBM using population-based data.

Methods

Data of patients with newly diagnosed DTC from 2010 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariable logistic regression analysis was utilized to identify predictors of developing SBM in patients with DTC and was further evaluated by receiver operator characteristics (ROC) analysis. Multivariable Cox regression was applied to identify prognostic factors associated with overall survival (OS) and cancer-specific survival (CSS).

Results

A total of 67,176 patients with DTC were screened from the database, with 0.36% (244/67,176) developed SBM. The age-adjusted incidence of SBM in patients with DTC was relatively stable during the study period with an average annual percentage change (AAPC) of 2.52. Multivariable logistic regression analysis recognized seven factors (older age, male gender, black race, other races, follicular histology, the American Joint Committee on Cancer (AJCC) T2, T3, T4 staging, and N1 staging) as predictors of developing SBM among the entire cohort, with the value of area under the curve (AUC) of 0.931 (95% CI: 0.915–0.947). The median survival time of DTC patients with SBM was 22 months (interquartile range, 7–47 months). The multivariable Cox regression analysis indicated multiple metastatic sites, surgical procedures, and chemotherapy as predictors for the survival of patients.

Conclusions

Predictors and prognostic factors of SBM in patients with DTC were identified in this study. Patients with risk factors should be given more attention in clinical practice.

Risk Factors and Prognosis for Metastatic Follicular Thyroid Cancer

BACKGROUND

Follicular thyroid cancer (FTC) is the second most common malignancy of thyroid. About 7%-23% of patients with FTC have distant metastasis. The aim of this study was to investigate the risk factors associated with distant metastasis and the impact of distant metastasis on survival in FTC patients.

METHODS

Patients with FTC were analyzed using a prospectively maintained dataset of thyroid cancer registered at a tertiary hospital in Taiwan between December 1976 and May 2020.

RESULTS

A total of 190 patients with a mean follow-up of 7.7 years were included in this study, including 29 with distant metastasis at diagnosis, 14 who developed metastasis during follow-up, and 147 without metastasis. Multivariate analysis adjusted for age, gender, tumor stage, and extrathyroidal invasion revealed old age (≥ 55 years) (adjusted odds ratio, 27.6; 95% confidence interval [CI], 8.75-86.8; P < 0.001) and extrathyroidal invasion (odds ratio, 24.1; 95% CI, 3.50-166.5; P = 0.001) were significantly associated with an increased risk of distant metastasis. Metastasis was correlated with higher cancer-specific mortality (adjusted hazard ratio, 35.5; 95% CI, 6.1-206.1; P < 0.001). In addition, patients with metastatic FTC diagnosed on initial presentation had the lowest 10-year cancer-specific survival rate (26.0%), followed by those who developed metastatic disease after initial treatment (76.6%), while patients without metastasis were all alive (100%) (P ≤ 0.002 for all comparisons).

CONCLUSIONS

Age and extrathyroidal invasion are significant risk factors for distant metastasis of FTC. Patients with metastatic FTC, especially when diagnosed on initial presentation, have dismal survival outcomes.

Machine learning for the prediction of bone metastasis in patients with newly diagnosed thyroid cancer

OBJECTIVES

This study aimed to establish a machine learning prediction model that can be used to predict bone metastasis (BM) in patients with newly diagnosed thyroid cancer (TC).

METHODS

Demographic and clinicopathologic variables of TC patients in the Surveillance, Epidemiology, and End Results database from 2010 to 2016 were retrospectively analyzed. On this basis, we developed a random forest (RF) algorithm model based on machine-learning. The area under receiver operating characteristic curve (AUC), accuracy score, recall rate, and specificity are used to evaluate and compare the prediction performance of the RF model and the other model.

RESULTS

A total of 17,138 patients were included in the study, with 166 (0.97%) developed bone metastases. Grade, T stage, histology, race, sex, age, and N stage were the important prediction features of BM. The RF model has better predictive performance than the other model (AUC: 0.917, accuracy: 0.904, recall rate: 0.833, and specificity: 0.905).

CONCLUSIONS

The RF model constructed in this study could accurately predict bone metastases in TC patients, which may provide clinicians with more personalized clinical decision-making recommendations. Machine learning technology has the potential to improve the development of BM prediction models in TC patients.

Bone metastases from differentiated thyroid carcinoma: current knowledge and open issues

Bone represents the second most common site of distant metastases in differentiated thyroid cancer (DTC). The clinical course of DTC patients with bone metastases (BM) is quite heterogeneous, but generally associated with low survival rates. Skeletal-related events might be a serious complication of BM, resulting in high morbidity and impaired quality of life. To achieve disease control and symptoms relief, multimodal treatment is generally required: radioiodine therapy, local procedures-including surgery, radiotherapy and percutaneous techniques-and systemic therapies, such as kinase inhibitors and antiresorptive drugs. The management of DTC with BM is challenging: a careful evaluation and a personalized approach are essential to improve patients' outcomes. To date, prospective studies focusing on the main clinical aspects of DTC with BM are scarce; available analyses mainly include cohorts assembled over multiple decades, small samples sizes and data about BM not always separated from those regarding other distant metastases. The aim of this review is to summarize the most recent evidences and the unsolved questions regarding BM in DTC, analyzing several key issues: pathophysiology, prognostic factors, role of anatomic and functional imaging, and clinical management.

Application of carbon nanoparticles combined with intraoperative neuromonitoring in papillary thyroid microcarcinoma surgery

PURPOSES

To improve the lymph node dissection as well as protect parathyroid gland and recurrent laryngeal nerve, the carbon nanoparticles and intraoperative neuromonitoring were applied in papillary thyroid microcarcinoma surgery.

METHODS

Carbon nanoparticles and intraoperative neuromonitoring were used in the experimental group, whereas the control group were not. Routine pathological examination was performed.

RESULTS

The lymph nodes dissected was significantly higher in the experimental group, but the metastatic lymph nodes were not. The number of mistakenly dissected parathyroid gland and postoperative hypoparathyroidism were 3 and 13 in the experimental group respectively, significantly less than 10 and 25 in the control group. The incidences of overall, transient and persistent recurrent laryngeal nerve palsy in the experimental group were 5.5%, 5.5% and 0% respectively, whereas in the control group were 8.6%, 6.9% and 1.7%.

CONCLUSIONS

Carbon nanoparticles can improve lymph node dissection in papillary thyroid microcarcinoma surgery, and the combination of carbon nanoparticles with intraoperative neuromonitoring can reduce surgical complications and improve patient quality of life.

Novel nomogram to predict risk of bone metastasis in newly diagnosed thyroid carcinoma: a population-based study

Background

The aim of this study was to develop and validate a visual nomogram for predicting the risk of bone metastasis (BM) in newly diagnosed thyroid carcinoma (TC) patients.

Methods

The demographics and clinicopathologic variables of TC patients from 2010 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database were retrospectively reviewed. Chi-squared (χ2) test and logistic regression analysis were performed to identify independent risk factors. Based on that, a predictive nomogram was developed and validated for predicting the risk of BM in TC patients. The C-index was used to compute the predictive performance of the nomogram. Calibration curves and decision curve analysis (DCA) were furthermore used to evaluate the clinical value of the nomogram.

Results

According to the inclusion and exclusion criteria, the data of 14,772 patients were used to analyze in our study. After statistical analysis, TC patients with older age, higher T stage, higher N stage, poorly differentiated, follicular thyroid carcinoma (FTC) and black people had a higher risk of BM. We further developed a nomogram with a C-index of 0.925 (95%CI,0.895–0.948) in the training set and 0.842 (95%CI,0.777–0.907) in the validation set. The calibration curves and decision curve analysis (DCA) also demonstrated the reliability and accuracy of the clinical prediction model.

Conclusions

The present study developed a visual nomogram to accurately identify TC patients with high risk of BM, which might help to further provide more individualized clinical decision guidelines.

Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion

BACKGROUND

Differentiated thyroid carcinoma (DTC) can invade the surrounding aerodigestive tract. Radical surgery for locally advanced DTC will require resection of the trachea, recurrent laryngeal nerve (RLN), inferior pharyngeal constrictor muscles (IPCMs), or a part of the esophagus. The purpose of this study was to demonstrate the effect of resection of these surrounding tissues combined with total thyroidectomy and neck dissection on swallowing function following surgery.

METHODS

We performed total thyroidectomy combined with neck dissection and resection of the RLN in 24 patients with DTC with extrathyroidal invasion (19 unilateral, 1 bilateral), IPCMs (n = 5), or muscle layers of esophagus (n = 9). Nine patients received a tracheostomy placement due to a window resection of the trachea for tumor invasion (n = 6) and necessary upper airway management (n = 3). We used the duration of nasogastric tube feeding to evaluate swallowing function following surgery.

RESULTS

Patients who underwent tracheostomy or IPCM resection showed significantly longer periods of tube feeding (p = 0.0057 and 0.0017, respectively). In contrast, resection of the unilateral RLN or esophageal muscle layer showed no difference in tube feeding duration. Multiple regression analysis indicated that tracheostomy and IPCM resection were significant independent predictors of longer periods of tube feeding (p = 0.04583 and 0.00087, respectively).

CONCLUSION

These results indicate that tracheostomy placement and resection of the IPCMs, together with total thyroidectomy, extends the tube feeding duration in the postoperative period.

A Single-Center, 10-Year Retrospective Study on Surgical Treatment and Prognosis Analysis of Differentiated Thyroid Carcinoma with Spinal Metastasis

Objective

Metastatic spinal differentiated thyroid carcinoma (MSDTC) is relatively rare in the clinic and often overlooked. The objective of the current study is to analyze the clinical characteristics and prognosis of patients with MSDTC who underwent surgical treatment to determine the prognostic factors that affect survival.

Methods

This study retrospectively analyzed the clinical data and postoperative follow-up results of MSDTC patients who underwent spinal surgery at the Orthopedic Department of Peking Union Medical College Hospital from January 2010 to January 2020. Clinical data and survival time were analyzed by Kaplan–Meier analysis.

Results

Eleven patients were included, and the average age was 58.3 years (range 37‒74). The average time from the initial surgery to the discovery of spinal metastasis was 42.9 months (range 0‒132), and the average follow-up time was 21.8 months (range 3‒80). Progression was identified in seven patients, and 10 patients (90.9%) died during the follow-up period. Kaplan–Meier analysis showed that extraosseous visceral metastasis (p=0.012), revised Tokuhashi score (p=0.035), Tomita score (p=0.038), and surgical method (p=0.028) were associated with overall survival (OS). In addition, skeletal visceral metastasis (p=0.017), revised Tokuhashi score (p=0.028), Tomita score (p=0.038), and surgical method (p=0.049) were associated with progression-free survival (PFS).

Conclusion

Surgical treatment is an effective method for treating MSDTC and leads to pain relief, restored function and increased spinal stability. Based on our single-center experience, extraosseous visceral metastasis, revised Tokuhashi score, Tomita score, and surgical methods may be potential prognostic factors for OS whilst visceral metastasis, revised Tokuhashi score, Tomita score, and surgical methods may be potential prognostic factors for PFS.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series

INTRODUCTION

Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors.

HYPOTHESIS

The French data for clinical results, survival and complications are in agreement with the international literature.

MATERIALS AND METHOD

The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%).

RESULTS

There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before.

CONCLUSION

The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Clinical Analysis of BRAFV600E Mutation and Its Correlation With Sonographic Image Characteristics in Papillary Thyroid Carcinoma in Chinese Coastal Areas

This study analyzed the characteristics of BRAF^V600E mutation in papillary thyroid carcinoma (PTC) in Chinese coastal areas. We intended to identify noninvasive methods to determine BRAF^V600E status in thyroid nodules prior to surgery. BRAF^V600E mutation and the sonographic characteristics of thyroid nodules were investigated in 670 PTC patients in our hospital. We aimed to determine the relationship between BRAF^V600E mutation and the clinicopathological and sonographic imaging characteristics of PTC. The mutation rate of the BRAF^V600E was 78.2%. BRAF^V600E mutation was significantly associated with central node (univariate analyses, P = .005; multivariate analyses, P < .001, odds ratio [OR] = 10.255) and lateral node metastases (univariate analyses, P = .001; multivariate analyses, P < .001, OR = 22). It was less frequent in PTC coexisting with Hashimoto's thyroiditis (univariate analyses, P = .016; multivariate analyses, P < .001, OR = .034). Nodules without blood flow had a significantly higher mutation rate of BRAF^V600E in PTC patients (univariate analyses, P = .026). BRAF^V600E mutation was significantly associated with high suspicion in the Thyroid Imaging Reporting and Data System 5 (univariate analyses, P = .004; multivariate analyses, P = .014, OR = 6.456). Our results strongly suggest that BRAF^V600E mutation plays a potential role in lymph node metastasis (central node metastasis, OR = 10.225; lateral node metastasis, OR = 22). Some sonographic imaging features might be helpful in estimating the status of BRAF^V600E preoperatively.

Efficacy of low radioiodine activity versus intermediate-high activity in the ablation of low-risk differentiated thyroid cancer

PURPOSE

The aim of our study was to compare the efficacy of thyroid remnant ablation using low (1.1 GBq) and intermediate-high radioiodine (RAI) activity (1.85-3.7 GBq) in low-risk differentiated thyroid carcinoma (DTC) and to evaluate the staging role of the whole body scan (WBS) in detection extrathyroidal disease.

MATERIALS AND METHODS

We retrospectively included 277 patients who underwent total thyroidectomy and RAI for low-risk DTC and divided them in two groups according to RAI activity at ablation: group 1 (n = 174) treated with low activity (1.1 GBq), and group 2 (n = 103) with intermediate-high activity (1.85-3.7 GBq). To evaluate the successful ablation rate, the WBS 1 year after RAI was visually interpreted using a three-point scale: score 0 in case of absence of visible RAI uptake in thyroid bed; score 1 in presence of faint uptake in the thyroid bed; and score 2 in case of significant RAI uptake in thyroid bed.

RESULTS

The success ablation rate was significantly higher in group 2 than group 1 (p < 0.001) with the presence of a positive WBS (score 1-2) in 65% low-activity group and 33% in intermediate-high group. Considering response to therapy categories, excellent response rate was significantly higher in group 2 (p = 0.020), while indeterminate response was higher in group 1 (p value = 0.005). Post RAI imaging revealed extrathyroidal uptake in 27 cases: 17 laterocervical nodal and 10 distant metastases. In both groups similar detection rate of nodal and distant metastases were recognized without any statistical difference.

CONCLUSIONS

The ablation rate with intermediate-high RAI activity (1.85-3.7 GBq) was better than with a low activity (1.1 GBq). First WBS may help to recognize nodal and distant metastases in about 10% of cases changing clinical stage and subsequent management.

Stereotactic radiotherapy using the CyberKnife is effective for local control of bone metastases from differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is associated with a good long-term prognosis, but bone metastases can adversely affect patients' quality of life and survival. Stereotactic radiotherapy (SRT) can deliver high-dose irradiation to target lesions and it has been reported to be useful for various cancers. However, few studies have examined the efficacy of SRT for thyroid cancer. In the present study, the aim was to investigate the efficacy of SRT using the CyberKnife for bone metastases from DTC. From September 2013 to April 2018, SRT with the CyberKnife system was used to treat 60 bone metastases from DTC in 13 patients. The patients' medical records were retrospectively reviewed to obtain information about the adverse events associated with SRT. Of the 60 lesions, 40 could be evaluated by follow-up CT for therapeutic effectiveness, and the RECIST criteria were used to assess the response. The cancers were papillary cancer in 3 patients, follicular cancer in 9 and poorly differentiated cancer in 1. SRT was delivered in 1-10 fractions, with a median dose of 27 Gy (range, 8-48 Gy). Adverse events were infrequent and mild. The median follow-up of the 40 lesions was 11 (range, 2-56) months. The responses were partial response in 2 lesions, stable disease in 37 lesions and progressive disease in 1 lesion, with a 1-year local control rate of 97.1%. The present study showed that SRT using the CyberKnife system was a feasible and effective treatment for bone metastases of DTC.

Improved Survival After Multimodal Approach with 131I Treatment in Patients with Bone Metastases Secondary to Differentiated Thyroid Cancer

Background: The objective of this study was to evaluate the overall survival (OS) of radioiodine (¹³¹I) treatments alone or combined with non-¹³¹I treatments in patients with bone metastases (BM) of differentiated thyroid cancer (DTC). Methods: This was a retrospective study of patients who were evaluated between 2001 and 2018 at MedStar Washington Hospital Center and who had DTC, BM, and at least one ¹³¹I treatment after the diagnosis of BM. The OS was analyzed by Kaplan-Meier survival curves and was compared by log-rank test between two groups: patients who received ¹³¹I treatments alone and those who received treatments combining ¹³¹I with non-¹³¹I treatments (CombTx). Non-¹³¹I treatments include surgery, radiofrequency ablation, cryotherapy, arterial embolization, external beam radiation, Cyberknife, systemic targeted therapy, and anti-resorptive medication. Results: A total of 77 patients met the above criteria and were followed up to 41 years. Thirty percent (23/77) of patients received ¹³¹I treatment alone, and 70% (54/77) received CombTx. For ¹³¹I treatment alone, the median survival was 3.9 years, and the 1-, 2-, 3-, 5-, and 10-year OS rates were 86%, 81%, 61%, 35%, and 23%, respectively. For CombTx, the median survival was 7.7 years, and the 1-, 2-, 3-, 5-, and 10-year OS rates were 96%, 92%, 86%, 69%, and 30%, respectively. Patients who had undergone initial ¹³¹I therapy within six months post thyroidectomy demonstrated a better median survival after BM diagnosis than those whose initial ¹³¹I therapy was six months or more after thyroidectomy (6.5 vs. 0.5 years; p < 0.001). Patients who received external beam radiation therapy demonstrated a better median survival than those who did not (7.8 vs. 4.4 years; p = 0.016). Patients who received denosumab demonstrated a better median survival than those who did not (7.7 vs. 5.2 years; p = 0.03). Patients who were <55 years of age at the initial diagnosis of DTC or at the initial diagnosis of BM had a better median OS than those diagnosed at ≥55 years of age (both p = 0.01). In the multivariate analysis, only age at initial diagnosis of DTC and initial ¹³¹I therapy within six months post thyroidectomy, and multiple ¹³¹I treatments were independent prognostic factors. Conclusions: In patients with DTC with BM, ¹³¹I treatment in combination with one or more non-¹³¹I direct and systemic treatments was associated with a significant increase in OS compared with those patients who were treated by ¹³¹I treatment alone.

The Prognosis of Papillary Thyroid Cancer with Initial Distant Metastasis is Strongly Associated with Extensive Extrathyroidal Extension: A Retrospective Cohort Study

BACKGROUND

Extensive extrathyroidal extension (ETE) has a significant role in the prognosis of papillary thyroid cancer (PTC) without distant metastasis, but its role in PTC with initial distant metastasis has never been studied. This study aimed to evaluate the prognostic significance of extensive ETE regarding disease progression, survival, and remission in PTC patients with initial distant metastasis.

METHODS

This retrospective cohort study included PTC patients with initial distant metastasis who underwent total thyroidectomy with a median follow-up period of 6.7 years. The prognostic significance of extensive ETE was assessed in terms of time to tumor progression (TTP), cancer-specific survival (CSS), and cumulative incidence of remission with all-cause death as the competing event.

RESULTS

The study enrolled 64 patients. Of these patients, 21 (32.8%) had extensive ETE, which was associated with a shorter TTP (adjusted hazard ratio [HR], 4.10; p = 0.015) and a lower CSS rate (p = 0.002, log-rank), particularly for patients 55 years of age or older with stage 4b disease (10-year CSS rate: 33.3% in those with and 92.3% in those without extensive ETE; p = 0.017). Additionally, remission was observed only in patients without extensive ETE (10-year cumulative incidence of remission: 0.0% in those with and 29.3% in those without extensive ETE; p = 0.013).

CONCLUSIONS

Extensive ETE of the primary lesion results in poorer prognoses for PTC patients with initial distant metastasis. The high CSS rate for patients with stage 4b PTC but no extensive ETE indicates that the prognosis of this patient population should be distinguished from that of other stage 4 cases.

Clinical and prognostic role of detection timing of distant metastases in patients with differentiated thyroid cancer

PURPOSE

Distant metastases (DM) from DTC occur in 5-25% of cases and are correlated to lower survival; the prognostic significance of the temporal onset of DM is unclear. Our aim was to retrospectively analyze the prevalence of DM and to assess the prognostic role of the timing of manifestation of DM regarding the outcome.

MATERIALS AND METHODS

We included 174 patients (mean age 64 years). According to the time of manifestation, DM were divided in two groups: synchronous DM (SDM, n = 108) defined as metastases present at initial diagnosis and metachronous DM (MDM, n = 66) as diagnosed during follow-up. SDM were further sub grouped in pre-RAIT when diagnosed during pre-surgery work-up (n = 35) and baseline-RAIT when detected by first whole body scan after RAIT (n = 73). Disease-specific survival (DSS) was analyzed using the Kaplan-Meier method.

RESULTS

Total RAI activities and number of treatments were significantly higher in MDM, also loss of RAI avidity was more frequent in MDM. Forty-four patients died during follow-up, of which 41 were DTC-related deaths, 5-year and 10-year DSS were 80% and 56%. On univariate analysis MDM had significantly shorter DSS; also histotype and RAI avidity were significant risk factors of impaired survival. On multivariate analysis, only loss of RAI avidity remained as independent negative predictor (p = 0.043). Considering SDM, DSS was significantly shorter in pre-RAIT group than baseline-RAIT (p = 0.004). Instead there was no significant difference between pre-RAIT-SDM and MDM in survival outcome (p = 0.875).

CONCLUSIONS

In DTC with DM, loss of RAI uptake has an important role in survival. No significant difference in survival outcome was discovered between SDM and MDM; but, among SDM, pre-RAIT had significant shorter DSS than baseline-RAIT.

Possible delayed diagnosis and treatment of metastatic differentiated thyroid cancer by adopting the 2015 ATA guidelines

OBJECTIVE

According to the 2015 American Thyroid Association (ATA) guidelines, thyroid ablation by iodine-131 (I-131) therapy is absolutely recommended only in patients with high-risk differentiated thyroid cancer (DTC). Often distant metastases are not recognized early and they can stay silent for long time. The aim of our study was to retrospectively analyze the prevalence of metastatic disease before and after I-131 and to evaluate the influence of the new ATA guidelines in the management of DTC.

METHODS

We retrospectively analyzed 140 patients showing distant metastases. All metastases were detected by whole-body scan after I-131 and confirmed by histology and/or other imaging modalities.

RESULTS

In 26/140 patients metastases were detected before I-131, while in 114/140 were discovered after I-131. Comparing patients with metastases detected before and after I-131, no differences were demonstrated considering age, sex, histotype, tumor size, multifocality of cancer and metastatic localization. Metastatic DTC discovered before radioiodine had higher thyroglobulin and received a higher radioiodine total activity and number of treatments. Considering patients with distant metastases, according to the 2015 ATA guidelines, 38 patients would have been categorized as high risk, 22 as low risk and 80 as intermediate risk. Among intermediate-risk patients, only in 25 cases (31%) I-131 treatment would have been appropriate according to 2015 ATA recommendations; in the remaining 56 cases (69%), I-131 would not have been recommended.

CONCLUSIONS

According to the 2015 ATA guidelines, most of metastatic patients would not have been treated after surgery, with the risk of late diagnosis and delayed treatment.

Outcomes of patients with bone metastases from differentiated thyroid cancer

Objective Bone metastases (BM) from differentiated thyroid cancer (DTC) are associated with poor survival rates. Due to the low frequency of this entity, we performed a multicentric retrospective study that aimed to evaluate the presentation, outcome and causes of death in this population. Subjects and methods We reviewed file records from 10 databases. BM were diagnosed by: i) biopsy and/or ii) radioiodine (RAI) bone uptake + elevated thyroglobulin (Tg) levels and/or c) bone uptake of 18-FDG in the PET-CT scan + elevated Tg levels. Results Fifty-two patients with DTC were included (44% male, mean age 54 years); 58% had papillary histology. BM were synchronous with DTC diagnosis in 46% of the participating cases. BM were symptomatic in 65% of the cases. Multiple BM were present in 65% of patients, while simultaneous metastatic disease in additional sites was found in 69%. Ninety-eight percent of patients received treatment for the BM, which included RAI therapy in 42 patients; 30 of them received cumulative RAI doses that were larger than 600 mCi 131I. The mean follow-up after a BM diagnosis was 34 months. The 2- and 5-year survival rates after diagnosis of the first BM were 64% and 38%, respectively. The status on the last evaluation was DTC-related death in 52% of the patients; 26% of them died from direct complications of BM or their treatments. Conclusion BM are usually radioiodine-refractory and are associated with a short overall survival, although most of the patients died of causes not directly related to the BM.

Bone Metastases in Follicular Carcinoma of Thyroid

Though the association between follicular carcinoma and bone metastasis is well established, the site-wise distribution is not known. One hundred seventy-three patients of follicular carcinoma presenting between 2003 and 2011 were selected from 1093 patients of follicular lesions presenting at a single institution. Of these, 59 (34%) with bone metastasis were included in the study. Fifty of the 59 patients (84.7%) had metastasis at presentation, while 9 developed bone metastasis during follow-up. Sixty-one percent had solitary metastasis, 15 (25.4%) had multiple bone involvement, while 8 patients (13.6%) had synchronous lung metastasis. Overall, the spine was the commonest site of bone metastases, seen in 20 patients (33.9%), followed by the pelvis, skull, long bones and sternum. Bone metastasis is a known phenomenon in follicular carcinoma. The spine is the commonest site followed by the pelvis.

LONG-TERM OUTCOMES AND PROGNOSTIC FACTORS IN PATIENTS WITH DIFFERENTIATED THYROID CANCER AND DISTANT METASTASES

OBJECTIVE

Distant metastatic spread is the most frequent cause of thyroid cancer-related death. The objective of this study was to evaluate overall and disease-related survival of patients with differentiated thyroid cancer (DTC) and distant metastases (DM) attending a single medical center and to investigate variables predictive of better long-term outcomes.

METHODS

The Rabin Medical Center Thyroid Cancer Registry was searched for patients with DM from DTC.

RESULTS

The cohort included 138 patients (58.7% female) diagnosed at age 54.7 ± 19.5 years. Mean primary tumor size was 33.9 ± 26 mm. Most patients (57.7%) were stage T3/T4; 48.7% had extrathyroidal extension; 53.5% had lymph node metastases. Histopathology yielded papillary and follicular thyroid carcinoma in 66.7% and 13.8%, respectively, and intermediate/poorly differentiated carcinoma in 19.6%. All but 2 patients underwent total thyroidectomy, and 133/138 (96.4%) received radioactive iodine (RAI) therapy. DM were synchronous in 55.1%. The mean follow-up was 8.2 years from detection of metastases. The common sites of metastases were the lungs (85.6% of patients), bones (39.9%), brain (5.8%) and liver (3.6%). At last follow-up, resolution was documented in 24.6% of patients, improvement/stable disease in 31.6%, and structurally progressive disease in 43.4%. By the end of the study, 40.6% of patients died, 23.2% of DTC. Improved overall survival and disease progression were associated with younger age, lung-only DM, and metastatic RAI avidity.

CONCLUSION

Patients with DTC and DM treated by standard-of-care approaches frequently achieve favorable long-term outcomes. Novel therapies might be necessary in only a minority of these patients, and the reported prognostic factors can aid in their identification.

ABBREVIATIONS

CR = complete response; DM = distant metastases; DTC = differentiated thyroid cancer; ETE = extra-thyroidal extension; M0 = detected during follow-up; M1 = detected at diagnosis; MSKCC = Memorial Sloan Kettering Cancer Center; NED = no evidence of disease; OS = overall survival; PFS = progression free survival; PTC = papillary thyroid cancer; RAI = radioactive iodine; Tg = thyroglobulin.

Postoperative Ambulatory Performance Status Significantly Affects Implant Failure Rate Among Surgical Treatment Strategies in Patients With Proximal Femur Metastasis

Surgical treatment strategies for proximal femur metastasis have been reported with mixed results. Little is known about risk factor for implant failure except for longer patient survival. Therefore, we determined whether implant survivorship differed among treatment strategies, as well as risk factors for implant failure. We retrospectively reviewed a consecutive 106 patients with proximal femur metastasis treated with prosthesis replacement (n = 38), intramedullary nail (n = 32), and dynamic hip screw (DHS) (n = 36). Eastern Cooperative Oncology Group (ECOG) scale and Karnofsky index were used to evaluate functional outcome. Patient characteristics and postoperative ambulatory performance status were assessed for their values in determining implant failure. Overall implant failure rate was 11.3% (12 of 106). Prosthesis replacement was related to better implant survivorship (P = 0.041), without mechanical failures. On the contrary, 7 of the 10 implant failures in the fixation group were considered mechanical failures. Better postoperative ambulatory status (ECOG ≤ 2) was a risk factor for implant failure (P = 0.03). Notably, for patients with poor ambulatory status (ECOG ≥ 3), implant survivorship was not different among choice of implants. In conclusion, prosthesis replacement would be a more durable option in the treatment of proximal femur metastasis. Postoperative ambulatory status could be an additional consideration. For patients with poor expected ambulatory performance status, fixation with intramedullary nail or DHS might be considered for a less technical demanding procedure.

Patterns of metastasis in follicular thyroid carcinoma and the difference between early and delayed presentation

Introduction Follicular thyroid cancer (FTC) has a good prognosis if treated early. The aim of this study was to look at the difference in outcomes in those who presented with metastasis early or late in their disease. Methods A retrospective cohort study was conducted of patients diagnosed with FTC (n=91) treated between 2000 and 2013. Demographic, laboratory, pathological and survival data were collected and analysed. Results Metastatic FTC was diagnosed in 20 cases (22%). The median age at diagnosis was 65 years (range: 17-86 years) and 65% of the patients were female. Twelve patients (60%) were diagnosed with metastatic disease at presentation, with the bones being the most common site (75%). In the remaining eight cases (40%), metastasis developed at a median of 4.5 years (range: 2-8 years) after initial thyroid surgery, lungs being the most common site (50%). Eighteen patients (90%) underwent surgical intervention for the primary disease. Sixteen patients (80%) received adjuvant radioactive iodine and eight (40%) received external beam radiotherapy. Widely invasive follicular cancer was the predominant histological diagnosis (90%). No prognostic association was observed with any of the parameters studied. The overall disease specific mortality rate was 40%. There was no significant difference in mortality between those who presented with metastatic disease and those who developed metastasis during the follow-up period (33% vs 50%, p=0.61). Conclusions The clinical outcome and prognosis for cases with metastatic disease is generally poor. Despite this, almost half of the patients in our study were still alive at a median follow-up of 5.5 years, regardless of whether they were diagnosed with metastatic disease on initial presentation or whether they developed metastasis after initial thyroid surgery.

Thyroid Gland Malignancies

Surgery remains the most important effective treatment for differentiated (DTC) and medullary thyroid cancer (MTC). Radioactive iodine (RAI) is another important treatment but is reserved only for DTC whose disease captures RAI. Once patients fail primary therapy, observation is often recommended, as most DTC and MTC patients will have indolent disease. However, in a fraction of patients, systemic therapy must be considered. In recent decades 4 systemic therapies have been approved by the United States FDA for DTC and MTC. Sorafenib and lenvatinib are approved for DTC and vandetanib and cabozantinib for MTC. Anaplastic thyroid cancer (ATC) is a rare and rapidly progressive form of thyroid cancer with a very high mortality rate. Treatment of ATC remains a challenge. Most patients are not surgical candidates at diagnosis due to advanced disease. External beam radiation and radiosensitizing radiation are the mainstay of therapy at this time. However, exciting new drugs and approaches to therapy are on the horizon but it will take a concerted, worldwide effort to complete clinical trials in order to find effective therapies that will improve the overall survival for this devastating disease.

Early prognostic factors at the time of diagnosis of bone metastasis in patients with bone metastases of differentiated thyroid carcinoma

OBJECTIVE

Bone is the second most common site of distant metastases from differentiated thyroid cancer (DTC). Patients with bone metastases were associated with poor clinical outcomes; however, their clinical courses are heterogeneous. The aim of this study is to evaluate early prognostic factors of patients with bone metastases from DTC at the time of diagnosis of bone metastasis.

METHODS

This retrospective study included 93 patients with bone metastases from DTC. We defined 'Pre-RAIT group' as patients whose bone metastases were detected before initial RAIT. The 'post-RAIT group' was defined as patients whose bone metastases were detected after initial RAIT or during the follow-up period.

RESULTS

Median age was 55.4years, and 55 patients (59%) had papillary thyroid cancer. Patients in the pre-RAIT group (n=32) demonstrated significantly poorer overall survival (OS) (HR=1.86, P=0.04) than those in the post-RAIT group. There was no significant difference in the OS according to the initial RAI avidity among all patients (P=0.18). RAI-avid bone metastases had better OS only in the pre-RAIT group (HR=0.23, P=0.01) but not in the post-RAIT group. In the post-RAIT group, older age (>45years), elevated serum thyroglobulin (Tg) level (>250ng/mL), and the presence of skeletal-related events (SREs) were significantly associated with poor OS. RAI avidity was not a significant prognostic factor in the post-RAIT group (P=0.33).

CONCLUSIONS

Patients whose bone metastases were diagnosed before initial RAIT demonstrate a poorer prognosis. RAI avidity is an early prognostic indicator in the pre-RAIT group. Old age, higher serum Tg levels, and SRE are associated with poor survival outcomes in the post-RAIT group.

Metastatic Follicular Carcinoma Thyroid Masquerading as a Primary Jaw Tumor

Metastatic tumours of the oral cavity are rare constituting approximately one percent of all oral malignancies. These tumors are clinically significant as their appearance may be the first indication of an undiscovered malignancy at a distant primary site or the first evidence of dissemination from a known primary tumor. Thyroid cancer metastasizing to the jaw bones is a rare occurrence and very few cases have been described in literature. We present an additional case which in fact masqueraded as a primary jaw tumor. Metastasis to jaw bones is generally associated with poor prognosis with a majority of the patients dying within 6 months of diagnosis. Thyroid cancers however seem to be an exception to this, resectable solitary jaw bone metastasis from differentiated thyroid cancers is associated with a much better prognosis and therefore should be considered for metastatectomy.

Unexpected Bone Metastases from Thyroid Cancer

Objective. To present a complicated case of differentiated thyroid carcinoma (DTC) with metastases to the skull that was evident on I-131 whole body scan (WBS) but negative on other imaging modalities in a low risk patient. Methods. We will discuss clinical course, imaging, pathological findings, and treatment of the patient with skull metastasis from DTC. Pertinent literature on imaging and pathology findings as well as radioactive iodine (RAI) treatment impact on quality of life and survival in patients with bone metastases from DTC will be reviewed. Results. The patient is a 37-year-old woman with a diagnosis of DTC who had focal areas of increased uptake in the head on WBS with no correlative findings on CT and MRI. Initially, false positive findings were suspected since patient had a low risk for developing metastases. However, the persistent findings on post-RAI treatment WBS, following two courses of treatment, were highly concerning for metastatic bone disease. WBC performed 6 months following the second RAI treatment revealed resolution of the findings. Conclusions. False positive findings in WBS are frequent and may be due to contamination, perspiration, or folliculitis of the scalp as well as benign lesions such as meningioma, hematoma, cavernous angioma, and metallic sutures. However, metastatic disease should always be considered even if the patient has low risk of distant metastatic disease and correlative images do not support the diagnosis. RAI therapy appears to improve the survival rates and quality of life of thyroid cancer patients with bone metastases based on retrospective studies.

Long-Term Follow-Up of the Therapeutic Outcomes for Papillary Thyroid Carcinoma With Distant Metastasis

Papillary thyroid carcinoma (PTC) patients with distant metastasis (DM) have variable clinical courses and therapeutic outcomes. Survival time after diagnosis of DM may be several months to years. Long-term follow-up is necessary to determine prognostic factors for survival in PTC with DM. The purpose of this study was to investigate the clinical features and therapeutic outcomes of PTC with DM after 10 years of follow-up. The study population consisted of 70 patients who underwent initial thyroidectomy before 2004 and had DM beyond the locoregional neck area. Of these 70 patients, 40 patients were diagnosed with DM before or within 9 months after initial thyroidectomy in first radioactive iodide (I) whole-body scintigraphy (group A), and 30 patients were diagnosed with DM during the follow-up period (group B). Patients with DM underwent 3.7 to 7.4 GBq I therapy every 6 to 12 months. After a mean follow-up period of 10.1 ± 0.9 years, the disease-specific mortality and remission rates were 70.0% (49/70) and 10% (7/70), respectively. The survival rates for patients in groups A and B were 72.5% and 96.7% at 1 year, 47.5% and 90.0% at 5 years, 40.0% and 70.0% at 10 years, 36.4% and 41.1% at 15 years, and 35.0% and 8.0% at 20 years, respectively. The percentage of male and older patients and patients with larger tumor size was higher in the mortality group than in the survival group, whereas the percentage of patients with I avid metastatic lesions (first DM) was lower in the mortality group. The percentage of patients with secondary primary cancers was higher in group B than in group A. In the multiple regression analysis, age and male gender were independently associated with disease-specific mortality. In conclusion, after a mean follow-up of 10.1 years, the disease-specific mortality rate for PTC with DM was 70.0%. Older patients and male PTC patients with DM need more aggressive treatment. The timing of DM diagnosis did not influence disease-specific mortality.

Lung metastases from differentiated thyroid carcinoma: prognostic factors related to remission and disease-free survival

OBJECTIVE

Distant metastases, although rare, account for maximum disease-related mortality in differentiated thyroid cancer (DTC). Lungs and bones are the most frequent sites of metastases. We sought to identify the prognostic factors in adult DTC patients presenting with pulmonary metastases at initial diagnosis.

DESIGN

Retrospective cohort study.

PATIENTS

From the medical records of 4370 patients, 200 patients aged more than 21 years who were identified to have pulmonary metastases at the time of diagnosis were included in the analysis.

RESULTS

The sites of metastases were lungs alone in 133 (67%) patients, and additional sites in remaining 67 (33%) patients were as follows: bones in 59, liver in 4, brain in 2 and both bone and liver in two patients. During the mean follow-up of 61 months (range, 12-312 months), 76 patients achieved remission, 121 (60·5%) patients had biochemically and/or structurally persistent disease and three patients showed disease progression. Multivariate analysis revealed presence of macro-nodular (chest X-ray positive) pulmonary metastases and concomitant skeletal metastases as independent factors decreasing the likelihood of remission. Of the 76 patients with remission, 16 (21%) developed subsequent recurrence. Patient age >45 years and follicular histopathology were independently associated with greater hazards of developing recurrence.

CONCLUSION

This study suggests that the patients with macro-nodular lung metastases and/or concomitant skeletal metastases have reduced odds of achieving remission. Moreover, significant number of patients recur even after complete remission with RAI treatment, hence strict surveillance is recommended especially in patients with age >45 years and/or with follicular histology of DTC.

Occult papillary thyroid carcinoma metastasis to the sacrum and the skull: an unusual presentation

This case represents occult follicular variant of papillary thyroid carcinoma (FVPTC) with large metastasis to the sacrum. The patient, a 42-year-old female, presented after hemithyroidectomy for benign follicular adenoma with lower back pain associated with fever and sweating. A lytic lesion of the left sacral bone was found on the CT with biopsy showing metastatic carcinoma with morphology and immunophenotype of thyroid gland primary tumor proven to be FVPTC. The patient had completion thyroidectomy with benign pathology.

Differentiated thyroid cancer in patients over 60 years of age at presentation: a retrospective study of 438 patients

OBJECTIVES

The aim of this study is to identify the prognostic factors predicting remission and subsequent disease relapse in patients with differentiated thyroid cancer (DTC) greater than 60years of age.

MATERIALS AND METHODS

The institute thyroid cancer database had 4370 patients with DTC, of which 447 (10%) were aged>60. However, 9 patients were excluded due to follow-up less than 1year. The prognostic factors in the remaining 438 patients were studied.

RESULTS

Among the 438 patients, 311 (71%) had only loco-regional disease (M0) and 127 (29%) had distant metastases (M1) at the time of initial presentation. The host factors predictive of distant metastases at presentation were female gender, primary tumor size (>4cm), follicular histology, and extra-thyroidal extension. Among Mo patients, 195 (63%) achieved complete remission while only 12 (9%) M1 patients did so. Average number of radioactive iodine ((131)I) doses administered to achieve complete remission was 2.3 (range, 1-6) and the mean cumulative dose was 3404MBq (range, 925-46,250MBq). In multivariate logistic regression among M0 patients, follicular histology, nodal metastases, and surgical treatment lesser than total/near-total thyroidectomy and among M1 patients, site of distant metastases (skeletal and multiple sites) were independent factors predicting non-remission. Among the patients (both M0 and M1) who achieved remission, factors associated with disease recurrence were primary tumor size (>4cm), nodal metastases, pulmonary metastases, and non-remission after first dose of radioactive iodine and were associated with greater chances of disease relapse.

CONCLUSION

This study highlights that DTC in older patients behaves more aggressively than in adults age<60years, and identifies several prognostic factors for remission and subsequent relapse.

Current treatment modalities for spinal metastases secondary to thyroid carcinoma

BACKGROUND

The spine is the most common site of bone metastases due to thyroid cancer, which develop in more than 3% of patients with well-differentiated thyroid cancer. Nearly half of patients with bone metastases from thyroid cancer develop vertebral metastases. Spinal metastases are associated with significantly reduced quality of life due to pain, neurological deficit, and increased mortality.

SUMMARY

Treatment options for patients with thyroid spinal metastases include radioiodine therapy, pharmacologic therapy, and surgical treatments, with recent advances in radiosurgery and minimally invasive spinal surgery as well. Therapeutic interventions require a multidisciplinary approach and aim to control pain, preserve or improve neurologic function, optimize local tumor control, and improve quality of life. We have proposed a three-tiered approach to the management and practical algorithms for patients with spinal metastases from thyroid carcinoma.

CONCLUSIONS

The introduction of novel and improved techniques for the treatment of spinal metastases has created the opportunity to significantly improve control of metastatic tumor growth and the quality of life for the patients with spinal metastases from thyroid cancer. In order for these options to be effectively used, a multidisciplinary approach must be applied in the management of the patients with thyroid spinal metastases.

Natural history of small radioiodine-avid bone metastases that have no structural correlate on imaging studies

Bone metastases from differentiated thyroid cancer are generally resistant to radioiodine (RAI) therapy and are associated with poor prognosis. However, in a recent study from our group we noted a small subgroup of patients with RAI-avid bone metastases who had no structural correlate on imaging studies, and had no skeletal complications during follow-up. The purpose of this study was to better define the natural history and outcome of these patients. In a retrospective review of medical records at Memorial Sloan-Kettering Cancer Center, 288 patients were identified with bone metastases from thyroid cancer between 1960 and 2011. Out of this group, 14 patients who had a RAI-avid bone metastasis without structural correlate on CT or MRI were included in the study. After a median follow-up period of 5 years (range 2-14 years) all patients were alive, none had evidence of structural bone metastases, and none had experienced skeletal-related events. The final disease status was: no evidence of disease in 6 patients (43 %), stable biochemical persistence in 2 patients (14 %), stable structural disease in 5 patients (36 %), and one patient with slowly progressive disease. To conclude, RAI-avid bone metastases with no structural correlate on high-resolution imaging studies often resolve following RAI treatment, do not cause skeletal-related complications, and do not have a major prognostic significance. Recognition of this unique type of bone metastases is important as it is not associated with the same poor prognosis and resistance to RAI therapy that is associated with structurally identifiable bone metastases.

Metastasis of thyroid cancer to the sternum after total thyroidectomy and laryngectomy

Metastasis of thyroid cancer to the sternum is rare. Ablation is the therapy of choice for patients with metastasizing differentiated thyroid cancer, while surgical resection is an option for those with resectable bony metastasis. This report describes a case of a 65-year-old woman with a sternal tumor. The patient was treated by partial sternal resection and sternal reconstruction with new material polypropylene/expanded polytetrafluoroethylene (ePTFE) composite. The postoperative course was uneventful, and she was free of recurrence after 1 year of follow-up. We conclude that surgery should be used to manage solid bony metastasis from thyroid papillary carcinoma. Further more, a polypropylene/ePTFE composite may be useful for sternal reconstruction after thoracotomy.

Surgical management of appendicular skeletal metastases in thyroid carcinoma

Background. Bone is a frequent site of metastasis from thyroid carcinoma, but prognostic factors for patients who have surgery for thyroid carcinoma bone metastases are poorly understood. Methods. A retrospective review at a single institution identified 41 patients that underwent surgery in the appendicular skeleton for thyroid carcinoma bone metastasis from 1988 to 2011. Results. Overall patient survival probability by Kaplan-Meier analysis after surgery for bone metastasis was 72% at 1 year, 29% at 5 years, and 20% at 8 years. Patients who had their tumor excised (P = 0.001) or presented with solitary bone involvement had a lower risk of death following surgery adjusting for age and gender. Disease progression at the surgery site occurred more frequently with a histological diagnosis of follicular carcinoma compared with other subtypes (P = 0.023). Multivariate analysis showed that tumor subtype, chemotherapy, and preoperative radiation treatment had no effect on survival after surgery. Patients treated with radioactive iodine had better survival following thyroidectomy, but not following surgery for bone metastases. Conclusions. For patients undergoing surgery for thyroid cancer bone metastasis, resection of the bone metastasis, if possible, has a survival benefit.

Evaluating the prognostic factors associated with cancer-specific survival of differentiated thyroid carcinoma presenting with distant metastasis

Background

Because patients with differentiated thyroid carcinoma (DTC) presenting with distant metastasis (DM) have a particularly poor prognosis, examining the prognostic factors in this group is essential. We aimed to evaluate the prognostic factors affecting cancer-specific survival (CSS) in DTC patients presenting with DM.

Methods

Of the 1227 DTC patients, 51 (4.2 %) presented with DM at diagnosis. All patients underwent a total thyroidectomy, followed by radioiodine (RAI) ablation and postablation whole body scan (WBS). Patients were considered to have an osseous metastasis if one of the metastatic sites involved a bone, while RAI avidity was determined by any visual uptake in a known metastatic site on the first WBS. Factors predictive of CSS were determined by univariate and multivariate analyses by the Cox proportional hazard model.

Results

In univariate analysis, older age (relative risk [RR] 1.050, 95 % confidence interval [CI] 1.010–1.091, P = 0.014), DM discovered before WBS (RR 3.401, 95 % CI 1.127–10.309, P = 0.030), follicular thyroid carcinoma (RR 3.095, 95 % CI 1.168–8.205, P = 0.025), osseous metastasis (RR 4.695, 95 % CI 1.379–15.873, P = 0.013), non-RAI avidity (RR 3.355, 95 % CI 1.280–8.772, P = 0.014), and external beam radiotherapy to DM (RR 3.241, 95 % CI 1.093–9.614, P = 0.034) were significant poor prognostic factors for CSS. In the multivariate analysis, after adjusting for other factors, osseous metastasis (RR 6.849, 95 % CI 1.495–31.250, P = 0.013) and non-RAI avidity (RR 7.752, 95 % CI 2.198–27.027, P = 0.001) were the two independent poor prognostic factors for CSS. Older age almost reached statistically significance (RR 1.055, 95 % CI 0.996–1.117, P = 0.068).

Conclusions

DTC patients presenting with DM accounted for 4.2 % of all patients. Because osseous metastasis and RAI avidity were independent prognostic factors, future therapy should be directed at improving the treatment efficacy of osseous and/or non-RAI-avid metastases.