Total tumour diameter is superior to unifocal diameter as a predictor of papillary thyroid microcarcinoma prognosis

The effect of total size, area, and volume of lesions in multifocal/multicentric breast cancers and unifocal breast cancers on survival: An observational study

In this study, we aimed to investigate the prognostic effect of the classifications made according to the stage of the largest lesion diameter (T-max stage) and of the sum of the longest diameters of the lesions (T-sum stage), the largest area stage (A-max stage), the sum of the largest areas (A-sum stage), the highest volume stage (V-max stage), the sum of the highest volume (V-sum stage) on disease-free survival, and overall survival (OS) in multifocal/multicentric breast cancers (MMBCs) and unifocal breast cancers (UBCs). The study included a total of 769 patients either with MMBC (n = 128) or UBC (n = 641) who underwent surgery between 2006 and 2015. In the analysis, the median age of 769 patients was 53.0 (20.0-94.0) years, and 16.6% of these 769 patients were MMBC and 83.4% were UBC. In multivariate analysis, lymphovascular invasion (LVİ), estrogen receptor, and nodal status were common independent prognostic factors, whereas T-max stage [(HR: 1.17) (CI 95%: 1.03-1.33) (P = .018)] was a prognostic factor for OS. In multivariate analysis, the T-max stage is an independent risk factor for OS. Therefore, T-max should be continued to be used for measurement and T-stage should be used for classification in MMBCs/UBCs.

The Impact of Total Tumor Diameter on Lymph Node Metastasis and Tumor Recurrence in Papillary Thyroid Carcinomas

(1) Introduction: The impact of multifocality/bilaterality on the prognosis of papillary thyroid carcinoma (PTC) is a matter of debate. In order to clarify this debate, several studies have attempted to identify additional parameters associated with poor prognosis, including total tumor diameter (TTD), in the context of multifocal PTCs. In this context, this study was carried out to investigate the impact of TTD on tumor recurrence and lymph node metastasis (LNM) in PTCs. (2) Materials and Methods: The sample of this single-center retrospective study consisted of 706 patients diagnosed with PTC. TTD was calculated as the sum of the largest diameters of tumor foci in multifocal tumors. The resulting TTDs were grouped into TTDs ≤ 10 mm, TTDs > 10 mm, TTDs ≤ 20 mm, and TTDs > 20 mm, using 10 mm and 20 mm as cutoff values. (3) Results: There was no significant difference between multifocal papillary microcarcinomas (PTMCs) with a TTD of >10 mm and unifocal PTCs with a primary tumor diameter (PTD) of >10 mm except for advanced age and lymphovascular invasion (LVI). In addition, perineural invasion (PNI) and TTD > 10 mm were found to be significant risk factors for LNM, and PNI, TTD > 10 mm, TTD > 20 mm, and bilaterality were found to be significant risk factors for recurrence. LVI, and TTD > 10 mm were found to be independent significant predictors for recurrence, and LVI and extrathyroidal extension (ETE) were found to be independent significant predictors for LNM. (4) Conclusions: Considering TTD > 10 mm in recurrence risk categorization models and adopting a clinical approach that takes into account multifocal PTMCs with TTD > 10 mm along with unifocal PTCs with PTD > 10 mm may be more useful in terms of clinical management of the disease.

The value of total tumor diameter in unilateral multifocal papillary thyroid carcinoma: a propensity score matching analysis

Background

Tumor multifocality is frequently observed in papillary thyroid carcinoma (PTC). However, the maximum tumor diameter (MTD), currently utilized in various staging schemes, might not accurately indicate the level of aggressiveness exhibited by multifocal tumors. We aimed to investigate the relationship between total tumor diameter (TTD) and clinicopathological features of papillary thyroid carcinoma.

Methods

Retrospective data analysis was done on 1936 individuals who underwent complete thyroidectomy for PTC. Patients were classified into subgroups according to unilateral multifocality, central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM). The relationships of clinicopathological features among these groups were analyzed.

Results

Unilateral multifocality was observed in 117 patients. The clinicopathological features of the unilateral multifocal PTC were similar to the unifocal PTC with approximate TTD. The unilateral multifocality played no independent role in CLNM and LLNM. Moreover, the efficiency of TTD in predicting CLNM and LLNM was significantly higher than that of MTD.

Conclusion

In the case of unilateral multifocal PTC, TTD is a more accurate indicator of the biological characteristics of the tumor than MTD.

Nomogram prediction for cervical lymph node metastasis in multifocal papillary thyroid microcarcinoma

Aim

Accurate preoperative prediction of cervical lymph node metastasis (LNM) in patients with mPTMC provides a basis for surgical decision making and the extent of tumor resection. This study aimed to develop and validate an ultrasound radiomics nomogram for the preoperative assessment of LN status.

Methods

A total of 450 patients pathologically diagnosed with mPTMC were enrolled, including 348 patients in the modeling group and 102 patients in the validation group. Univariate and multivariate logistic regression analyses were performed on the basic information, ultrasound characteristics, and American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scores of the patients in the modeling group to identify independent risk factors for LNM in mPTMC and to construct a logistic regression equation and nomogram to predict the risk of LNM. The validation group data were used to evaluate the predictive performance of the nomogram.

Results

Male sex, age <40 years, a single lesion with a maximum diameter >0.5 cm, capsular invasion, a maximum ACR score >9 points, and a total ACR score >19 points were independent risk factors for the development of cervical LNM in mPTMC. Both the area under the curve (AUC) and concordance index (C-index) of the prediction model constructed from the above six factors were 0.838. The calibration curve of the nomogram was close to the ideal diagonal line. Furthermore, decision curve analysis (DCA) demonstrated a significantly greater net benefit of the model. The external validation demonstrated the reliability of the prediction nomogram.

Conclusions

The presented radiomics nomogram, which is based on ACR TI-RADS scores, shows favorable predictive value for the preoperative assessment of LNs in patients with mPTMC. These findings may provide a basis for surgical decision making and the extent of tumor resection.

A Comparison of the Performances of Artificial Intelligence System and Radiologists in the Ultrasound Diagnosis of Thyroid Nodules

AIMS

The purpose of this paper is to prospectively evaluate the performance of an artificial intelligence (AI) system in diagnosing thyroid nodules and to assess its potential value in comparison with the performance of radiologists with different levels of experience, as well as the factors affecting its diagnostic accuracy.

BACKGROUND

In recent years, medical imaging diagnosis using AI has become a popular topic in clinical application research.

OBJECTIVE

This study aimed to evaluate the performance of an AI system in diagnosing thyroid nodules and compare it with the performance levels of different radiologists.

METHODS

This study involved 426 patients screened for thyroid nodules at the First Affiliated Hospital of Guangzhou Medical University between July 2017 and March 2019. All of the nodules were evaluated by radiologists with various levels of experience and an AI system. The diagnostic performances of two junior and two senior radiologists, an AI system, and an AI-assisted junior radiologist were compared, as were their diagnostic results with respect to nodules of different sizes.

RESULTS

The senior radiologists, the AI system, and the AI-assisted junior radiologist performed better than the junior radiologist (p < 0.05). The area under the curves of the AI system and the AI-assisted junior radiologist were similar to the curve of the senior radiologists (p > 0.05). The diagnostic results concerning the two nodule sizes showed that the diagnostic error rates of the AI system, junior radiologists, and senior radiologists for nodules with a maximum diameter of ≤1 cm (Dmax ≤ 1 cm) were higher than those for nodules with a maximum diameter of 1 cm (D_max > 1 cm) (23.4% vs. 12.1%, p = 0.002; 26.6% vs. 7.3%, p < 0.001; and 38.3% vs. 14.6%, p < 0.001).

CONCLUSION

The AI system is a decision-making tool that could potentially improve the diagnostic efficiency of junior radiologists. Micronodules with Dmax ≤ 1cm were significantly correlated with diagnostic accuracy; accordingly, more micronodules of this size, in particular, should be added to the AI system as training samples. Other: The system could be a potential decision-making tool for effectively improving the diagnostic efficiency of junior radiologists in the community.

Predictive Factors for Bilateral Disease in Papillary Microcarcinoma: A Retrospective Cohort Study

Background: Based on risk stratification, the therapeutic options in papillary microcarcinoma (PTMC) can be active surveillance or surgery. Multifocal tumor occurrence can be decisive in determining the treatment strategy. The objective of this study was to identify risk factors for bilateral tumor occurrence in PTMC to enable individual therapy planning. Methods: A total of 545 PTMC patients who underwent thyroidectomy from 2008 to 2020 were retrieved. Univariate and multivariate analyses were performed to evaluate risk factors for bilateral PTMC. Results: 25.1% (n = 137) of all patients had multifocal PTMC, and 13.2% (n = 72) bilateral PTMC, respectively. In contrast to the maximum tumor size, the total tumor size significantly influenced a bilateral tumor manifestation (median total tumor size 5 mm versus 8.5 mm for bilateral PTMC, p < 0.001). A cut-off level for the total tumor size of >10 mm resulted in a sensitivity and specificity of 29.2% and 94.7%, respectively, in predicting a bilateral tumor manifestation, AUC 0.680 (95% CI, 0.611−0.748, p < 0.001). A cut-off of >4 tumors showed a sensitivity of 99.4% and a specificity of 97.5%, AUC 0.897 (95% CI, 0.870−0.924, p < 0.001) in predicting bilaterality. Conclusion: We could demonstrate for the first time that a total tumor size of >10 mm and more than four tumors significantly increased the risk of bilateral PTMC tumor involvement. These findings enable a risk-adjusted patient treatment.

Total tumor diameter is a better indicator of multifocal papillary thyroid microcarcinoma: A propensity score matching analysis

BACKGROUND

Accurate evaluation of the risk of papillary thyroid microcarcinoma (PTMC) is the key to treatment. However, the maximum diameter (MD), which is currently used in various staging systems, may not truly reflect the aggressiveness of multifocal tumors.

METHODS

Clinical and pathological data for 1001 patients with papillary thyroid carcinoma who underwent surgery at the Hangzhou First People's Hospital were retrospectively analyzed. First, the relationship between total tumor diameter (TTD) and clinicopathological features in multifocal PTMC was explored. Then, patients were divided into subgroups according to the TTD. The baseline was consistent after using the propensity score matching method, and the differences between groups were compared. In addition, the effectiveness of TTD and MD in evaluating central lymph node metastasis (CLNM) was analyzed and compared.

RESULTS

TTD is associated with a range of clinicopathological features, including lymph node metastasis, extrathyroidal extension, and risk stratification. Assuming the same MD and number of foci, the invasiveness of multifocal PTMC with TTD >1 cm was significantly higher than that with TTD <1 cm, and even higher than unifocal non-PTMC. Moreover, the efficiency of TTD in predicting CLNM was also significantly higher than that of MD.

CONCLUSION

For multifocal PTMC, TTD is a more realistic indicator of tumor biological characteristics than MD. The aggressiveness of PTMC with TTD >1 cm was significantly enhanced, and surgical treatment should be actively sought in such cases.

Total Tumor Diameter and Unilateral Multifocality as Independent Predictor Factors for Metastatic Papillary Thyroid Microcarcinoma

Simple Summary

Papillary thyroid microcarcinoma is currently the most frequent endocrine cancer at this time. Usually, this form of cancer is indolent, but there are situations in which it metastasizes. The current classification guidelines are rather simplistic and do not comprehend the whole disease spectrum. Studies that have addressed this issue have evaluated various stages of papillary thyroid carcinoma, considering the scarcity of studies based on European demographic data. We aim to further investigate whether total tumor diameter and multifocality are directly correlated with metastatic forms of papillary thyroid microcarcinoma. The results of this study could validate the confidence with which current guidelines are used or could open new avenues in using the total tumor diameter instead of the size of the largest tumor.

Abstract

The purpose of this study was to assess whether total tumor diameter (TTD) and multifocality are predictors for metastatic disease in papillary thyroid microcarcinomas (PTMC). Eighty-two patients with histologically proven PTMC were retrospectively included. Patients were divided according to the presence of metastatic disease in the metastatic (n = 41) and non-metastatic (n = 41) demographic-matched group. The morphological features of PTMCs (primary tumor diameter, multifocality, TTD, number of foci, and tumor site) were compared between groups using univariate, multivariate, and receiver operating characteristic analyses. TTD (p = 0.026), TTD > 10 mm (p = 0.036), and Unilateral Multifocality (UM) (p = 0.019) statistically differed between the groups. The combination of the two independent predictors (TTD and UM) was able to assess metastatic risk with 60.98% sensitivity and 75.61% specificity. TTD and UM can be used to predict metastatic disease in PTMC, which may help to better adapt the RAI therapy decision. We believe that TTD and multifocality are tumor features that should be considered in future guidelines.

Clinical Characteristics-Assisted Risk Stratification for Extent of Thyroidectomy in Patients With 1-4 cm Solitary Intrathyroidal Differentiated Thyroid Cancer

BACKGROUND

Differentiated thyroid cancer (DTC) is the most common type of thyroid cancer. The 2015 American Thyroid Association (ATA) guidelines recommend that lobectomy is suitable for solitary intrathyroidal DTC (SI-DTC) of 1-4 cm. However, some SI-DTC patients with other high-risk characteristics still have poor prognosis and require more aggressive surgical methods. This study aimed to explore the clinical characteristics that are important for the identification and treatment of high-risk patients with SI-DTC of 1-4 cm.

METHODS

The study cohort was obtained from the SEER database, consisting of data between 2004 and 2013. The outcome measures were thyroid carcinoma-specific mortality (CSM) and all-cause mortality (ACM). Patient survival curves were examined using Kaplan-Meier analyses with log-rank tests and Cox proportional hazards regression analyses. Hazard ratios (HRs) were used to show the magnitude of the effect of disease stage on DTC-specific patient mortality.

RESULTS

The study included 55,947 patients with SI-DTC of 1-4 cm and 4,765 patients with DTC >4 cm. Tumor size, surgical approach, age, sex, race, and radiation exposure were independent risk factors for CSM and ACM. SI-DTC patients with female, age ≤45, and 1 cm< tumor size ≤2 cm were at low risk of CSM [HR = 0.014 (0.002-0.115)] and ACM [HR = 0.115 (0.077-0.171)] when stratified by age, sex, and tumor size. Compared to T3 patients, CSM was not significantly different in male patients, age >45, 2 cm< tumor size ≤3 cm [HR = 0.839 (0.414-1.700)] and male patients, age >45, 1 cm< tumor size ≤2 cm [HR = 0.751 (0.410-1.377)]. Furthermore, compared to T3 patients without extrathyroidal extension (ETE) and lymph node metastasis (LNM), more subgroups of SI-DTC of 1-4 cm had a similar prognosis. In addition, patients with SI-DTC of 1-4 cm showed similar rates of CSM and ACM to T3 patients without ETE, LNM, and distant metastasis (DM). Similar results were obtained when we set the age cut-off value as 55 years, according to the 8th edition of AJCC TNM system.

CONCLUSIONS

Our study demonstrated that sex, age, and tumor size clearly differentiate SI-DTC of 1-4 cm into low-and high-risk categories. Survival rates were significantly lower in subgroups containing old males with larger tumors compared to younger females with small tumors. Total thyroidectomy may be favored in these high-risk subgroup patients.

Predicting factors of central lymph node metastases in patients with unilateral multifocal papillary thyroid microcarcinoma

Background

Unilateral multifocal papillary thyroid microcarcinoma (UM-PTMC) is not rare, and the suitable extent of operation is controversial. Total thyroidectomy is associated with a high risk of hypoparathyroidism and recurrent laryngeal nerve injury. Hemithyroidectomy should be considered in patients without lymph node metastases. This study aimed to identify factors predicting central lymph node metastases (CLNM) in patients with UM-PTMC.

Methods

A total of 1,453 patients with thyroid cancer underwent surgery at our hospital from January 2018 to June 2018, and 115 patients with UM-PTMC were selected and assessed retrospectively. The relationship between CLNM and clinicopathologic features of UM-PTMC were analyzed by both univariate and multivariate analyses.

Results

Of the 115 patients with UM-PTMC, CLNM were confirmed by pathology in 57 patients. Univariate and multivariate analyses identified the sum diameter of all tumors (≥1.0 cm) [odds ratio (OR) =2.295; 95% confidence interval (CI): 1.036-5.086; P=0.041] and positive CLNM via ultrasonography (OR =5.882; 95% CI: 1.562-22.153; P=0.009) as independent predictors of CLNM.

Conclusions

CLNM are common in patients with UM-PTMC. The sum diameter of all tumors (≥1.0 cm) and positive CLNM via ultrasonography are independent risk factors for CLNM. Our data should be considered in the decision process relating to performing total thyroidectomy or hemithyroidectomy in patients with UM-PTMC.

Total tumor diameter: the neglected value in papillary thyroid microcarcinoma

BACKGROUND

Tumor multifocality is not uncommon in papillary thyroid carcinoma (PTC), especially in micro-PTC. However, assessing the size of the largest tumor may underestimate effect of additional foci. We aimed to investigate the effect of total tumor diameter (TTD) on clinicopathological features of micro-PTC.

METHODS

Data from 442 patients who underwent thyroidectomy with cervical lymph node dissection for PTC were retrospectively analyzed. Patients were classified into subgroups according to multifocality and TTD. The relationships of clinicopathological features among these groups were analyzed.

RESULTS

Multifocality was observed in 119 patients (26.9%). TTD > 1 cm and presence of extrathyroidal extension (ETE) were significantly higher in multifocal tumors compared to unifocal tumor (P < 0.001, P = 0.016, respectively). When comparing multifocal micro-PTC with TTD > 1 cm to those with unifocal micro-PTC or multifocal micro-PTC with TTD ≤ 1 cm, the proportions of cases with ETE, central lymph node metastasis (CLNM), and lateral lymph node metastasis (LLNM) were significantly higher (all P < 0.05). There was no significant difference in terms of these parameters between multifocal micro-PTC with TTD > 1 cm and macro-PTC or multifocal macro-PTC. The risk of CLNM was 2.056 (P = 0.044) times higher in multifocal micro-PTC with TTD > 1 cm than in unifocal micro-PTC.

CONCLUSION

For multifocal micro-PTC, TTD can better assess the aggressiveness of the tumor. Multifocal micro-PTC with TTD > 1 cm was more aggressive than unifocal micro-PTC or multifocal micro-PTC with TTD ≤ 1 cm.

Ultrasound Elastic Parameters Predict Central Lymph Node Metastasis of Papillary Thyroid Carcinoma

BACKGROUND

This study aimed to explore the new factors that can predict central lymph node metastasis (CLNM) of papillary thyroid carcinoma (PTC) independently from ultrasound characteristics, elastic parameters, and endocrine indicators.

METHODS

A total of 391 patients with PTC undergoing thyroidectomy and prophylactic central lymph node dissection from January 2017 to June 2019 were collected to determine the independent predictors of CLNM by single-factor and multivariate logistic regression analysis.

RESULTS

Multivariate logistic regression analysis showed 9 independent predictors of CLNM, age, male, tumors in the middle or lower poles (without tumors in the isthmus), tumors in the isthmus, multiple tumors, and maximum tumor diameter measured by ultrasound, microcalcification, visible surrounding blood flow signal, and the maximum value of elastic modulus (Emax).We used the aforementioned factors to establish a scoring prediction model: predictive score Y(P) = 1/[1 + exp (1.444 + 0.084 ∗ age - 0.834 ∗ men - 0.73 ∗ multifocality - 2.718 ∗ tumors in the isthmus - 0.954 ∗ tumors in the middle or lower poles - 0.086 ∗ tumor maximum diameter - 1.070 ∗ microcalcification - 0.892 ∗ visible surrounding blood flow signal - 0.021 ∗ Emax)]. The area under the curve of the receiver operating characteristic was 0.827. It was found that 0.524 was the highest index of Youden, and the best cutoff value for predicting CLNM. When Y(P)≥0.524, the risk of CLNM in patients with PTC is predicted to be high. Predictive accuracy was 78.5% and 72.4% in the internal validation group and 78.6% in the external validation group.

CONCLUSIONS

These data indicate that the scoring prediction model could provide a scientific and quantitative way to predict CLNM in patients with PTC.

Prognostic significance of the sum of the diameters of single foci in multifocal papillary thyroid cancer: the concept of new-old tumor burden

AIM

The prognostic value of multifocality (Mu) in papillary thyroid cancer (PTC) remains controversial. The present study aimed to investigate this issue and test the possible prognostic significance of the sum of the diameters of single foci (SDSF), the total number of foci (TNF), and primary tumor size (PTS) in multifocal PTC.

METHODS

We retrospectively analyzed a single-center consecutive series of 370 PTCs. For multifocal cases we analyzed bilaterality occurrence, SDSF, TNF, and PTS.

RESULTS

Mu was observed in 41.1% PTCs, and bilaterality in 30%. Mu was associated with an advanced T-category. In bilateral multifocal PTC, the PTS was larger, and microPTC was less frequent, while T-categories were higher. Mu and bilaterality per se had no impact on prognosis. At univariate analysis, PTS, SDSF, vascular invasion, lymph node metastases, distant metastases, T-categories, Initial Risk Stratification System score, second treatment and TERT promoter mutation correlated with persistence/recurrence or death in the multifocal PTC group. On multivariate Cox proportional hazards regression analyses, SDSF again independently predicted persistence/recurrence or death in multifocal PTCs. We found that a cut-off for SDSF less than 40 mm was able to identify multifocal PTC patients with a very low risk of persistence/recurrence (negative predictive value 96.9%). Disease-free survival was significantly shorter in patients with multifocal PTCs and SDSF ⩾40 mm.

CONCLUSIONS

Mu and bilaterality per se were not prognostically significant. SDSF emerged as a new independent prognostic factor for persistence/recurrence of multifocal PTC. SDSF might better represent the tumor burden in multifocal PTC, with SDSF < 40 mm identifying multifocal PTC patients with a good prognosis.

Small Cell Carcinoma: a Rare Subtype of Thyroid Cancer with Unanticipated Prognosis

The prognosis of small cell thyroid carcinoma (SCTC) in a large cohort has not been well reported in the literature. In this study, we analyzed the mortality of SCTC, in comparison to medullary thyroid cancer (MTC) and anaplastic thyroid cancer (ATC), based on the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, to determine the prognosis of SCTC. Information regarding patients with a diagnosis of MTC, ATC, or SCTC, between 2004 and 2013, was acquired from the SEER database. Patient survival curves were assessed by Cox proportional hazards regression analyses, Kaplan-Meier analyses, and log-rank tests. In a Kaplan-Meier analysis of the entire cohort of thyroid cancer patients, cancer-specific survival declined sharply for patients with SCTC, but it declined more modestly for patients with MTC. The cancer-specific survival was not significantly different between SCTC and ATC. Unadjusted Cox regression analysis showed that SCTC had a higher cancer-specific mortality than MTC but a similar prognosis as ATC. SCTC showed a higher cancer-specific mortality than MTC and ATC after adjustments for various confounding factors. SCTC was found to have a more highly lethal clinical course than MTC and had a similar death rate to ATC. Therefore, we recommend that aggressive, radical treatment like surgery or radiation should be performed for these patients.

Active surveillance for young patients with insular thyroid cancer: an initial and novel finding

Insular thyroid cancer (ITC) is a relatively rare thyroid malignancy that has an unclear prognosis. Recent studies have indicated that watchful waiting is sufficient for younger patients with more differentiated thyroid lesions such as papillary thyroid microcarcinoma (PTMC). In this study, we investigated the prognosis of younger patients (< 45 and < 55 years old) with ITC and compared their outcomes to patients with PTMC and follicular thyroid microcarcinoma (FTMC). We hypothesized that ITC, like PTMC and FTMC, can be managed with active surveillance in younger patients with this disease. We investigated a large cohort of younger patients with ITC, PTMC, or FTMC who were listed in the Surveillance, Epidemiology, and End Results database between 2004 and 2013. Patient mortality was examined by Kaplan-Meier analyses with log-rank tests and Cox proportional hazards regression analyses. In the study cohort, the rate of cancer-specific mortality per 1000 person-years for younger ITC patients (< 45 and < 55 years) was lower than that for PTMC and FTMC. Kaplan-Meier analyses revealed that the cancer-specific and all-cause mortality rates in younger ITC patients were similar to those of PTMC and FTMC. Similar results were obtained when cases with tumor extension were excluded from the analysis. The unanticipated excellent prognosis of younger patients with ITC challenges the current clinical practice of automatically treating this disease, and offers new implications for management such as pursuing active surveillance instead.

Predictive Factors of Recurrence for Multifocal Papillary Thyroid Microcarcinoma With Brafv600e Mutation: A Single Center Study of 1,207 Chinese Patients

Background: The American Thyroid Association (ATA) guidelines risk stratify Braf^v600e mutated multifocal papillary thyroid microcarcinoma (BMPTMC) into different recurrence risk groups by the extent of extrathyroidal extension (ETE). These findings and modifications for BMPTMC need to be verified in additional studies. Methods: A retrospective cohort study was conducted in BMPTMC patients who underwent total thyroidectomy (TT) and central lymph node dissection (CLND) from 2008 to 2013. Overall, 1,207 patients were included, and predictive factors were identified by univariate and multivariate analysis over a mean 7.5-year follow up. Results: BMPTMC with ETE to capsule shows the same recurrence rate (3.8%) with intrathyroidal BMPTMC. Moreover, BMPTMC with ETE only to strap muscle, which belongs to high-risk group according to ATA guideline, shows relatively lower recurrence rate (13.3%) compared with some intermediate risk categories such as cN1 and >5 pN1. Multivariate analysis using a Cox proportional hazards regression model shows that total tumor diameter (TTD) is associated with significantly higher recurrence for BMPTMC with or without other risk factors (Hazard Ratio (HRO) = 9.86 [95%CI 5.35-18.20], p = 0.00; HRO = 2.32 [95%CI 1.12-4.85], p = 0.02; respectively), while Hashimoto thyroiditis (HT) is found to be protective against the recurrence (HRO = 0.51 [95%CI 0.33-0.79], p = 0.00; HRO = 0.47 [95%CI 0.25-0.89], p = 0.02; respectively). Conclusions: Taken together, capsular ETE and gross ETE to the strap muscles did not have the expected significant influence on recurrence for Chinese BMPTMC patients who underwent TT and CLND. Rather than the extent of ETE, TTD and the lack of HT were identified as predictors for recurrence among BMPTMC with or without other risk factors (vascular invasion, cN1, pN1>5, pN1>3 cm).

Is biopsy enough for papillary thyroid microcarcinoma?: An analysis of the SEER database 2004 to 2013 with propensity score matching

The treatment of papillary thyroid microcarcinoma (PTMC) remains deeply controversial. In this study, we investigated the prognosis of patients who underwent biopsy alone, as compared with other forms of thyroidectomy approaches. We sought to provide reference information for treatment selection in cases of PTMC.The analysis included a large cohort of 34,972 PTMC patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2013. Survival was examined by Kaplan-Meier analyses with log-rank tests, Cox proportional-hazards regression analyses, and propensity score matching analyses.In the study cohort, the rate of cancer-specific mortality per 1000 person-years was higher for patients who underwent biopsy alone than for those who underwent other surgical approaches. According to multivariate Cox regression analyses, patients undergoing biopsy had similar cancer-specific survival rates and higher all-cause survival rates in comparison with patients undergoing other surgical approaches. After matching for influential factors using propensity scores, Kaplan-Meier analyses also showed that patients undergoing biopsy had similar cancer-specific survival rates and lower all-cause survival rates in comparison with patients undergoing other surgical approaches.Our results provided helpful implications for the treatment of patients with PTMC.

Prognosis of FTC compared to PTC and FVPTC: findings based on SEER database using propensity score matching analysis

The significance of prognosis of follicular thyroid cancer (FTC) compared to other subtypes of thyroid cancer, based on large cohort data has only been addressed in a few studies, and the results remain controversial. In this study, we investigated the prognosis of FTC compared to papillary thyroid carcinoma (PTC) and follicular variant PTC (FVPTC) based on Surveillance, Epidemiology, and End Results database (SEER) Program data using propensity score matching. We evaluated data from 128,703 patients with thyroid cancer who were included in the SEER database between 2004 and 2013. Patient mortality was evaluated using Cox proportional hazards regression analyses and Kaplan-Meier analyses with log-rank tests. The average prognosis of FTC was poorer than both PTC and FVPTC. The multivariate Cox regression analysis revealed that the cancer-specific survival rate for FTC was lower than that for PTC and FVPTC without adjusting for risk factors. Furthermore, after propensity score matching analysis for relevant factors, the cancer-specific mortality rate for FTC was higher than that for PTC and FVPTC. These results based on a large population cohort database provide a benefit reference for individual and precise treatment and management of patients with FTC.

MiR-129 regulates growth and invasion by targeting MAL2 in papillary thyroid carcinoma

MAL2, a member of the MAL proteolipid family, is essential for raft-mediated transport. In this study, we investigated the roles and underlying mechanism of MAL2 in the development of papillary thyroid carcinoma (PTC). Up-regulation of MAL2 was found in human PTC tissues and significantly correlated with poor overall survival (OS). Knockdown of MAL2 dramatically suppressed PTC cell proliferation and invasion in vitro and inhibited tumor growth in vivo. We further found that miR-129 suppressed the expression of MLA through directly binding to the 3' untranslated region (3' UTR). While forced miR-129 expression suppressed growth and invasion of PTC cells, re-expression of MAL2 rescued these effects. Taken together, our data indicated that MAL2 acted as an oncogene and was negatively regulated by miR-129, supporting the potential therapeutic strategy against PTC by targeting miR-129-MAL2 axis.

Surgical options for thyroid cancer and post-surgical management

INTRODUCTION

Differentiated thyroid cancer (DTC), which includes papillary and follicular, is the most common type of thyroid cancer and the incidence is rising. Survival rates of DTC are excellent, so the focus of management should be to optimize the initial oncological surgical resection, while providing follow up and adjunct therapies to improve long-term outcomes.

AREAS COVERED

It is important for providers to be aware of the most recent guidelines for DTC management, as practices have changed in recent years. In this review, we will highlight some of the updates in the American Thyroid Association (ATA) guidelines and the American Joint Committee on Cancer (AJCC) edition changes in order to better guide practitioners in the management of the evolving treatment strategies. Management of DTC includes diagnosis of thyroid nodules, defining the best operative or non-operative treatment for patients using a multidisciplinary approach, and surveillance of DTC to optimize patients in terms of both clinical and quality of life outcomes.

EXPERT COMMENTARY

As the rate of DTC rises yet the mortality remains stable, management focuses on disease-free follow up and optimal long-term outcomes. Current controversies in management of DTC include proper oncological surgery depending on the nature and size of the DTC, the cytopathology nomenclature, management of lymph node disease, and appropriate surveillance strategies. Preoperative risk stratification is key. We have many modalities to aid in that stratification, such as identifying known concerning features of nodules with expert-performed ultrasound, thyroglobulin (Tg) levels, molecular testing, and evidence based outcomes data for recurrence rates. However, many individual cases still present with multiple management options, thus highlighting the importance of patient discussion and a multidisciplinary approach. It is important for providers to recognize that the short and long-term follow up must be guided by surveillance studies, and patients need to be re-risk stratified in order to optimize detection of recurrence yet sustain quality of life.

Mixed subtype thyroid cancer: A surveillance, epidemiology, and end results database analysis

The prognosis of patients with mixed subtype thyroid cancer (MSTC) is unclear. The present study compared the prognoses of MSTC, papillary thyroid cancer (PTC), and follicular thyroid cancer (FTC) to provide a new perspective regarding the treatment guidelines for these diseases. We evaluated data from patients with thyroid cancer who were included in the Surveillance, Epidemiology, and End Results database between 2004 and 2013. Patient mortality was evaluated using Cox proportional hazards regression analyses and Kaplan-Meier analyses with log-rank tests. The univariate Cox regression analysis showed that the cancer-specific survival rate for MSTC was lower than that for PTC and FTC. However, in the multivariate Cox regression analysis, the cancer-specific survival rate for MSTC was similar to that for PTC and FTC. Before matching influence factors, the cancer-specific survival rate for MSTC was lower than that for PTC and FTC. However, after propensity score matching for relevant factors, the cancer-specific survival rate for MSTC was also similar to that for PTC and FTC. Our result would be beneficial and provide a guideline for the understanding of MSTC.