Adequate surgery for papillary thyroid cancer

Risk Factors for Predicting Lymph Nodes Posterior to Right Recurrent Laryngeal Nerve (LN-prRLN) Metastasis in Thyroid Papillary Carcinoma: A Meta-Analysis

OBJECTIVE

To evaluate the risk factors for predicting lymph nodes (LN) posterior to right recurrent laryngeal nerve metastasis in thyroid papillary carcinoma.

METHODS

PubMed, PMC, EMBASE, and the Cochrane Library were systematically searched for articles published spanning 30/06/2009-30/8/2018 using multiple search terms. Thirteen articles involving 10,014 patients were reviewed in our meta-analysis. Stata 15.1 software was used for the meta-analysis.

RESULTS

The rate of LN posterior to right recurrent laryngeal nerve (LN-prRLN) metastasis was 8.65%. Univariate analysis showed that age (P = 0.001), gender (P < 0.001), tumour size (P < 0.001), lateral LN metastasis (P < 0.001), extrathyroidal invasion (P < 0.001), multifocality (P = 0.005), capsule invasion (P < 0.001), tumour location (P = 0.076), lymph nodes anterior to right recurrent laryngeal nerve (LN-arRLN) metastasis (P < 0.001), and central LN metastasis (P < 0.001) were significantly associated with the increased incidence of LN-prRLN metastasis in thyroid papillary carcinoma.

CONCLUSION

PTC patients aged <45, male, and with tumours > 1 cm, lateral LN metastasis, extrathyroidal invasion, multifocality, capsule invasion, LN-arRLN metastasis, or central LN metastasis were significantly correlated with lymph nodes posterior to right recurrent laryngeal nerve metastasis, indicating LN-prRLN dissection.

Predictors of metastasis to lymph nodes posterior to the right recurrent laryngeal nerve in differentiated thyroid carcinoma: A prospective study

OBJECTIVES

To study the clinicopathological characteristics and the risk factors of lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) metastasis in differentiated thyroid carcinoma; and to identify the indication for LN-prRLN dissection.

METHODS

We treated 145 patients with differentiated thyroid carcinoma with appropriate surgical intervention. The specimens were examined by the pathologists. The right paratracheal lymph nodes were divided into two groups: anterior or posterior to right recurrent laryngeal nerve (VIa or VIp compartment, respectively). We recorded the clinical characteristics, histopathological features of the primary tumors, and lymph node metastasis of the patients. The results were statistically analyzed.

RESULTS

There were 85 patients (58.6%) with central lymph node metastasis, of whom 61 (42.1%) had metastasis in VIa compartment; 16 patients (11.0%) had VIp subdistrict metastasis; and 25 patients had lateral lymph node metastasis. Multiplicity, larger tumor (≥1 cm), and coexistence of central lymph node metastasis, VIa compartment metastasis, and lateral lymph node metastasis were all significantly related with LN-prRLN metastasis, while sex, age, location of the tumor, and extrathyroid extension of the tumor showed no significant relation (p > 0.05).

CONCLUSION

The incidence of LN-prRLN metastasis was lower than other central lymph nodes, as well as lymph nodes anterior to right recurrent laryngeal nerve. When there were multiple foci of tumors, or the tumor was larger than 1 cm, or central or lateral LN metastasis was indicated by preoperative ultrasound or confirmed by intraoperative frozen sections, it is strongly recommended that exploration and dissection of the LN-prRLN should only be performed by experienced surgeons.

Survival from Differentiated Thyroid Cancer: What Has Age Got to Do with It?

BACKGROUND

In most staging systems, 45 years of age is used to differentiate low risk thyroid cancer from high risk thyroid cancer. However, recent studies have questioned both the precise 45 year age point and the concept of using a binary cut off as accurate predictors of disease specific mortality.

METHODS

A cohort of 3664 thyroid cancer patients that received surgery and adjuvant treatment at Memorial Sloan Kettering Cancer Center (MSKCC) from the years 1985 to 2010 were analyzed to determine the significance of age at diagnosis as a categorical variable at a variety of age cutoffs (5 year intervals between 30 and 70 years of age). The unadjusted and adjusted hazard ratio for the association between disease-specific survival and age was determined using a Cox proportional hazards model adjusted for other predictive variables sex, histology, and pathological T, N, and M status. Furthermore, predictive nomograms of disease-specific mortality were created and validated on an external dataset of 4551 patients to evaluate the impact of age at diagnosis as both a categorical and continuous variable.

RESULTS

In the MSKCC cohort, with a median follow-up time of 54 months (range 1-332), there were 59 deaths from thyroid cancer with a 10 year disease-specific survival of 96%. Adjusted hazard ratios for all age cutoffs from age 30 to age 70 years were significant. There was no specific cutoff age which risk stratifies patients with differentiated thyroid cancer (DTC). Categorizing age into five strata (<40, 40-49, 50-59, 60-69 and >70 years) showed a 37-fold increase in hazard ratio from age <40 years to age >70 years. A predictive nomogram using age as a continuous variable with other predictive variables had a high concordance index of 96%. Validation on the external cohort had a concordance index of 73%.

CONCLUSIONS

Mortality from DTC increases progressively with advancing age. There is no specific cutoff age which risk stratifies patients with DTC. A predictive nomogram using age as a continuous variable may be a more appropriate tool for stratifying patients with DTC and for predicting outcome.

Papillary thyroid carcinoma in Denmark, 1996-2008: outcome and evaluation of established prognostic scoring systems in a prospective national cohort

BACKGROUND

Regional as well as national series show an increasing incidence of thyroid cancer largely small size papillary thyroid carcinoma (PTC). Prognostic scoring systems have been developed, but these do not take into account the rapidly changing case mix, and adjustments may be required. The purposes of this study were to evaluate treatment outcomes and to analyze the value of older prognostic scoring systems tested on a relatively new, unselected national cohort of PTC patients.

METHODS

This was a national prospective cohort study conducted in Denmark, which has a population of 5.5 million.

RESULTS

A total of 1350 patients were diagnosed with PTC during 1996-2008, and the median follow-up time was 7.9 years. The 10-year recurrence-free survival rate was 90.2%, and the 10-year crude and cause-specific survival (CSS) rates were 83.7% and 93.8% respectively. By multivariate Cox regression, it was possible to confirm age, metastases (distant and nodal), extrathyroidal extension, and tumor size as predictors of mortality, whereas only nodal metastases, extrathyroidal extension, and tumor size were predictors of recurrence. In analyses of older prognostic scoring systems, a significant correlation between the risk group ranks was found for survival as well as recurrence. The c-index for CSS was highest for MACIS (0.92) and lowest for AMES (0.80). In the TNM, MACIS, and EORTC systems, most patients were classified as stage 1, and for these patients, the 10-year CSS rate was approximately 99.5%, confirming the generally excellent survival.

CONCLUSION

This national study provides further evidence that a favorable prognosis is to be expected for patients diagnosed with PTC. Also, it was possible to confirm age, metastases, extrathyroidal extension, and tumor size as predictors of mortality, whereas only nodal metastases, extrathyroidal extension, and tumor size were predictors of recurrence. All the scoring systems evaluated were able to produce a highly significant risk group stratification, showing that in spite of the changes in the case mix of PTC, these systems are still applicable, and in fact contain valuable prognostic information useable for treatment planning.

Methylation of DACT2 promotes papillary thyroid cancer metastasis by activating Wnt signaling

Thyroid cancer is the most common endocrine malignant disease and the incidence is increasing. DACT2 was found frequently methylated in human lung cancer and hepatocellular carcinoma. To explore the epigenetic change and the role of DACT2 in thyroid cancer, 7 thyroid cancer cell lines, 10 cases of non-cancerous thyroid tissue samples and 99 cases of primary thyroid cancer samples were involved in this study. DACT2 was expressed and unmethylated in K1, SW579, FTC-133, TT, W3 and 8505C cell lines. Loss of expression and complete methylation was found in TPC-1 cells. Restoration of DACT2 expression was induced by 5-aza-2′deoxycytidine treatment. It demonstrates that the expression of DACT2 was regulated by promoter region methylation. In human primary papillary thyroid cancer, 64.6% (64/99) was methylated and methylation of DACT2 was related to lymph node metastasis (p<0.01). Re-expression of DACT2 suppresses cell proliferation, invasion and migration in TPC-1 cells. The activity of TCF/LEF was inhibited by DACT2 in wild-type or mutant β-catenin cells. The activity of TCF/LEF was increased by co-transfecting DACT2 and Dvl2 in wild-type or mutant β-catenin cells. Overexpression of wild-type β-catenin promotes cell migration and invasion in DACT2 stably expressed cells. The expression of β-catenin, c-myc, cyclinD1 and MMP-9 were decreased and the level of phosphorylated β-catenin (p-β-catenin) was increased after restoration of DACT2 expression in TPC-1 cells. The expression of β-catenin, c-myc, cyclinD1 and MMP-9 were increased and the level of p-β-catenin was reduced after knockdown of DACT2 in W3 and SW579 cells. These results suggest that DACT2 suppresses human papillary thyroid cancer growth and metastasis by inhibiting Wnt signaling. In conclusion, DACT2 is frequently methylated in papillary thyroid cancer. DACT2 expression was regulated by promoter region methylation. DACT2 suppresses papillary thyroid cancer proliferation and metastasis by inhibiting Wnt signaling.

The role of surgery in the current management of differentiated thyroid cancer

In the last decades, a surprising increased incidence of differentiated thyroid cancer (DTC), along with a precocious diagnosis of "small" tumors and microcarcinomas have been observed. In these cases, better oncological outcomes are expected, and a "tailored" and "less aggressive" multimodal therapeutic protocol should be considered, avoiding an unfavorable even if minimal morbidity following an "overtreatment." In order to better define the most suitable surgical approach, its benefits and risks, we discuss the role of surgery in the current management of DTCs in the light of data appeared in the literature. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is still argument of intensive research, and indications and extension of lymph node dissection (LD) are still under debate. In particular, endocrine and neck surgeons are still divided between proponents and opponents of routine central LD (RCLD). Considering the available evidence, there is agreement about total thyroidectomy, therapeutic LD in clinically node-positive DTC patients, and RCLD in "high risk" cases. Nevertheless, indications to the best surgical treatment of clinically node-negative "low risk" patients are still subject of research. Considering on the one hand, the recent trend toward routine central lymphadenectomy, avoiding radioactive treatment, and on the other hand, the satisfactory results obtained reserving prophylactic LD to "high risk" patients, we think that further prospective randomized trials are needed to evaluate the best choice between the different surgical approaches.

Treatment for malignant struma ovarii in the eyes of thyroid surgeons: a case report and study of Chinese cases reported in the literature

Malignant struma ovarii (MSO) is a rare malignant ovarian germ cell tumor that has been scarcely reported by thyroid surgeons focusing on treatment. There are no golden standards for its treatment. There has not been any Chinese case included in the English language literatures. This is the first study by collecting all Chinese cases with clinical information. We emphasize on using I therapy after operation.Presented is a case of struma ovarii with malignant histologic features who underwent definitive initial surgery of reproductive system tumors and a total thyroidectomy combined with thyroid-stimulating hormone (TSH)-suppressive therapy following treatment with I. Furthermore, a Chinese full-text database literature search for cases of MSO was performed, and advisable clinical data were collected following our treatment advice.Clinical data from 34 additional cases were compiled. As Chinese genetic background and environment are different from those of Western countries, our clinical data closely mirror theirs in some aspects. In addition, we provide a rare gene mutation type of MSO by the case from our department.Integrating literatures with the experience of thyroid surgeons, we recommend "multidisciplinary joint treatment" for MSO, namely traditional radical initial surgery of ovarian cancer and a total thyroidectomy combined with TSH-suppressive therapy following treatment with I for those who do not desire preservation of fertility.

Differentiated thyroid carcinoma: an analysis of 249 patients undergoing therapy and aftercare at a single institution

PURPOSE

Well-differentiated thyroid cancer (WDTC) is rising in incidence across the world over the past 3 decades. We aimed to evaluate the natural history and clinical outcome of differentiated thyroid carcinoma by a retrospective analysis of 249 patients treated at a single institution.

METHODS

A cohort of 249 patients who underwent thyroidectomy for WDTC in the last 10 years in Maadi Military Hospital was studied. Main outcome measures were clinical management at the diagnosis, survival, morbidity, and prognostic risk factors.

RESULTS

Mean age at diagnosis was 44.7 (SD, 14.6) years, where 52.2% were 45 years or older. Females represent 70.7% (P = 0.01), with female-to-male ratio of 4.1:1. Near-total thyroidectomy was done in 70.7% of the cases where papillary cancer was found in 80.8% and node metastasis in 10.5%. Radioactive I (RA I) was given an all cases (dose range, 80-150 mCi) with ablation success rate of 79.2%. Locoregional recurrence and metastasis (lungs and bones) were found in 2% and 6.8%, respectively. Multivariate Cox regression analysis showed that the mean ablation dose of RA I (odds ratio, 1.045; 95% confidence interval, 0.936-1.1189; P = 0.01) and presence of remote deposits (odds ratio, 1.049; 95% confidence interval, 0.836-1.1189; P = 0.01) are the significant influential factor in ablation success rate and survival, respectively.

CONCLUSIONS

Our data suggest that proper ablation dose of RA I and absence of remote metastasis are the powerful predictors for excellent outcome in WDTC patients.

Changing trends in well differentiated thyroid carcinoma over eight decades

INTRODUCTION

The incidence of well differentiated thyroid cancer (WDTC) is rising in the USA. The objective of this study is to present the changes in incidence, presentation, management and outcomes of WDTC within our institution over the past 8 decades.

METHODS

2797 patients managed between 1932 and 2005 at Memorial Sloan Kettering Cancer Center were identified from our institutional database.

RESULTS

There has been an increase in the number of patients managed per decade. Although the median age was 45 years, patients managed post-1985 were more likely to be over 45 years (53% versus 44%, p < 0.001). The percentage of women increased from 68% to 72% (p = 0.026), and the percentage of papillary carcinomas also increased, from 78% to 92%, p < 0.001. An increase in early stage tumors was observed with pT1 lesions increasing from 19% to 48%. Patients in the latter cohort were less likely to have thyroid lobectomy (29% versus 72%, p < 0.001). There was a significant change in the use of RRA, with 8% of the early versus 44% of the latter group receiving post-operative RRA (p < 0.001). Since the introduction of risk group stratification disease specific survival (DSS) has not changed significantly. With a median follow up of 90 months, 10 year DSS rates were below 90% in the cohort managed prior to the 1970s, which rose to >95% thereafter (p < 0.001).

CONCLUSIONS

Older patients with earlier stage disease present an increasing workload for surgical oncologists. Excellent outcomes remain unchanged despite increasingly aggressive surgical and medical management.

BRAF(V600E) mutation analysis from May-Grünwald Giemsa-stained cytological samples as an adjunct in identification of high-risk papillary thyroid carcinoma

The BRAF(V600E) mutation is specific for thyroid papillary cancer (PTC) and correlates with PTCs invasiveness. This study investigated whether detection of BRAF(V600E) mutation can be performed on routinely stained FNABs. We also examined if establishment of the BRAF(V600E) mutation could help in identification of patients at higher risk for metastatic disease. DNA was isolated from 134 FNABs samples (20 follicular neoplasm, ten suspicious for malignancy, and 104 malignant) using Pinpoint Slide DNA Isolation System. BRAF(V600E) mutation was detected by PCR followed by sequencing. DNA was successfully extracted from all examined FNABs samples. In follicular neoplasm, suspicious for malignancy and malignant FNABs, BRAF(V600E) mutation was found in 0/20 (0%), 2/10 (20%), and 47/104 (45.2%) of cases, respectively. Extra-thyroidal extension was detected in 35/47 (74.4%) BRAF(V600E) positive and in 24/57 (42.1%) wild-type BRAF cases (p = 0.001). Metastases were detected in 37/47 (78.7%) BRAF(V600E) positive and in 28/57 (49.1%) wild-type BRAF cases (p = 0.002). Our results showed that stained FNAB specimens can be used for DNA extraction and assessment of BRAF(V600E) mutation. Detection of BRAF(V600E) mutation had limited value in diagnoses of malignancy in follicular neoplasms but can ascertain malignancy in subset of suspicious for malignancy FNABs. In malignant FNABs, BRAF(V600E) mutation was significantly associated with presence of extra-thyroidal extension and metastases after surgery.