Impact of primary surgery on outcome in 300 patients with pathologic tumor-node-metastasis stage III papillary thyroid carcinoma treated at one institution from 1940 through 1989

Theranostics of Thyroid Cancer

Molecular imaging is pivotal in evaluating and managing patients with different thyroid cancer histotypes. The existing, pathology-based, risk stratification systems can be usefully refined, by incorporating tumor-specific molecular and molecular imaging biomarkers with theranostic value, allowing patient-specific treatment decisions. Molecular imaging with different radioactive iodine isotopes (ie, I131, I123, I124) is a central component of differentiated carcinoma (DTC)'s risk stratification while [18F]F-fluorodeoxyglucose ([18F]FDG) PET/CT is interrogated about disease aggressiveness and presence of distant metastases. Moreover, it is particularly useful to assess and risk-stratify patients with radioiodine-refractory DTC, poorly differentiated, and anaplastic thyroid cancers. [18F]F-dihydroxyphenylalanine (6-[18F]FDOPA) PET/CT is the most specific and accurate molecular imaging procedure for patients with medullary thyroid cancer (MTC), a neuroendocrine tumor derived from thyroid C-cells. In addition, [18F]FDG PET/CT can be used in patients with more aggressive clinical or biochemical (ie, serum markers levels and kinetics) MTC phenotypes. In addition to conventional radioiodine therapy for DTC, new redifferentiation strategies are now available to restore uptake in radioiodine-refractory DTC. Moreover, peptide receptor theranostics showed promising results in patients with advanced and metastatic radioiodine-refractory DTC and MTC, respectively. The current appropriate role and future perspectives of molecular imaging and theranostics in thyroid cancer are discussed in our present review.

Silencing long non-coding RNAs nicotinamide nucleotide transhydrogenase antisense RNA 1 inhibited papillary thyroid cancer cell proliferation, migration and invasion and promoted apoptosis via targeting miR-199a-5p

The increasing incidence of papillary thyroid cancer (PTC) has attracted many researchers to investigate the mechanism underlying PTC progression. This study explored the growth and apoptosis of PTC cells based on an lncRNA regulatory mechanism. The expression of nicotinamide nucleotide transhydrogenase antisense RNA 1 (NNT-AS1) in PTC cell lines and PTC tissues was analyzed by qRT-PCR. The mutual binding site between NNT-AS1 and miR-199a-5p was predicted by starBase and confirmed by dual-luciferase reporter assay. The correlation between NNT-AS1 and miR-199a-5p was shown by Pearson correlation test. The viability, clone formation, migration, invasion and apoptosis of TPC-1 and IHH-4 cells were examined by CCK-8, colony formation, wound-healing, transwell, and flow cytometry assays, respectively. The expressions of Bax, cleaved Caspase-3, Bcl-2, E-Cadherin, N-Cadherin and SNAIL in TPC-1 and IHH-4 cells were determined by Western blot or qRT-PCR. NNT-AS1 expression was upregulated in PTC cells and tissues. In TPC-1 cells, silencing NNT-AS1 inhibited viability, clone formation, migration, and invasion as well as the expressions of N-Cadherin, SNAIL and Bcl-2, but promoted the expressions of E-Cadherin, Bax, and cleaved caspase-3. The effects of NNT-AS1 overexpression on IHH-4 cells were opposite to those of silencing NNT-AS1. In PTC tissues, miR-199a-5p was low-expressed and targeted by NNT-AS1, and it was negatively correlated with NNT-AS1. MiR-199a-5p inhibitor promoted TPC-1 cell progression, but miR-199a-5p mimic inhibited IHH-4 cell progression. NNT-AS1 and miR-199a-5p exerted opposite effects on PTC cells. Silencing NNT-AS1 inhibited PTC cell proliferation, migration and invasion, but promoted apoptosis via upregulation of miR-199a-5p.

Preoperative charcoal suspension tattoo for the detection of differentiated thyroid cancer recurrence

Recurrent differentiated thyroid carcinoma can easily be detected by means of ultrasound (US) and thyroglobulin, and often requires further surgical intervention. Revision surgery is often a technical challenge with significant risk of complications, considering the altered anatomy, with a possibility of leaving behind residual neoplasm. Preoperative US-guided tattooing localization has been introduced to reduce and prevent these potential problems during revision surgery. Encouraging results have been reported in the literature. Under US guidance, the lesion is identified and 0.5-2 ml of colloidal charcoal is injected in its proximity using a 23 gauge needle. The extraction is accompanied by injection at constant pressure of charcoal in order to leave a trace of pigment along the path of the needle till the skin. From April 2008 to January 2016 we performed revision surgery in 27 patients for lymph-nodes metastasis in differentiated thyroid cancer, using the technique of preoperative charcoal tattoo localization. Our previous study on the first group of 13 patients published in 2012, reported the preliminary results in terms of success rate and complications. The tolerance of charcoal injection was good for all patients and the procedure was demonstrated to be useful, contributing to the removal of metastatic lesion in 93% of procedures. We have registered minor surgical complications during revision in the central compartment of the neck: Transitory hypoparathyroidism in 2 cases (11%) and transitory vocal cord paresis in 3 cases (16%). Based on these results, preoperative charcoal tattoo localization in revision surgery of the neck for differentiated thyroid cancer recurrence can be considered a safe technique, easy to perform, with low-costs and useful during surgical procedures, providing a significant reduction of iatrogenic damage and risks.

Utility of quantitative contrast-enhanced ultrasound for the prediction of extracapsular extension in papillary thyroid carcinoma

The aim of this study was to find an accurate method for the detection of extracapsular extension (ECE) in papillary thyroid carcinoma (PTC). A total of 102 patients with 109 PTC nodules were retrospectively enrolled. Contrast-enhanced ultrasound (CEUS) characteristics were evaluated. The diagnostic efficacy of quantitative CEUS and tumor size was analyzed. The qualitative CEUS features did not differ significantly between the ECE and non-ECE groups (P > 0.05). All of the quantitative CEUS parameters with the exception of peak intensity and tumor size were found to differ significantly between the ECE and non-ECE groups (P < 0.05). Multivariate stepwise logistic regression analysis demonstrated that time from peak to one half (TPH), tumor size and wash-in slope (WIS) were the significantly different parameters between the ECE and non-ECE groups (P = 0.000, P = 0.005 and P = 0.030, respectively).The sensitivity and specificity in the diagnosis of ECE were: TPH, 75.4% (43/57) and 78.9% (41/52), respectively; WIS, 87.7% (50/57) and 42.3% (22/52), respectively; and tumor size, 71.9% (41/57) and 65.4% (34/52), respectively. Quantitative CEUS analysis and tumor size are essential for the prediction of ECE in PTC; in particular TPH has good diagnostic value in detecting ECE. Our study provides important insights into the prediction of ECE in PTC.

The Art and Science of Thyroid Surgery in the Age of Genomics: 100 years after Theodor Kocher

Cancer is a disorder of the genome. The thyroid cancer genome is being decoded. Recent studies have identified a mutation or a genetic alteration in 95% of thyroid cancers. The National Cancer Institute initiated the Cancer Genome Atlas project in 2006 to catalogue genetic mutations associated with cancer, using genome sequencing and bioinformatics. The project has expanded to carry out genomic characterization and sequence analysis of thyroid cancer. The concept of risk stratification based on traditional parameters will soon vacate their role for clear molecular markers of non-invasive/focal, invasive/metastatic and systemic stages/phases of neoplastic disorder. A refined classification scheme based on genomics and its phenotypic expressions will accurately reflect the biologic differences between the different morphologic definitions we use today. Tumor differentiation/de-differentiation, and clinical behavior of an individual cancer will be defined by molecular markers, in addition to standard morpho-pathology. Empiricism in science of medicine and surgery has acquired a new method for testing the appropriate treatment for individual patients; that is molecular pathology, governed by genomics. The technology is present and rapidly evolving. The surgeons will determine the extent of interventions with molecular evidence and guidance.

Pediatric papillary thyroid cancer: current management challenges

Although with a standardized incidence of 0.54 cases per 100,000 persons, differentiated thyroid cancer (DTC) is a rare disease in children and adolescents, it nonetheless concerns ~1.4% of all pediatric malignancies. Furthermore, its incidence is rising. Due to the rarity and long survival of pediatric DTC patients, in most areas of treatment little evidence exists. Treatment of pediatric DTC is therefore littered with controversies, many questions therefore remain open regarding the optimal management of pediatric papillary thyroid cancer (PTC), and many challenges remain unsolved. In the present review, we aim to provide an overview of these challenging areas of patient and disease management in pediatric PTC patients. Data on diagnosis, surgery, radionuclide, and endocrine therapy are discussed, and the controversies therein are highlighted.

Prophylactic Level VII Nodal Dissection as a Prognostic Factor in Papillary Thyroid Carcinoma: a Pilot Study of 27 Patients

BACKGROUND

Prognostic value of prophylactic level VII nodal dissection in papillary thyroid carcinoma has been highlighted.

MATERIALS AND METHODS

A total of 27 patients with papillary thyroid carcinoma with N0 neck underwent total thyroidectomy with level VI and VII nodal dissection through same collar neck incision. Multicentricity, bilaterality, extrathyroidal extension, level VI and VII lymph nodes were studied as separate and independent prognostic factors for DFS at 24 months.

RESULTS

21 females and 6 males with a mean age of 34.6 years old, tumor size was 5-24 mm. (mean 12.4 mm.), multicentricity in 11 patients 2-4 foci (mean 2.7), bilaterality in 8 patients and extrathyroidal extension in 8 patients. Dissected level VI LNs 2-8 (mean 5 LNs) and level VII LNs 1-4 (mean 1.9). Metastatic level VI LNs 0-3 (mean 1) and level VII LNs 0-2 (mean 0.5). Follow-up from 6-51 months (mean 25.6) with 7 patients showed recurrence (3 local and 4 distant). Cumulative DFS at 24 months was 87.8% and was significantly affected in relation to bilaterality (p-value<0.001), extrathyroidal extension (p-value<0.001), level VI positive ((p-value<0.001) and level VII positive ((p-value<0.001) LNs. No recurrences were detected during the follow-up period in the absence of level VI and level VII nodal involvement.

CONCLUSIONS

Level VII prophylactic nodal dissection is an important and integral prognostic factor in papillary thyroid carcinoma. A larger multicenter study is crucial to reach a satisfactory conclusion about the necessity and safety of this approach.

Recurrence of papillary thyroid cancer after optimized surgery

Recurrence of papillary thyroid cancer (PTC) after optimized surgery requires a full understanding of the disease, especially as it has changed in the last 15 years, what comprises optimized surgery, and the different types and implications of disease relapse that can be encountered. PTC has evolved to tumors that are much smaller than previously seen, largely due to various high quality imaging studies obtained for different reasons, but serendipitously identifying thyroid nodules that prove to be papillary thyroid microcarcinomas (PTMC). With rare exception, these cancers are cured by conservative surgery without additional therapy, and seldom result in recurrent disease. PTC is highly curable in 85% of cases because of its rather innocent biologic behavior. Therefore, the shift in emphasis from disease survival to recurrence is appropriate. As a result of three technologic advances-high-resolution ultrasound (US), recombinant TSH, and highly sensitive thyroglobulin (Tg)-disease relapse can be discovered when it is subclinical. Endocrinologists who largely control administration of radioactive iodine have used it to ablate barely detectable or even biochemically apparent disease, hoping to reduce recurrence and perhaps improve survival. Surgeons, in response to this new intense postoperative surveillance that has uncovered very small volume disease, have responded by utilizing US preoperatively to image this disease, and incorporated varying degrees of lymphadenectomy into their initial treatment algorithm. Bilateral thyroid resection-either total or near-total thyroidectomy-remains the standard for PTC >1 cm, although recent data has re-emphasized the value of unilateral lobectomy in treating even some PTC measuring 1-4 cm. Therapeutic lymphadenectomy has universal approval, but when lymph nodes in the central neck are not worrisome to the surgeon's intraoperative assessment, although that judgment in incorrect up to 50%, whether they should be excised has reached a central point of controversy. Disease relapse can occur individually or in combination of three different forms: lymph node metastasis (LNM), true soft tissue local recurrence, and distant disease. The latter two are worrisome for potentially life-threatening consequences whereas nodal metastases are often persistent from the initial operation, and mostly comprise a biologic nuisance rather than virulent disease. A moderate surgical approach of bilateral thyroid resection, with usual central neck nodal clearance, and lateral internal jugular lymphadenectomy for node-positive disease can be performed safely, and with about a 5% recurrence rate.

Extent of surgery for papillary thyroid cancer is not associated with survival: an analysis of 61,775 patients

OBJECTIVE

To examine the association between the extent of surgery and overall survival in a large contemporary cohort of patients with papillary thyroid cancer (PTC).

BACKGROUND

Guidelines recommend total thyroidectomy for PTC tumors >1 cm, based on older data demonstrating an overall survival advantage for total thyroidectomy over lobectomy.

METHODS

Adult patients with PTC tumors 1.0-4.0 cm undergoing thyroidectomy in the National Cancer Database, 1998-2006, were included. Cox proportional hazards models were applied to measure the association between the extent of surgery and overall survival while adjusting for patient demographic and clinical factors, including comorbidities, extrathyroidal extension, multifocality, nodal and distant metastases, and radioactive iodine treatment.

RESULTS

Among 61,775 PTC patients, 54,926 underwent total thyroidectomy and 6849 lobectomy. Compared with lobectomy, patients undergoing total thyroidectomy had more nodal (7% vs 27%), extrathyroidal (5% vs 16%), and multifocal disease (29% vs 44%) (all Ps < 0.001). Median follow-up was 82 months (range, 60-179 months). After multivariable adjustment, overall survival was similar in patients undergoing total thyroidectomy versus lobectomy for tumors 1.0-4.0 cm [hazard ratio (HR) = 0.96; 95% confidence interval (CI), 0.84-1.09); P = 0.54] and when stratified by tumor size: 1.0-2.0 cm [HR = 1.05; 95% CI, 0.88-1.26; P = 0.61] and 2.1-4.0 cm [HR = 0.89; 95% CI, 0.73-1.07; P = 0.21]. Older age, male sex, black race, lower income, tumor size, and presence of nodal or distant metastases were independently associated with compromised survival (P < 0.0001).

CONCLUSIONS

Current guidelines suggest total thyroidectomy for PTC tumors >1 cm. However, we did not observe a survival advantage associated with total thyroidectomy compared with lobectomy. These findings call into question whether tumor size should be an absolute indication for total thyroidectomy.

Prediction of thyroid extracapsular extension with cervical lymph node metastases (ECE-LN) by CEUS and BRAF expression in papillary thyroid carcinoma

The aim of our study was to find a specific imaging (contrast-enhanced ultrasound, CEUS) to detect extracapsular extension and cervical lymph node metastases (ECE-LNM) that associated with BRAF protein expression in papillary thyroid carcinoma (PTC). Preoperative utrasonography (US) or CEUS was performed in the diagnosis of extracapsular extension (ECE) in 317 patients with 369 PTC. BRAF protein status was tested on the primary tumor and lymph node involvement. The diagnostic accuracy of CEUS and US was evaluated after thyroid surgery. The association between CEUS and BRAF expression were then analyzed to investigate the diagnostic value of ECE-LNM in PTC. The sensitivity and specificity of CEUS were higher than those in US in the diagnosis of ECE in patients with PTC (91.1, 86.5 vs 49, 55 %). BRAF protein overexpression were significantly associated with ECE (P = 0.0003) and lymph node metastasis (LNM) positive cases (P = 0.0014). The results of CEUS, not US, have a significant correlation with BRAF expression status in PTC samples (P < 0.0001). Associated with BRAF protein expression status, the routine preoperative CEUS could have a good value in the diagnosis of ECE-LNM in PTC and facilitate a surgeon to improve further clinical management.

Therapeutic strategy for low-risk thyroid cancer in Kanaji Thyroid Hospital

It is well-known that differentiated thyroid carcinoma (DTC) has a generally indolent character and shows a favorable prognosis in comparison with many other carcinomas. The therapeutic strategy for patients with DTC in Japan has differed from that in Western countries. Total thyroidectomy followed by radioactive iodine (RAI) ablation has been standard in Western countries, whereas limited hemi-thyroidectomy and subtotal thyroidectomy has been extensively accepted in Japan. Papillary thyroid carcinoma (PTC) accounts for over 90% of all thyroid cancers in Japan. The majority of patients with PTC are categorized into a low-risk group on the basis of the recent risk-group classification schemes, and they show excellent outcomes. Several management guidelines for thyroid cancers have been published in Western countries. However, the optimal therapeutic options for PTC remain controversial, and high-level clinical evidence aimed at resolving these issues is lacking. Moreover, as socioeconomic differences in medical care exist, conventional policies for the treatment of PTC have differed between Japan and other countries. This review focuses on the special features of treatment in Japan for patients with low-risk DTC involving subtotal thyroidectomy without adjuvant therapies, rather than total thyroidectomy with RAI, with the aim of preserving quality of life. At our institution in Japan, we have had extensive experience with RAI treatment for high-risk DTC patients, and this represents a very rare situation. Here we introduce the therapeutic strategy for low-risk thyroid cancer in Japan, including the measures adopted at our institution.

Role of chronic lymphocytic thyroiditis in central node metastasis of papillary thyroid carcinoma

OBJECTIVE

(1) To investigate the role of chronic lymphocytic thyroiditis (CLT) in central node metastasis of papillary thyroid carcinoma (PTC) and (2) to evaluate the presence of chronic lymphocytic thyroiditis according to PTC-specific molecular markers.

STUDY DESIGN

Historical cohort study.

SETTING

Academic medical center.

SUBJECTS AND METHODS

All patients who underwent total thyroidectomy with central neck dissection for PTC at Oregon Health & Science University between 2005 and 2010 were screened for the presence of CLT and reviewed for clinical prognostic factors. Patients with inadequate central neck dissections were excluded. Molecular markers for PTC were analyzed on archived tumor samples.

RESULTS

A total of 139 patients met selection criteria. The rate of CLT was 43.8%. The rate of central node positivity was 63%. Presence of CLT was associated with a significantly lower proportion of central node metastases (49% vs 74%, P = .003) and angiolymphatic invasion (31% vs 15%, P = .03). There was no significant difference in mean age, tumor size, and extracapsular extension. Molecular genotyping did not reveal a significant difference in the types of mutations found in both groups.

CONCLUSION

The data indicate a lower incidence of central compartment lymph node metastasis in those with CLT in this patient population, suggesting a potential protective role in tumor spread. The equal distribution of tumor mutations between the carcinomas with and without evidence of CLT argues against a mutation-specific antigen as the immunologic stimulus. Further research is needed to characterize the role of autoimmunity in thyroid cancer.

Central cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the central compartment

BACKGROUND

Papillary thyroid cancer (PTC) is a common endocrine cancer and commonly presents with lymph node (LN) metastases. The role of surgical removal of the central cervical LN compartment is poorly defined. There are no prospective randomized controlled trials addressing the relevance to the extent of the initial surgical approach.

DESIGN AND METHODS

A systematic review of studies of patients with PTC undergoing either prophylactic or therapeutic lymphadenectomy of the central LNs was carried out. Studies involving imaging modalities in the detection of LNs in PTC were also analysed.

RESULTS

Twenty-one studies contained data on 4188 patients undergoing prophylactic or imaging-guided removal of the central compartment. Imaging-guided surgery retrieved cancerous central LNs in 346 or 30% of eligible patients, whilst prophylactic central neck dissection yielded histopathological proof of cancer in 898 or 26·2% of patients. Five imaging studies revealed data on the use of ultrasound (US) and/or computerized tomography (CT). The sensitivity of US and CT was poor, ranging from 50% to 70% when accurately calculated.

CONCLUSION

Metastatic central LNs are found in nearly half of all patients with PTC when prophylactic central lymph node dissection (CLND) is performed. With unreliable imaging modalities, prophylactic CLND should be performed on all patients with PTC.

Right paraesophageal lymph node dissection in papillary thyroid carcinoma

BACKGROUND

This study was designed to identify the patients with papillary thyroid carcinoma (PTC) who would benefit from RPELN dissection.

SUMMARY BACKGROUND DATA

The value of the right paraesophageal lymph nodes (RPELNs), which are located posterior to the right recurrent laryngeal nerve, may be underestimated. Although the RPELNs are common sites of nodal recurrence, few related studies have been reported.

METHODS

We retrospectively reviewed the medical records of 369 patients (286 female, 83 male) who underwent total thyroidectomy (327 patients) or right lobectomy (42 patients) with therapeutic or prophylactic central lymph node dissection for primary PTC between August 2008 and January 2010 at the Department of Surgery, Samsung Medical Center.

RESULTS

Central lymph node (CLN) metastases were present in 51.2% (189 of 369) of the patients, and RPELN metastases were present in 12.2% (45 of 369) of the patients. The rate of RPELN metastasis was 19.6% (37 of 189) in patients with CLN metastases, but only 4.4% (8 of 180) in patients with no CLN metastases (P < .001). A univariate analysis revealed that RPELN metastasis was significantly correlated with the size of the tumor, the perithyroidal extent (capsular invasion), CLN metastasis, and lateral lymph node metastases. There were no significant differences in terms of gender, mean age, or number of tumors between groups. A multivariate analysis revealed that tumor size (>1 cm) and number of CLN metastases (≥ 3) were significantly correlated with RPELN metastasis.

CONCLUSIONS

RPELN dissection should be considered in patients with right thyroid cancer, tumors larger than 1 cm, or multiple CLN metastases.

Efficacy of ultrasound-guided percutaneous ethanol injection treatment in patients with a limited number of metastatic cervical lymph nodes from papillary thyroid carcinoma

CONTEXT

Repeated neck explorations can be a difficult task in patients with recurrent metastatic cervical lymph nodes from papillary thyroid carcinoma (PTC).

OBJECTIVE

The aim of this retrospective study has been to assess the efficacy of ultrasound (US)-guided percutaneous ethanol injection (PEI) as treatment of metastatic cervical lymph nodes from PTC.

MATERIALS AND METHODS

Sixty-nine patients who previously had undergone thyroidectomy for PTC were selected for inclusion. However, three patients were later excluded due to lack of follow-up. Lymph node status was determined by US-guided fine-needle aspiration biopsy and/or by raised levels of thyroglobulin in washouts from the cytological needle. Guided by US, 0.1-1.0 ml of 99.5% ethanol was injected into the metastatic lymph nodes.

RESULTS

Three patients (eight metastatic lymph nodes in total) were reassigned to surgery due to progression (multiple new metastases), leaving 63 patients and 109 neck lymph nodes to be included. Mean observation time was 38.4 months (range, 3-72). A total of 101 of the 109 (93%) metastatic lymph nodes responded to PEI treatment, 92 (84%) completely and nine incompletely. Two did not respond, and four progressed. Two lymph nodes previously considered successfully treated showed evidence of malignancy during follow-up. No significant side effects were reported.

CONCLUSION

US-guided PEI treatment of metastatic lymph nodes seems to be an excellent alternative to surgery in patients with a limited number of neck metastases from PTC. This procedure should replace "berry picking" surgery.

Impact of prophylactic central neck lymph node dissection on early recurrence in papillary thyroid carcinoma

BACKGROUND

Although the role of prophylactic central neck lymph node dissection (CNLD) in the treatment of papillary thyroid carcinoma (PTC) is controversial, many surgeons perform routine prophylactic CNLD. The present study compares local recurrence rates in PTC patients undergoing total thyroidectomy with and without prophylactic CNLD.

MATERIALS AND METHODS

A retrospective review of 206 patients undergoing thyroidectomy for PTC was conducted at two tertiary referral centers. Of these, 81 patients had total thyroidectomy for PTC and a follow-up between 2 and 9 years with a mean of 3.1 years. Of these 81 patients, 45 underwent routine prophylactic CNLD and 36 did not. For those two groups, demographics, clinical and pathologic findings, radioactive iodine (RAI) treatment, and the incidence of recurrence were compared. Univariate statistical analysis was performed.

RESULTS

There was no significant difference in age, gender, multifocality, or extrathyroidal extension for the two groups. Patients with CNLD had an average tumor size of 1.4 cm versus 2 cm in the group without CNLD (p < 0.05). Patients who underwent CNLD had an average of 8 nodes removed, and positive nodes were found in 33%. Patients with CNLD received a higher dose of RAI, 102.7 mCi versus 66.3 mCi (p < 0.05). The incidence of positive nodes correlated with an increased RAI dose (r = 0.55). Rates of parathyroid removal and autotransplantation were higher in the CNLD group, 36 and 16% in the CNLD group versus 22 and 3% in the group without CNLD (p = 0.4 and p = 0.07). Rates of temporary hypocalcemia were higher in the CNLD group (31 versus 5%; p = 0.001), however rates of permanent hypocalcemia were similar, 1/35 in the no CNLD group versus 0/45 in the CNLD group (p = 0.4). There was a higher recurrence rate among patients without CNLD 6/36 (16.7%) versus 2/45 (4.4%), although this difference was not statistically significant (p = 0.13).

CONCLUSIONS

Routine CNLD as an adjunct to total thyroidectomy identifies positive nodes in over 30% of patients with PTC. The discovery of positive nodes is associated with higher doses of RAI for postoperative ablation, and there is a trend toward decreased recurrence in patients undergoing CNLD.

Clinical and pathological factors related to 18F-FDG-PET positivity in the diagnosis of recurrence and/or metastasis in patients with differentiated thyroid cancer

BACKGROUND

Objectives were to analyze the relationship between a positive (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) result and clinical and tumor factors in patients treated for differentiated thyroid cancer (DTC) and under suspicion of recurrence or metastasis, and to determine the diagnostic validity of PET in DTC patients with elevated serum thyroglobulin (Tg) and negative (131)I whole-body scan ((131)I-WBS).

METHODS

We studied 50 DTC patients with elevated serum Tg and negative WBS treated with total thyroidectomy and (131)I ablation. Thyroxin treatment was withdrawn and patients were on iodine-free diet before WBS. Tg, anti-Tg antibodies, and thyroid-stimulating hormone (TSH) were determined. Patients with negative WBS and elevated Tg underwent PET study 1 week later. PET findings were verified by pathology findings or other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US)] and/or 12-month follow-up. The relationship between PET findings and tumor (histological type, size, multifocality, thyroid capsular invasion, lymph-node and/or metastatic involvement) and clinical (age at diagnosis, sex, Tg, accumulated iodine dose, and recurrence time) variables was analyzed.

RESULTS

PET was positive in 32/39 patients with confirmed disease (82% sensitivity) and negative in 7/11 of disease-free cases (64% specificity), a positive predictive value (PPV) of 89%. Tumor size (P < 0.05) and thyroid capsular invasion (P < 0.05) were significantly associated with positive PET study. The relationship of PET findings with Tg levels and age at diagnosis was close to significance.

CONCLUSION

(18)F-FDG-PET study offers a high sensitivity and positive predictive value (PPV) in patients with negative WBS and Tg positive. The use of FDG-PET is strongly recommended in DTC patients with large tumors, thyroid capsule invasion or poor-prognosis variants.

The therapeutic management of differentiated thyroid cancer

BACKGROUND

The management of thyroid cancer is difficult because the tumors comprise a wide range of biologic behaviors, from small papillary thyroid microcarcinomas that pose little or no threat to survival for the patient, to anaplastic thyroid cancers that are arguably the most lethal tumor. Although it may be difficult initially to determine at which end of the prognostic spectrum a patient resides, one can ordinarily estimate a patient's risk for tumor recurrence and mortality based on a triad of features as simple as the patient's age at the time of diagnosis, the tumor stage at presentation, and its initial response to therapy. While staging systems are available to assist in the management process, all are inexact and leave wide gaps in the treatment plan for a given patient. This is largely because randomized controlled trials are lacking as a result of the low incidence and generally favorable prognosis of the disease. As a practical matter, it may sometimes be difficult to reassure a patient, given the generally favorable prognosis of this group of tumors, knowing that without adequate therapy some become unexpectedly aggressive and recur years after initial management. The treatment of these tumors rests on a fine balance of providing care that reflects the anticipated course of the disease without overtreating the patient or providing reassurance that is unfounded.

OBJECTIVE

To outline the treatment strategy for patients with differentiated thyroid cancer based on the available literature and to guide clinicians through a management algorithm utilizing patient and tumor characteristics.

METHODS

This review is limited to the treatment of patients with differentiated thyroid cancer - papillary and follicular thyroid cancer - and the standard therapy required for the majority of patients.

RESULTS/CONCLUSION

The treatment of differentiated thyroid cancer requires a multidisciplinary approach, involving an experienced surgeon, radiologists and an endocrinologist. There are many unanswered questions in the management algorithm and ongoing research is needed to further define the best treatment strategy for patients with differentiated thyroid cancer.

Management of patients with low-risk papillary thyroid carcinoma

OBJECTIVE

To define a rational, cost-effective, simple approach to managing most patients with papillary thyroid cancer (PTC) who are at low-risk of either cause-specific mortality or tumor recurrence.

METHODS

Taking advantage of the collective experience of a cohort of 2512 patients with PTC who had initial definitive treatment at the Mayo Clinic in Rochester, Minnesota, between 1940 and 2000, a 5-step approach to the management of low-risk PTC has been devised. This program is based on appropriate preoperative ultrasound localization of neck disease and potentially curative surgery consisting of near-total or total thyroidectomy, with appropriate neck nodal exploration and resection.

RESULTS

The emphasis of the present program is on the extent of initial surgery, where optimal care is ascribed to a near-total thyroidectomy with curative intent and appropriate neck nodal resection as predicated by appropriate preoperative ultrasonography evaluation of regional lymph nodes. Radioiodine remnant ablation (RRA) is not applicable to patients with PTC who are defined on the day of definitive initial surgery to be at low risk as defined by a metastasis, age, completeness of resection, invasion, and size (MACIS) score of less than 6.

CONCLUSION

The outlook for patients with low-risk PTC is very optimistic, with rates at 30 postoperative years of only 1% for cause-specific mortality and less than 15% for tumor recurrence at any site. The long-term results obtained by potentially curative bilateral resection, appropriate regional lymph nodal excision, and selective use of RRA are excellent. Realistically improving these acceptably low rates for cause-specific mortality and tumor recurrence may be difficult.

Thyroid cancer invasion of neck structures: epidemiology, evaluation, staging and management

PURPOSE OF REVIEW

This review addresses the issue of direct extra-capsular invasion of thyroid cancer; this may occur in several ways and to varying degrees. The evidence regarding the prognostic and treatment implications of extra-thyroidal spread is examined. The phenomenon is most common in papillary carcinoma of the thyroid and that is the focus for this review. Less common, but more aggressive tumours (medullary and anaplastic carcinoma) are not considered here.

RECENT FINDINGS

Overall, around 15% of thyroid cancers exhibit extra-thyroid spread but the rate is much higher in specific subgroups. The presence of invasive disease affects the staging of the tumour, and the implications for surgery can be substantial if complete tumour extirpation is to be achieved. No particular examination is completely accurate in detecting extra-thyroid spread preoperatively. Invasion posteriorly carries greater morbidity and mortality than anterior spread. The presence of extra-thyroid spread usually warrants adjuvant radiotherapy (radioiodine or external beam).

SUMMARY

Histologic assessment is the gold standard for detecting invasive thyroid cancer. Thyroidectomy is effectively a staging procedure by which the presence and extent of invasive disease can be established and subsequent management determined. Extra-thyroidal spread influences morbidity and mortality.

Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique

Total thyroidectomy is the treatment of choice for clinically significant papillary thyroid cancer (PTC); however, 10-15% develop palpable local recurrence in the cervical lymph nodes. Metastases in the cervical lymph nodes account for 75% of loco-regional recurrence and up to 50% of these patients eventually die of their disease. It is generally accepted that surgical excision of grossly involved lymph node disease should be carried out. The role of routine lymph node dissection, however, is greeted with far more controversy. Regional lymph node metastases have been shown to be associated with more frequent tumour recurrence. Not only is recurrence associated with increased disease-related mortality, but recent data have shown that the presence of involved lymph nodes is associated with adverse survival. Additionally, there have been significant changes to the way patients are managed after treatment for PTC in recent years. Surveillance previously relied on clinical assessment and radioiodine scans whereas now the use of serum thyroglobulin and high-resolution ultrasound are the standard as evidenced by recommendations by the American Thyroid Association. These techniques have greater sensitivity and subsequently lymph node metastases are being detected earlier and more frequently. This has led to a paradigm shift in the aims of treatment of PTC, from a focus on survival data to a focus on disease-free status. Routine central neck lymph node dissection can be carried out with no increased morbidity and can achieve lower 6-month stimulated thyroglobulin levels when compared with total thyroidectomy alone. Routine ipsilateral level VI lymph node dissection in addition to total thyroidectomy should be carried out for the management of clinically significant PTC.

Microscopic regional lymph node status in papillary thyroid carcinoma with and without lymphadenopathy and its relation to outcomes

AIM

The aim of this study was to evaluate microscopic nodal status in papillary thyroid carcinoma (PTC) with and without lymphadenopathy and its relation to outcomes.

MATERIALS AND METHODS

We retrospectively analyzed 134 patients with PTC who underwent initial thyroidectomy. Forty-two patients with lymphadenopathy underwent therapeutic modified neck dissection (MND) and 92 without lymphadenopathy underwent prophylactic MND. The frequencies, numbers, and percentages of lymph node metastasis (LNM) were determined to evaluate nodal status; then, whether each nodal status influence to outcomes was analyzed. Disease-free survival (DFS) and disease-specific survival (DSS) were assessed (Kaplan-Meier method and log-rank test).

RESULTS

Lymphadenopathy was significantly related to local recurrence and DFS, but not DSS. The frequency (100 vs 67.4%), number (15.8 vs 2.7), and percentage (49.7 vs 17.8%) were significantly higher in patients with lymphadenopathy than in those without lymphadenopathy (p < 0.0001). Similarly, these were significantly higher in patients who developed recurrence than in those who did not. Recurrence was frequent in older patients with lymphadenopathy. The frequency, number, and percentage were also higher in older patients who developed local recurrence.

CONCLUSIONS

Lymphadenopathy and microscopic nodal status are significantly related to recurrence. Only a few nodes seem to be involved pathologically when no lymphadenopathy.

Advanced thyroid carcinoma: An experience of 385 cases

AIMS

To report clinical outcomes of a large series of cases with advanced thyroid cancer.

STUDY DESIGN

Three hundred and eighty-five patients at the UICC stages III and IV were selected for the study with thyroid cancer.

RESULTS

Papillary carcinoma and sclerosing carcinoma have better survival than the Hürthle cell and insular types. Lymphatic metastasis does not appear to worsen the prognosis. All the tumour forms offer the chance of long survival.

CONCLUSIONS

Surgical treatment is the primary treatment of thyroid carcinoma. The combined treatments of surgery, metabolic beam therapy, suppressive hormone therapy, radiotherapy and chemotherapy cure a high percentage of patients with the tumour at an advanced stage.

Clinicopathological Characteristics and Long-term Outcome in Patients with Distant Metastases from Differentiated Thyroid Cancer

BACKGROUND

Distant metastases are seen in a minority of patients with differentiated thyroid carcinoma (DTC) but account for most of its disease-specific mortality. Studies on the long-term outcome of patients with distant metastases are controversial.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 660 patients with differentiated thyroid carcinoma followed at our institution from 1994 to 2004. Forty-four patients (6.7%) had distant metastases, with a prevalence of 4.8% for papillary thyroid cancer, 21% for follicular thyroid cancer, and 10% for Hurthle cell cancer. Primary near-total thyroidectomy followed by I(131) radiation was performed in 97% of patients with metastases (86% operated on in 1980-2003). Mean age at thyroidectomy was 49+/-19 years, and the female-to-male ratio was 1.9:1.

RESULTS

The distant metastasis occurred synchronously with the primary tumor in 45.5% and after a median follow-up of 9 years in the others. Affected sites were lungs (n=24), bones (n=11), lungs and bones (n=9), brain (n=3), and uterus (n=1). Median duration of follow-up was 12 years (range: 1-42 years) from thyroidectomy and 5.5 years (range: 1-24 years) from diagnosis of distant metastases. The 5- and 10-year survival rates (all causes) after diagnosis of distant metastases were 88% and 77%, respectively. No significant differences in survival curves were found by age, sex, metastasis site, histopathology, or interval to distant metastasis.

CONCLUSIONS

We conclude that complete resection of the thyroid gland at diagnosis and high-dose adjuvant radioactive iodine are associated with improved survival in patients with metastatic DTC.

Detection and surgical treatment of cervical lymph nodes in differentiated thyroid cancer

There is considerable controversy regarding the treatment of patients with cervical metastases from differentiated thyroid cancer. Most have papillary carcinoma and the main areas of contention relate to methods of assessment and staging, surgical management and mode of follow up. there is little evidence to support elective anatomical imaging with CT or MRI in those patients with suspected or proven malignancy at the primary site as indicated by fine needle aspiration cytology (FNAC) but who have no clinical evidence of nodal disease. The role of routine ultrasound (US) in the pre-operative assessment of suspected or known malignancy is developing but is largely unproven. When it is performed, high risk areas for metastatic neck disease (levels II-V) should be assessed. Suspicious nodes on US should be further evaluated by FNAC. Suspected or proven neck disease may be further assessed pre-operatively with CT or MRI and then treated surgically. Disease in the central compartment requires a total thyroidectomy and level VI central compartment neck dissection. Suspected or proven lateral compartment cancer should be treated by selective neck dissection (at least levels III, IV, and V) below the accessory nerve. There is no role for 'Berry picking' and clinically node negative high risk patients should have an elective central compartment level VI neck dissection. Sentinel node biopsy lays no role and neither does elective lateral compartment surgery in patients with no clinical or radiological evidence of disease. For follow up, US represents the most sensitive means of detecting neck recurrences and in the presence of an elevated serum thyroglobulin, imaging may also include whole body iodine-131 scanning and anatomical imaging with CT or MRI. The role of PET remains controversial but is likely to develop further as the technique becomes more widely available. In the future, the concentration of patients with this disease in large center can only improve the way we treat differentiated thyroid cancer.

Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis

CONTEXT

Reliable prognostic factors are needed in papillary thyroid cancer patients to adapt initial therapy and follow-up schemes to the risks of persistent and recurrent disease. OBJECTIVE AND SETTINGS: To evaluate the respective prognostic impact of the extent of lymph node (LN) involvement and tumor extension beyond the thyroid capsule, we studied a group of 148 consecutive papillary thyroid cancer patients with LN metastases and/or extrathyroidal tumor extension. Initial treatment, performed at the Institut Gustave Roussy between 1987 and 1997, included in all patients a total thyroidectomy with central and ipsilateral en bloc neck dissection followed by radioactive iodine ablation.

RESULTS

Uptake outside the thyroid bed, demonstrating persistent disease, was found on the postablation total body scan (TBS) in 22% of the patients. With a mean follow-up of 8 yr, eight patients (7%) with a normal postablation TBS experienced a recurrence. Ten-year disease-specific survival rate was 99% (confidence interval, 97-100%). Significant risk factors for persistent disease included the numbers of LN metastases (>10) and LN metastases with extracapsular extension (ECE-LN >3), tumor size (>4 cm), and LN metastases location (central). Significant risk factors for recurrent disease included the numbers of LN metastases (>10), ECE-LN (>3), and thyroglobulin level measured 6-12 months after initial treatment after T4 withdrawal.

CONCLUSION

We highlight an excellent survival rate and suggest risk classifications of persistent and recurrent disease based on the numbers of LN metastases and ECE-LN, LN metastases location, tumor size, and thyroglobulin level.

Contemporary management of thyroid cancer

Thyroid cancer is a relatively common and frequently curable malignant neoplasm, accounting for nearly 2% of all new cancers diagnosed annually in the United States. The diagnostic and management options have evolved considerably in the past decade, and a current understanding of these trends in the standard of care have assumed an important consideration in the practices of head and neck surgeons and endocrinologists alike. We sought to review the epidemiology and pathology of the several types of thyroid cancer and to present our evidence-based management algorithm. Every effort was made to offer alternative treatment strategies and supporting data where available. In addition to reviewing well-established approaches to diagnosis and management, emphasis is placed on newer techniques, including minimally invasive thyroidectomy, molecular detection of disease propensity, and the use of recombinant thyrotropin prior to radioiodine ablation.

Prognostic factors determining long-term survival in well-differentiated thyroid cancer: an analysis of four hundred eighty-four patients undergoing therapy and aftercare at the same institution

OBJECTIVES

Identification of the prognostic factors relevant for long-term survival in differentiated thyroid cancer in a homogenously treated patient cohort in order to allow a better initial risk stratification.

METHODS

Four hundred eighty-four (358 females/126 males) patients with differentiated thyroid cancer (330 papillary [68.2%]; 154 follicular [31.8%]) were included. Inclusion criteria consisted of treatment with a uniform therapy scheme and continuous aftercare in the same institution. Initial diagnosis was between 1975-1995 (age at diagnosis, 14-84 years, median, 49.7). Tumor stage: pT1, n = 92; pT2, 211; pT3, 58; pT4, 123. Low-risk: <or=pT3 NX M0, 331; high-risk pT4 and/or M1, 153. After thyroidectomy all patients had at least two (131)I therapies (4-month interval; first, 2-4 GBq; second, 3.7-8 GBq). The median follow-up was 7.6 years (range, 0.2-23.9). The role of eight variables as prognostic factors was tested by regression analysis.

RESULTS

The corrected cause-specific 5-, 10-, and 20-year survival rates in the whole cohort were 0.95, 0.90, 0.83, respectively; for the low risk-category of papillary cancer, 0.99, 0.97, 0.89; for follicular cancer, 0.98, 0.89, 0.89 (difference papillary/follicular p = 0.0004). The cause-specific survival rates in the high-risk category of papillary cancer were 0.89, 0.85, and 0.85; for follicular cancer, 0.88, 0.73 and 0.52 (p = 0.0016). Variables with significant negative influence on survival were distant metastases, persisting elevated human thyroglobulin levels after one (131)I therapy, age greater than 45 and gender in follicular cancer. Locoregional external radiotherapy did not improve survival but was associated with comorbidity. The aggressiveness of the initial operative resection was also not a prognostic factor for survival. pT4 NX M0 patients of our patient cohort did not exert significant differences in long-term survival compared to pT13 NX M0. This was also true for patients older than 45 years, where the 5- and 10-year survival rates for pT4 NX M0 were 0.93 and 0.90.

CONCLUSION

Our therapy and aftercare strategy results in a high long-term survival rate especially for high-risk patients. In our patient sample radical initial lymph node resection did not extend long-term survival.

Ultrasound-guided biopsy and ablation in the neck

Management and therapy of conditions of the thyroid, parathyroid glands, and cervical lymph nodes have evolved rapidly during the past 15 years. The development and continued improvement of high-resolution ultrasound (US) equipment, US-guided biopsy, and image-guided ablative techniques have fueled this change. These technical improvements and the knowledge and experience gained during this time have decreased the rate of unnecessary surgery in patients with thyroid nodules. They have also allowed more limited neck dissection in patients with parathyroid adenomas and have led to the development of US-guided ablative techniques that have eliminated the need for surgery in some cases. This article reviews the rationale and techniques of US-guided biopsy of the thyroid, parathyroid, and cervical lymph nodes. Established and evolving ablative techniques of these structures are also examined.

Percutaneous ethanol injection for treatment of cervical lymph node metastases in patients with papillary thyroid carcinoma

OBJECTIVE

The objective of this study was to evaluate the technique, efficacy, and side effects of percutaneous ethanol injection in patients with limited cervical nodal metastases from papillary thyroid carcinoma.

SUBJECTS AND METHODS

Fourteen patients who had undergone thyroidectomy for papillary thyroid carcinoma presented with limited nodal metastases (one to five involved nodes) in the neck between May 1993 and April 2000. All patients had received previous iodine-131 ablative therapy with a mean total dose per patient of 7,548 MBq. Ten of the patients either were considered poor surgical candidates or preferred not to have surgery, and all were unresponsive to iodine-131 therapy. Each metastatic lymph node was treated with percutaneous ethanol injection, and patients received both clinical and sonographic follow-up.

RESULTS

Twenty-nine metastatic lymph nodes in our 14 patients were injected. Mean sonographic follow-up was 18 months (range, from 2 months to 6 years 5 months). All treated lymph nodes decreased in volume from a mean of 492 mm(3) before percutaneous ethanol injection to a mean volume of 76 mm(3) at 1 year and 20 mm(3) at 2 years after treatment. Six nodes were re-treated 2-12 months after initial percutaneous ethanol injection because of persistent flow on color Doppler sonography (n = 4), stable size (n = 1), or increased size (n = 1). Two patients developed four new metastatic nodes during the follow-up period that were amenable to percutaneous ethanol injection. Two patients developed innumerable metastatic nodes that precluded retreatment with percutaneous ethanol injection. No major complications occurred. All patients experienced long-term local control of metastatic lymph nodes treated by percutaneous ethanol injection. In 12 of 14 patients, percutaneous ethanol injection was successful in controlling all known metastatic adenopathy.

CONCLUSION

Sonographically guided percutaneous ethanol injection is a valuable treatment option for patients with limited cervical nodal metastases from papillary thyroid cancer who are not amenable to further surgical or radioiodine therapy.