Long-term prognosis of differentiated thyroid cancer with lung metastasis in Korea and its prognostic factors

Cytosolic Cadherin 4 promotes angiogenesis and metastasis in papillary thyroid cancer by suppressing the ubiquitination/degradation of β-catenin

BACKGROUND

Although the long-term prognosis of papillary thyroid cancer (PTC) is favorable, distant metastasis significantly compromises the prognosis and quality of life for patients with PTC. The Cadherin family plays a pivotal role in tumor metastasis; however, the involvement of Cadherin 4 (CDH4) in the metastatic cascade remains elusive.

METHODS

The expression and subcellular localization of CDH4 were determined through immunohistochemistry, immunofluorescence, and western blot analyses. The impact of CDH4 on cell migration, invasion, angiogenesis, and metastasis was assessed using transwell assays, tube formation assays, and animal experiments. Immunoprecipitation assay and mass spectrometry were employed to examine protein associations. The influence of CDH4 on the subcellular expression of β-catenin and active β-catenin was investigated via western blotting and immunofluorescence. Protein stability and ubiquitination assay were employed to verify the impact of CDH4 on β-catenin degradation. Rescue experiments were performed to ensure the significance of CDH4 in regulating nuclear β-catenin signaling.

RESULTS

CDH4 was found to be significantly overexpressed in PTC tissues and predominantly localized in the cytoplasm. Furthermore, the overexpression of CDH4 in tumor tissues is associated with lymph node metastasis in PTC patients. Cytosolic CDH4 promoted the migration, invasion, and lung metastasis of PTC cells and stimulated the angiogenesis and tumorigenesis of PTC; however, this effect could be reversed by Tegavivint, an antagonist of β-catenin. Mechanistically, cytosolic CDH4 disrupted the interaction between β-catenin and β-TrCP1, consequently impeding the ubiquitination process of β-catenin and activating the nuclear β-catenin signaling.

CONCLUSIONS

CDH4 induces PTC angiogenesis and metastasis via the inhibition of β-TrCP1-dependent ubiquitination of β-Catenin.

FAPI PET/CT provides higher uptake and better target to back ground in recurrent and metastatic tumors of patients with Iodine refractory papillary thyroid cancer compared with FDG PET CT

PURPOSE

The role of fibroblast activation protein inhibitor (FAPI) PET CT scan is not well documented in papillary thyroid cancer (PTC) patients. Patients with radioiodine refractory PTC and high thyroglobulin levels need PET/CT scan which is generally done by 18F FDG. In the current study, the diagnostic performance of 68Ga FAPI and FDG PET/CT scans were compared head to head in patients with radioiodine refractory PTC.

METHOD

Fourteen patients with negative whole body Iodine scans and high thyroglobulin levels underwent whole body PET scans with, respectively, 120-310 and 145-370 MBq 68Ga FAPI-46 and 18F FDG. SUVmax of the back ground in the blood pool and liver and the hottest, largest and average neck, mediastinum, lung and bone lesions were calculated and compared.

RESULT

Ten patients had at least one active (SUVmax>blood pool) lesion similarly in two scans. The liver and blood pool SUVmax values were 1.25(0.2) and 1.7(0.2) in FAPI and 2.65(0.2) and 2.0(0.2) in FDG PET images, respectively. The difference was significant (p=0.001). Standard SUV of the hottest lesion to liver was above 3 in all FAPI scans but in half of FDG scans. Target lesion number and intensity were similar between two PET studies but in a patient out of 5 pulmonary metastatic patients, pulmonary nodules were negative (SUVmax=0.9) in FDG while positive (SUVmax= 3.8) in FAPI images (i.e. 20% patient upstaged).

CONCLUSION

FAPI accumulates in the recurrent and metastatic lesions of patients with Iodine refractory PTC at least as well as FDG with particular privileges as lower injected activity and lower back ground.

The efficacy and safety in radioactive iodine refractory thyroid cancer patients treated with sorafenib

Background

Sorafenib included in Chinese medical insurance is the earliest targeted drug for radioactive iodine refractory differentiated thyroid cancer (RR-DTC). This study is to further demonstrate the clinical efficacy and safety of sorafenib used in Zhujiang Hospital of Southern Medical University.

Methods

RR-DTC patients treated at our Department of Nuclear Medicine in Zhujiang Hospital of Southern Medical University (October 2017-May 2020) were retrospectively analyzed. Treatment effects, progression-free survival (PFS), and adverse effects (AEs) during medication were evaluated.

Results

Of the 31 patients included, 26 patients were evaluated for efficacy with a median follow-up time of 17.5 months (4.0-51.0 months). The disease control rate (DCR) was 57.7% (n = 15) and the objective response rate (ORR) was 26.9% (n = 7). Most patients with disease control had thyroglobulin decreases of more than 60% (p = 0.004), ORRs were favorable in patients with lung metastasis and lung-only metastasis (p = 0.010 and 0.001, respectively). The PFS of the 26 patients analyzed was 16.5 months (95%CI: 14.41 -23.90 months). In the subgroup analysis, female, patients with lung-only metastasis, hand-foot skin syndrome (HFS), and thyroglobulin response ≥ 60% observed longer PFS (p = 0.038, 0.045, 0.035, and 0.000, respectively), while patients with bone metastasis had lower PFS (p = 0.035). The most common toxicity profile was HFS (93.5%), followed by diarrhea (83.9%), alopecia (74.2%). All the side effects were mainly grade 1-2. Grade 3-4 adverse reactions were more common in diarrhea and HFS.

Conclusions

Sorafenib has promising efficacy in RR-DTC, especially in patients with lung metastasis and lung-only metastasis. The AEs of sorafenib were generally mild, and the main AE was HFS.

Assessment of Pulmonary Metastasis in Differentiated Thyroid Carcinoma: Value of HRCT Correlation with Functional Imaging

Pulmonary metastases in thyroid carcinoma demonstrates varying imaging characteristics and disease biology and the outcome. The valuable complimentary role of high-resolution CT (HRCT) in conjunction with functional imaging such as radioiodine scan has been discussed and illustrated in this review along with the varied clinical and imaging presentations of lung metastases from differentiated thyroid cancer (DTC). A multi-modality patient-specific diagnostic approach and awareness about the atypical presentations helps in early identification as well as effective management of these patients, and especially in certain situations that could need multi-disciplinary management. While HRCT of the lungs as an added tool provides detailed visualization of the lung parenchyma, in the era of hybrid imaging, the routine adoption of SPECT-CT in patients with pulmonary metastases (in diagnostic or post-treatment settings) could provide equivalent or even incremental information from further management viewpoint.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

Long-term outcomes and prognostic factors of patients with lung metastases from differentiated thyroid cancer after radioiodine therapy in Japan

Long-term survival in patients with differentiated thyroid cancer (DTC) and lung metastasis remains unexplored in Japan. This study aimed to investigate the long-term survival and prognostic factors of radioiodine therapy (RIT) in a University Hospital setting. This retrospective study included 62 patients with lung metastases from DTC who received RIT between March 2005 and December 2016. According to the ¹³¹I whole-body scan and chest computed tomography results, lung metastases were classified as ¹³¹I-avid or non-¹³¹I-avid, and miliary, micronodular, or macronodular metastases. The 5- and 10-year overall survival (OS) rates from the initial RIT were calculated by the Kaplan-Meier method, and a proportional hazard fit analysis was performed to determine prognostic factors. With a median follow-up of 7.9 years, the 5- and 10-year OS rates from the initial RIT were 93% and 72%, respectively. Univariable and multivariable analyses of patient subgroups revealed that macronodular lung metastases (defined as nodules >1 cm), older age at initial RIT, and high thyroglobulin values (>400 ng/mL) at initial RIT predicted low OS. The 5- and 10-year OS rates of DTC patients with lung metastases were similar to those in previous Japanese reports, which included a smaller sample size compared with ours. Patients with ≤1 cm lung metastases, aged ≤55 years, and a thyroglobulin level of ≤400 ng/mL at the initial RIT had favorable outcomes.

Radioiodine Therapy in Pediatric Differentiated Thyroid Cancer: Dosimetry, Clinical Care, and Future Challenges

ABSTRACT

Thyroid cancer is very rare in children. 131 I therapy after thyroidectomy is established in pediatric differentiated thyroid cancer (DTC). Pediatric DTC guideline is silent on the optimum amount of 131 I that could be safely and effectively administered to children who are more radiosensitive. Like adult DTC, children are also given 131 I therapy empirically based either on age or body weight. Pediatric DTC guideline recommends that patient-specific dosimetry is important in children. Still, due to the low incidence rate and the practical difficulties of dosimetry, it has neither been established nor adopted in routine practice. This review article aims to discuss current approaches of 131 I therapy in children and young adult patients with DTC and dosimetric data obtained by several investigators. Efforts are required to simplify dosimetric procedures and precise results, especially in determining lesion size. We prefer 3-dimensional dosimetry over planar dosimetry, where lesion size could be measured accurately. 124 I PET/CT-based dosimetry is expected to give accurate dosimetric results. The most challenging aspect is that no randomized controlled trials are available to compare the empiric 131 I therapy results versus dosimetry-based treatment outcomes in children and young adults. Suppose dosimetry-based 131 I therapy could be shown to have better outcomes, namely, successful ablation rate, better disease-free survival, and lesser treatment-emergent adverse events than empirical 131 I treatment. In that case, one can argue in favor of the former. Unfortunately, no convincing study is currently available. Thus, there is a need for a randomized control trial to settle this issue.

Survival prognostic factors for differentiated thyroid cancer patients with pulmonary metastases: A systematic review and meta-analysis

Background

The prognostic factors for differentiated thyroid cancer (DTC) patients with pulmonary metastases (PM) remain scantly identified and analyzed. Therefore, this systematic review and meta-analysis were performed to identify and summarize the prognostic factors in adult DTC patients with PM to help distinguish patients with different prognoses and inform the rational treatment regimens.

Method

We performed a comprehensive search of the relevant studies published in the Cochrane Library, PubMed, Scopus, Embase, Wanfang database, VIP database, China National Knowledge Infrastructure, and Google Scholar from their inception until February 2021. The pooled hazard ratios (HR) for overall survival and/or progression-free survival (PFS) with 95% confidence intervals were applied to evaluate and identify the potential prognostic factors. Pooled OS at different time points were also calculated for the available data. A random-effects model was used in the meta-analysis.

Results

The review and meta-analysis included 21 studies comprising 2722 DTC patients with PM. The prognostic factors for poor OS were: age over 40 years (HR=7.21, 95% confidence interval [CI] 1.52-34.10, P=0.01, N=788), age over 45 years (HR=2.18, 95% CI 1.26-3.77, P<0.01, N=601), male gender (HR=1.01, 95% CI 1.01-1.19, P=0.03, N=1396), follicular subtype of thyroid cancer (HR=1.63, 95% CI 1.36-1.96, P<0.01, N=2110), iodine non-avidity (HR=3.10, 95% CI 1.79-5.37, P<0.01, N=646), and metastases to other organs (HR=3.18, 95% CI 2.43-4.16, P<0.01, N=1713). Factors associated with poor PFS included age over 45 years (HR=3.85, 95% CI 1.29-11.47, P<0.01, N=306), male gender (HR=1.36, 95% CI 1.06-1.75, P=0.02, N=546), iodine non-avidity (HR=2.93, 95% CI 2.18-3.95, P<0.01, N=395), pulmonary metastatic nodule size over 10mm (HR=2.56, 95% CI 2.02-3.24, P<0.01, N=513), and extra-thyroidal invasion (HR=2.05, 95% CI 1.15-3.67, P=0.02, N=271). The pooled 1, 3, 5, 10, 15, and 20-years OS were 95.24%, 88.46%, 78.36%, 64.86%, 56.57%, and 51.03%, respectively.

Conclusions

This review and meta-analysis identified the prognostic factors of DTC patients with PM. Notably, FTC, metastases to other organs, and iodine non-avidity were particularly associated with poor prognosis. The identified prognostic factors will help guide the clinical management of DTC patients with PM.

Systematic review registration

https://inplasy.com/inplasy-2022-2-0026/, identifier (INPLASY202220026).

Clinical outcomes of a cohort of 271 patients with lung metastases from differentiated thyroid carcinoma

CONTEXT

Lung is the most common site of distant metastases from differentiated thyroid carcinoma (DTC).

OBJECTIVE

To investigate the outcomes of a cohort of patients with DTC and lung metastases (LM).

METHODS

A retrospective analysis of a cohort of 271 patients with LM was performed.

RESULTS

The female-to-male ratio was 1:1 and the median follow-up time was 5.9 (1.1-38.4) years. Papillary thyroid carcinoma (PTC) was the most frequent type (83.4%), mainly the classic variant, followed by follicular thyroid carcinoma (FTC, 10.3%) and Hürthle cell carcinoma (HTC, 6.3%). The prevalence of PTC, FTC and HCC was different between the micronodular and macronodular LM groups [87.4%, 6.3% and 6.3% vs. 74.6%, 19.0% and 6.3%, respectively (p = .013)]. Only 5.0% of the patients had LM diagnosed after a period of remission. LM were submitted to radioactive iodine treatment (RAIT) in 84.5% (52.8% showed ¹³¹ iodine avid metastases). Complete remission was only achieved in 12.2%. Micronodular disease and age <55 years at LM diagnosis were associated with a better prognosis (p < .05). We found no difference in survival between patients with LM treated or not with RAIT. However, in patients submitted to RAIT, there was a tendency for longer survival in the group of patients with ¹³¹ I avid lesions.

CONCLUSION

The classic variant of PTC was the most frequent histology found in LM of DTC. LM are rarely diagnosed in the follow-up when complete remission is achieved after surgery and ¹³¹ I. Younger age at LM diagnosis and a micronodular pattern are associated with a better prognosis.

Prognosis of Anaplastic Thyroid Cancer with Distant Metastasis

Anaplastic thyroid cancer (ATC) is derived from follicular thyroid cells and is associated with high mortality risk. Obtaining information to characterize ATC is difficult because ATC with distant metastasis is extremely rare. This study determined the clinical characteristics of ATC with distant metastasis. The medical records of 152 patients with ATC at Gangnam Severance Hospital were reviewed between January 2004 and March 2022. The primary endpoint was the overall survival of the total patient sample, patients with ATC and distant metastasis, and those with ATC and brain metastasis. Of the 152 patients with ATC, 88 had distant metastasis at diagnosis. The 5-year disease-specific survival was 24% for total ATC and 10% for ATC with distant metastasis. Survival for >1 year was 32% for total ATC and 15% for ATC with distant metastasis. The median survival rate differed significantly between the total ATC and ATC with distant metastasis groups (228.5 vs. 171 days). Among the ATC cases, 11% had brain metastasis; thus, brain MRI or CT is worth considering at diagnosis and follow-up, even if there were no statistical difference in overall survival between patients with ATC with and without brain metastasis.

Efficacy of Combination Therapy with Lenvatinib and Radioactive Iodine in Thyroid Cancer Preclinical Model

Patients with differentiated thyroid cancer (DTC) usually have good prognosis, while those with advanced disease have poor clinical outcomes. This study aimed to investigate the antitumor effects of combination therapy with lenvatinib and ¹³¹I (CTLI) using three different types of DTC cell lines with different profiling of sodium iodide symporter (NIS) status. The radioiodine accumulation study revealed a significantly increased radioiodine uptake in K1-NIS cells after lenvatinib treatment, while there was almost no uptake in K1 and FTC-133 cells. However, lenvatinib administration before radioiodine treatment decreased radioiodine uptake of K1-NIS xenograft tumor in the in vivo imaging study. CTLI synergistically inhibited colony formation and DTC cell migration, especially in K1-NIS cells. Finally, ¹³¹I treatment followed by lenvatinib administration significantly inhibited tumor growth of the NIS-expressing thyroid cancer xenograft model. These results provide important clinical implications for the combined therapy that lenvatinib should be administered after ¹³¹I treatment to maximize the treatment efficacy. Our synergistic treatment effects by CTLI suggested its effectiveness for RAI-avid thyroid cancer, which retains NIS function. This potential combination therapy suggests a powerful and tolerable new therapeutic strategy for advanced thyroid cancer.

Impact of Lung Metastasis versus Metastasis of Bone, Brain, or Liver on Overall Survival and Thyroid Cancer-Specific Survival of Thyroid Cancer Patients: A Population-Based Study

We investigate the impact of lung metastasis versus metastasis of bone, brain, or liver on overall survival (OS) and thyroid cancer-specific survival (TCSS) in patients with thyroid cancer (TC). Therefore, de-identified SEER 18 registry data of primary TC patients diagnosed between 2010 and 2016 were analyzed. The primary outcome was the prognosis of TC patients with lung metastasis compared with other sites. The secondary outcomes included the prognosis comparison between patients with and without surgery and between single and multiple metastasis sites. Isolated lung metastasis was associated with worse OS and TCSS than bone metastasis (both p < 0.05) and was associated with worse OS than liver metastasis (p = 0.0467). Surgery performed either for the primary or distant site was associated with better OS and TCSS in patients with metastasis of lung or bone (p < 0.05). Isolated lung metastasis was related to better OS and TCSS than lung−liver, lung−brain, and lung−other multiple metastases. The multivariable analysis revealed that age < 55 years, surgery to the primary site, and to the distant site(s) were associated with better outcomes, while T4 and Tx were associated with worse outcomes. Nevertheless, it revealed that the other race (i.e., any race other than white, black, or unknown) and male gender were associated with better TCSS only (p < 0.05). Isolated lung metastasis is associated with a worse prognosis in TC patients compared with bone or liver metastasis. Surgery performed either for the primary or distant site(s) is associated with better survival outcomes in TC patients with metastasis of lung or bone.

Treatment Response following Radioactive Iodine Therapy in Miliary versus Macronodular Pulmonary Metastases in Papillary Thyroid Carcinoma

Background  Pulmonary metastases in papillary thyroid carcinoma have two common presentations—micro/miliary (MM) and macronodular metastases (MN). The mainstay of treatment, posttotal thyroidectomy, is multiple radioactive iodine ablations (RAIA) every 6 to 12 months. Response assessment is determined by decline in stimulated serum thyroglobulin levels (sTg), disease regression on chest x-ray (CXR), computed tomography thorax, or whole body iodine scintigraphy (TWBS).

Aim  This study aims to assess the difference in response to RAIA based on the pattern of presentation.

Methodology  Retrospective analysis of patients from January 2008 to July 2017 was done. Patients with pulmonary metastases treated with RAIA (3700MBq per therapy as opposed to theAmerican Thyroid Association recommendation of 7400MBq per therapy) and a minimum follow-up of 8 months were included. The initial and the final sTg, TWBS, and CXR were analyzed for both groups. Final outcome in terms of complete response, disease regression, static disease, and disease progression was determined.

Results  Of the total of 1,793 patients, 71 were included. There were 43 females and 28 males. The median age was 39 years and the range was 14 to 79 years. Forty-five (63.3%) patients had MM and 26 (36.6%) patients had MN disease. The average number of therapies was three and maximum follow-up period was 15 years. Of the 45 MM patients, 1 had progression, 7 were static, 23 had regression, and 14 had complete response. Of the 26 MN patients, 22 had progression, 2 were static, 1 had regression, and 1 had complete response.

Conclusion  MM metastases, when compared with MN disease, respond to RAIA with a better outcome. In addition to achieving comparable response with a lower dose per therapy, there were no radiation-related long-term complications reported.

Delay of initial radioactive iodine therapy beyond 3 months has no effect on clinical responses and overall survival in patients with thyroid carcinoma: A cohort study and a meta-analysis

Background

More than a third of thyroid carcinoma (TC) patients require treatment with radioactive iodine (RAI), but the timing of initial RAI therapy after thyroidectomy remains controversial.

Methods

We included 1224 differentiated thyroid carcinoma (DTC) patients during 2015–2019, divided them into the early (≤3 months) and the delayed (>3 months) groups based on the interval between surgery and the initial RAI. Clinical outcomes were assessed within 6–8 months of treatment with RAI, including excellent response (ER), indeterminate response (IDR), biochemical incomplete (BIR) and structural incomplete response (SIR). Further transformed them into dichotomous outcomes, we therefore introduced the ordered/binary logistic regression to assess the relation of time interval and quaternary/dichotomous outcomes, respectively. Finally, we conducted a meta‐analysis for cohort study to investigate the effect of timing of RAI therapy on the prognosis of TC.

Results

Delay RAI therapy beyond 3 months reduced the IR (BIR + SIR) rate in the present cohort study (RR = 0.67, 95% CI: 0.49–91). Following meta‐analysis including 38,688 DTC patients confirmed these results (RR = 0.77, 95% CI: 0.66–0.91), further revealed the duration of treatment does not influence OS (pooled RR = 1.05, 95% CI: 0.83–1.33).

Conclusion

Delayed initial RAI therapy beyond 3 months but no later than 6 months did not impair the prognosis of TC.

Predictive Value of Clinical and Pathological Characteristics for Metastatic Radioactive Iodine-Refractory Differentiated Thyroid Carcinoma: A 16-year Retrospective Study

PURPOSE

To assess predictive value of clinical and pathological characteristics for metastatic radioactive iodine-refractory differentiated thyroid carcinoma (RAIR-DTC) in early stage retrospectively.

METHODS

We studied 199 metastatic DTC patients who were divided into two groups (TgAb negative and TgAb positive). The stimulated Tg (Sti-Tg) at the first and second radioiodine therapy (RIT) were defined as Sti-Tg1 and Sti-Tg2, the suppressed Tg (Sup-Tg) were designated as Sup-Tg1 and Sup-Tg2, while the TgAb were defined as TgAb1 and TgAb2, respectively. Univariate analysis and Logistic regression were used to investigate the effects of 13 observed factors to predict RAIR-DTC.

RESULTS

In TgAb negative group, ROC curve analysis showed that cut-off values of age, Sti-Tg2/Sti-Tg1 and Sup-Tg2/Sup-Tg1 to predict RAIR-DTC were 40 years old, 57.0% and 81.0%, respectively. Age, extrathyroid invasion, Sti-Tg2/Sti-Tg1, Sup-Tg2/Sup-Tg1 and BRAF gene mutation were proved to be independent factors predicting RAIR-DTC. In TgAb-positive group, ROC curve analysis showed that cut-off values of age, TgAb1 and TgAb2/TgAb1 to predict RAIR-DTC were 55 years old, 297 IU/ml (14.8 times higher than the upper limit) and 53.6%, respectively.

CONCLUSIONS

For TgAb-negative DTC, age over 40, extraglandular invasion, mutated BRAF gene, Sti-Tg decreased less than 43%, and Sup-Tg decreased less than 19% after the first two courses of RIT were independent predictors for RAIR-DTC. For TgAb-positive DTC, age over 55, extraglandular invasion, mutated BRAF gene, distant metastasis before RIT, TgAb level 14.8 times higher than the upper limit, TgAb dropped less than 46.4% after two courses of RIT were influencing factors.

Differentiating pulmonary metastasis from benign lung nodules in thyroid cancer patients using dual-energy CT parameters

OBJECTIVES

To explore the importance of quantitative characteristics of dual-energy CT (DECT) between pulmonary metastasis and benign lung nodules in thyroid cancer.

METHODS

In this retrospective study, we identified 63 patients from our institution's database with pathologically proven thyroid cancer who underwent DECT to assess pulmonary metastasis. Among these patients, 22 had 55 pulmonary metastases, and 41 had 97 benign nodules. If nodules showed increased iodine uptake on I-131 single-photon emission computed tomography-computed tomography or increased size in follow-up CT, they were considered metastatic. We compared the clinical findings and DECT parameters of both groups and performed a receiver operating characteristic analysis to evaluate the optimal cutoff values of the DECT parameters.

RESULTS

Patients with metastases were significantly older than patients with benign nodules (p = 0.048). The DECT parameters of the metastatic nodules were significantly higher than those of the benign nodules (iodine concentration [IC], 5.61 ± 2.02 mg/mL vs. 1.61 ± 0.98 mg/mL; normalized IC [NIC], 0.60 ± 0.20 vs. 0.16 ± 0.11; NIC using pulmonary artery [NIC_PA], 0.60 ± 0.44 vs. 0.15 ± 0.11; slope of the spectral attenuation curves [λHU], 5.18 ± 2.54 vs. 2.12 ± 1.39; and Z-effective value [Z_eff], 10.0 ± 0.94 vs. 8.79 ± 0.75; all p < 0.001). In the subgroup analysis according to nodule size, all DECT parameters of the metastatic nodules in all subgroups were significantly higher than those of the benign nodules (all p < 0.05). The cutoff values for IC, NIC, λHU, NIC_PA, and Z_eff for diagnosing metastases were 3.10, 0.29, 3.57, 0.28, and 9.34, respectively (all p < 0.001).

CONCLUSIONS

DECT parameters can help to differentiate metastatic and benign lung nodules in thyroid cancer.

KEY POINTS

• DECT parameters can help to differentiate metastatic and benign lung nodules in patients with thyroid cancer. • DECT parameters showed a significant difference between benign lung nodules and lung metastases, even for nodules with diameters ≥ 3 mm and < 5 mm. • Among the DECT parameters, the highest diagnostic accuracy for differentiating pulmonary metastases from benign lung nodules was achieved with the NIC and IC, followed by the NIC_PA and λHU, and their cutoff values were 0.29, 3.10, 0.28, and 3.57, respectively.

Risk stratification in differentiated thyroid cancer with RAI-avid lung metastases

OBJECTIVE

Radioactive iodine (RAI) therapy is effective for differentiated thyroid cancer (DTC) patients with lung metastasis. However, some patients have a poor prognosis despite the RAI accumulation. The utility of inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR), has been reported as a prognostic factor for many carcinomas. This study aimed to investigate the risk factors related to DTC patient survival with RAI-avid lung metastasis and to attempt risk stratification.

DESIGN AND METHODS

This retrospective study included 123 patients with RAI-accumulating lung metastatic DTC. The cause-specific survival (CSS) rate from the time of detection of lung metastasis was tested using the Kaplan-Meier log-rank test, and the multivariate analysis was calculated using the Cox proportional hazards model. NLR was retrospectively calculated using the blood sample collected before initial RAI treatment. The NLR cutoff value was 2.6 on the ROC curve.

RESULTS

Age ≥ 55 years at the time of operative treatment, follicular carcinoma, lung metastasis tumor ≥ 10 mm in diameter, age ≥ 55 years at the time of detection of lung metastasis, age ≥ 55 years at the time of RAI treatment, and NLR ≥ 2.6 at the initial RAI treatment were predictive of decreased CSS. Multivariate analysis identified that the independent prognostic factors were lung metastatic tumor ≥ 10 mm in diameter and NLR ≥ 2.6. Patients in the high-risk group with both factors had significantly lower CSS rates than those in the low- and intermediate-risk groups with one or none of these factors.

CONCLUSIONS

The high-risk group patients had significantly poorer survival, and these patients could be considered as future candidates for tyrosine kinase inhibitor therapy.

Investigating 18F-FDG PET/CT Parameters as Prognostic Markers for Differentiated Thyroid Cancer: A Systematic Review

Aims: The aim of this study was to determine whether ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) parameters might be prognostic markers for patients with differentiated thyroid carcinoma (DTC).

Methods: We searched for eligible articles in PubMed, EMBASE (Ovid), Cochrane Library, and ClinicalTrials.gov from inception to February 2021. We included studies addressing the association between ¹⁸F-FDG PET/CT parameters and clinical outcomes among patients with DTC. Quality assessment was performed using the Quality in Prognosis Studies (QUIPS) tool.

Results: A total of 25 studies including 2,954 patients (1,994 females, 67.5%) were included; 2,416 patients (81.8%) had papillary thyroid carcinoma (PTC), and the mean or median follow-up time ranged from 19.1 months to 17.1 years. Thirteen (52.0%) studies were assessed as “unclear” for the domain of study participation. The most common timing of PET/CT scans was after thyroidectomy (in 20 of 25 studies, 80%), especially in patients with an elevated thyroglobulin (Tg) and a negative radioiodine whole-body scan (WBS). The most common PET parameter was FDG uptake. Twelve of 17 (70.6%) and 12 of 12 (100%) studies showed an association between PET/CT parameters and disease progression and survival in patients with DTC, respectively.

Conclusion:¹⁸F-FDG PET/CT parameters alone or combined with other variables can serve as prognostic markers to identify DTC patients with poor outcomes, especially in the setting of an elevated Tg and a negative WBS. Future research is needed to confirm these findings and to examine the prognostic value of PET/CT parameters for DTC patients, considering the heterogeneity in PET/CT parameters, unclear information of patients, and PET/CT-adapted treatment modifications.

Synchronous Lung Adenocarcinoma and Papillary Thyroid Carcinoma The Metastases at the Centre of the Discussion

Synchronous tumours are defined as two or more independent primary neoplasms of different origins diagnosed at the same time in 1 individual. Although rare, its incidence is increasing and the proper diagnosis and staging of each tumour is crucial in defining the patient prognosis and the best therapeutic choice. We present a case of a 56-year-old woman presenting with a lung adenocarcinoma and pulmonary metastases initially diagnosed as stage IV and who was started on a tyrosine kinase inhibitor (erlotinib). In the meantime, she was also diagnosed with papillary thyroid carcinoma and was submitted to complete thyroidectomy. After 6 cycles of erlotinib, thoracic CT showed a decrease in the dimensions of the primary pulmonary tumour, but an increase in the size and number of pulmonary metastases while blood tests showed elevated thyroglobulin. This therefore raised the possibility that the metastases could have originated from the thyroid carcinoma. Anatomo-pathological examination of the lung metastases confirmed this hypothesis. In conclusion, it is important to confirm the origin of metastases in synchronous tumours given this can lead to a re-staging of tumours and a different prognosis, along with other therapeutic options. A multidisciplinary team meeting is crucial to define management and therapeutic approaches for these patients.

LEARNING POINTS

Although rare, synchronous primary tumours are a possibility and physicians should be aware of this possibility.Papillary thyroid carcinoma may metastasize to the lungs and its differential diagnosis should be made in the presence of lung carcinoma.When in doubt, anatomo-pathological examination of the metastases should be performed for proper staging of both tumours and to decide on the best therapeutic option.

Early detection of progressive disease using thyroglobulin doubling-time in metastatic differentiated thyroid carcinoma treated with radioactive iodine

OBJECTIVE

Detectable serum thyroglobulin (Tg) in patients with differentiated thyroid carcinoma (DTC) after total thyroidectomy indicates progression of the disease. Thyroglobulin doubling-time (TgDT) is a powerful prognostic predictor in patients with DTC. We aimed to evaluate the value of the dynamic TgDT for early detection of progressive disease (PD) in the patients of metastatic DTC with I radioactive iodine (RAI) therapy.

METHODS

We retrospectively evaluated 21 patients undergoing RAI therapy with metastatic DTC. Patients were defined as PD or non-PD according to Response Evaluation Criteria in Solid Tumors 1.1. TgDT was calculated by Excel-based software using Tg values measured during routine follow-up. Whole data (WDT), initial four data (IDT) and recent four data (RDT) of TgDT after total thyroidectomy were calculated and compared.

RESULTS

Among the 21 patients (10 men; median age, 62 years old; range, 33-80), 11 patients were classified into PD and 10 were into non-PD. The initial Tg after total thyroidectomy showed a significant difference between PD and non-PD patients (P = 0.013). Short WDT, IDT and RDT (less than one year) showed a high correlation with PD (P < 0.05). RDT showed the highest predictive value for PD (P < 0.001). All the 11 PD patients showed RDT less than one year before PD (median follow-up, 157 days; range, 88-252).

CONCLUSIONS

RDT is a powerful PD predictor in patients with metastatic DTC. Dynamic monitoring of RDT should be applied for the early detection of PD in clinic.

Long-term scintigraphic and clinical follow up in patients with differentiated thyroid cancer and iodine avid bone metastases

AIM

The aim of this study was to evaluate the long-term overall therapy outcomes and clinicopathological risk factors in patients with differentiated thyroid cancer (DTC) and iodine avid bone metastases.

METHODS

Our study included 93 patients [female to male ratio (2:1)]. All patients were subjected to clinical examination, laboratory assessment, I-131 whole body scan, and neck ultrasound. Iodine avid metastases were treated with successive radioactive iodine-131 (RAI-131) doses. The overall response was defined as complete response (CR), incomplete response (IR) [partial response (PR) and stable disease (SD)], and progressive disease (PD).

RESULTS

Fifty-four patients had follicular carcinoma and 39 with papillary type. Isolated bone metastases, bone and lung metastases, and multi-organ metastases were found in 45, 34, and 14 patients, respectively. The overall CR, PR, SD, and PD were found in 8.6%, 28%, 46.2%, and 17.2% patients, respectively. Adjunctive radiotherapy resulted in more CR, IR, and low PD rates compared to RAI-131 therapy (9.0%, 78.3%, 12.7% vs. 7.9%, 56.8%, and 23.7%, respectively) (P = 0.03). The overall survival rate was 88.2% and median follow-up period was 123 months. Female patients, papillary carcinoma, and single focal lesion had better overall response rate. Males, extrathyroidal extension, vascular invasion, and lymph nodes metastases had increased PD and decreased global response rates.

CONCLUSION

Despite of low CR rate (8.6%), most patients with DTC and iodine avid bone metastases had SD (46.2%) and long lived (88.2%). Adjunctive radiotherapy reduced PD and improved outcome. Males, extra thyroid extension and vascular invasion were bad prognostic factors.

Metastatic site discriminates survival benefit of primary tumor surgery for differentiated thyroid cancer with distant metastases: A real-world observational study

The role of primary tumor surgery in the management of differentiated thyroid cancer (DTC) with distant metastases (DM) remains controversial. We aimed to explore the survival benefit of primary tumor surgery in patients with different metastatic sites.A retrospective cohort study based on the SEER database was conducted to identify DTC patients with DM diagnosed between 2010 and 2016. Patients were divided into following 2 groups: surgery and non-surgery group. Propensity score weighting was employed to balance clinicopathologic factors between the 2 groups.Of 3537 DTC patients with DM, 956 (66.0%) patients underwent primary tumor surgery while 493 (34.0%) patients did not. There were 798 all-cause deaths and 704 DTC-specific deaths over a median follow-up of 22 months. The weighted 3-year overall survival (OS) for the surgery group was 55.2%, compared to 27.8% (P < .001) for the non-surgery group. The magnitude of the survival difference of surgery was significantly correlated with metastatic sites (Pinteraction <.001). Significant survival improvements in surgery group compared with non-surgery group were observed in patients with lung-only metastasis (adjusted HR = 0.45, P < .001), bone-only metastasis (adjusted HR = 0.40, P < .001), and liver-only metastasis (adjusted HR = 0.27, P < .001), whereas no survival improvement of surgery was found for patients with brain-only metastasis (adjusted HR = 0.57, P = .059) or multiply organ distant metastases (adjusted HR = 0.81, P = .099).The survival benefit from primary tumor surgery for DTC patients with DM varies by metastatic sites. Decisions for primary tumor surgery of DTC patients with DM should be tailored according to metastatic sites.

The Benefit of Primary Tumor Surgical Resection in Distant Metastatic Carcinomas of the Thyroid

OBJECTIVES/HYPOTHESIS

Thyroid cancer with distant metastasis (TCDM) at diagnosis has significantly worse survival rates when compared to localized/regional thyroid cancer. This study sought to report on the characteristics of patients presenting with TCDM and the potential survival advantage of surgical resection.

STUDY DESIGN

Data were acquired from the Surveillance, Epidemiology, and End Results (SEER) database with cases from 2004 to 2015.

METHODS

TCDM cases (n = 2,558) were identified from the SEER database. The Bonferroni correction was applied for multivariate analysis. Kaplan-Meier analysis was utilized to obtain disease-specific survival (DSS) rates. Cox regression analysis was utilized to identify independent factors significantly associated with survival.

RESULTS

The average age of diagnosis of TCDM was 62.0 (±17.5) years. Patients were predominantly white (74.6%), female (54.6%), in a relationship (56.0%), and between ages 36 and 80 years (76.4%). Cases consisted of papillary (57.2%), follicular (16.0%), medullary (8.9%), anaplastic (17.9%) TCDM histological variants. Overall 1-, 5-, and 10-year DSS rates were 72.0%, 56.8%, and 43.8%, respectively. Anaplastic and medullary variants had the worst 10-year DSS (0% and 25.5%, respectively). Patients who underwent surgical resection only and surgical resection with radiation were 49% and 59% less likely to die, respectively. Treatment, age, histology, T staging, relationship status, and metastasis site were determined to be significant predictors of survival.

CONCLUSIONS

Surgical resection with radiation was found to be a significant predictor of survival after applying the Bonferroni correction for all thyroid cancer variants except medullary. To increase survival, surgical intervention should be recommended in patients who are deemed to be medically tolerant of surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1026-1034, 2021.

Experience of sorafenib treatment in differentiated thyroid cancer from Taiwan

BACKGROUND

Sorafenib has been shown to prolong the progression free survival (PFS) of advanced radioiodine (RAI) refractory differentiated thyroid cancer (DTC) and has been approved by the FDA as the result of the phase III DECISION trial. Sorafenib has been reimbursed for the treatment of RAI refractory DTC in Taiwan since Jan 2017. High percentage of adverse events (AE) was noted in DECISION trial. We conducted a study to show the real-world experience of sorafenib in Taiwan.

METHODS

We retrospectively collected the clinical data, including dose, AE, and PFS of sorafenib, of the DTC patients who received sorafenib treatment in National Cheng Kung University Hospital and China Medical University Hospital by chart review from 2012 to 2018.

RESULTS

Thirty-six advanced DTC patients with progression were included in this study. The starting dose of sorafenib in most patients was 200 mg twice daily and the mean daily maintenance dose was 433 mg. Five patients had partial response (13.9%) and 28 patients had stable disease (77.8%). The median PFS was 17.3 months (95% confidence interval: 11.9-33.6 months). Daily maintenance dose ≥ 600 mg was associated with better PFS (median PFS, not reached). The most common toxicity of sorafenib was hand foot skin reaction (69%), followed by diarrhea (42%), and skin rash (33%). Most of the toxicities were grade I/II.

CONCLUSION

Higher maintenance dose of sorafenib is associated with longer PFS while starting from half dose is feasible to minimize the incidence of high grade toxicities in the real-world use of sorafenib.

Estimating the Growth Rate of Lung Metastases in Differentiated Thyroid Carcinoma: Response Evaluation Criteria in Solid Tumors or Doubling Time?

Background: Estimating the growth rate of lung metastases for the treatment of patients with metastases of differentiated thyroid carcinoma (DTC) is important. This study aimed to evaluate survival outcomes according to different criteria for estimating the growth rate of lung metastases. Methods: Patients with macronodular (≥1 cm) lung metastases of DTC who underwent total thyroidectomy and high-dose radioactive iodine therapy between 1995 and 2013 were enrolled. The time to progressive disease (PD) by the Response Evaluation Criteria in Solid Tumors (RECIST), average tumor volume doubling time of the two dominant target lung lesions (midDT), and thyroglobulin doubling time (TgDT) were measured in each patient, and their association with disease-specific survival (DSS) was evaluated. Results: Forty-four patients with target lung metastatic nodules with an initial maximal diameter of 1.3 cm (median) were followed-up for a median of 6.8 years after the diagnosis of lung metastases. Based on RECIST, 12 patients (27.3%) showed fast tumor progression, with time to PD <1 year. When assessed by midDT, nine patients (20.5%) had midDT ≤1 year, showing rapid tumor progression. Seven of 33 patients (21.2%) who were negative for thyroglobulin antibody had midDT <1 year. Growth rates assessed by all three criteria were significantly associated with DSS. However, midDT had the highest predictive value for DSS, with a proportion of variation explained of 33.6%. Five-year DSS was 29.6% in patients with midDT ≤1 year, 50.0% in patients with time to PD <1 year, and 42.9% in patients with TgDT <1 year. Conclusions: Among the different criteria for estimating the growth rate of metastases in patients with lung metastases of DTC, midDT was the most powerful for predicting DSS, in comparison with RECIST and TgDT. Performing at least three serial chest computed tomography scans during the first year from the diagnosis of lung metastases can facilitate early detection of patients with rapid tumor progression and provide objective guidance for initiation of systemic therapy.

Thyroid metastasis from non-small cell lung cancer

Non-thyroid malignancies to the thyroid gland resulting from distant metastases are extremely rare, and such cases are rarely seen in clinical settings. The question of how a tumor metastasizes to the thyroid remains unanswered. Here we report a case of lung adenocarcinoma metastasizing to the thyroid gland. The article covers the pathological features, treatments, examination reports, and the postoperative follow-up reviews of the patient. In this article, we discuss the diagnostic method, the spread route, the prognosis, the mechanism and above all, the treatment. In addition, we searched the PubMed and ISI Web of Science databases for articles published in English using the key words "lung", "thyroid", and "metastasis", and we reviewed nearly all the reports about thyroid malignancies being metastasized from lung cancer. This rare case emphasizes the importance of the multifaceted comprehensiveness of the cephalometry diagnosis, pathological diagnosis, and immunohistochemical analysis to ensure that such rare cases are not missed. We declare that all cases of thyroid malignancies metastasized from the lungs shall be reported at large for further clinical research.

Tumor doubling time predicts response to sorafenib in radioactive iodine-refractory differentiated thyroid cancer

Sorafenib has emerged as an effective therapeutic option for radioactive iodine (RAI)-refractory, locally advanced or metastatic differentiated thyroid cancer (DTC). We investigated the efficacy and safety of sorafenib treatment in a real-world setting and unveil predictive markers of responsiveness to sorafenib. The treatment response, progression-free survival (PFS), overall survival, and adverse events (AEs) of sorafenib-treated RAI-refractory, locally advanced or metastatic DTC patients at three institutes were retrospectively reviewed, and their tumor doubling time was calculated by three investigators. Total eighty-five patients were treated with sorafenib, and seven patients discontinued sorafenib due to AEs before the first tumor assessment. The median PFS was 14.4 months, and the objective response rate was 10.3% in 78 patients who were able to evaluate the tumor response. Age, sex, histologic type, tumor location, RAI avidity, or the presence of FDG-PET uptake did not affect PFS. However, smaller tumor size (≤1.5 cm) of the target lesions in lung showed better PFS (hazard ratio [HR] 0.39, p = 0.01), and tumors with the shortest doubling time (≤6 months) had worse outcome (HR 2.70, p < 0.01). Because of AEs, dose reductions or drug interruptions were required in 64% of patients, and eventually, 23% of patients discontinued sorafenib permanently. The most common AE was hand-foot skin reaction (HFSR). Patients with severe HFSR showed better PFS, but there were no statistical significance (HR 0.65, p = 0.05). In conclusion, small tumor size and long doubling time of each target lesion can be a prognostic marker to predict the responsiveness to sorafenib in RAI-refractory DTC patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with distant metastasis in pediatric thyroid cancer: evaluation of the SEER database

Objectives Controversies regarding factors associated with distant metastasis in pediatric thyroid cancer remain among the scientific community. The aim of this study was to investigate factors influencing distant metastasis in pediatric thyroid cancer. Methods We reviewed 1376 patients (aged 2 to 18 years) with thyroid cancer treated between 2003 and 2014. Data collected and analyzed included sex, race, age at diagnosis, year of diagnosis, pathological type, number of tumor foci, tumor extension, T-stage, N-stage, surgical procedure and radiation. Univariate and multivariate analyses were conducted to evaluate factors influencing distant metastasis of pediatric thyroid cancer. Results In the univariate analysis, factors influencing distant metastasis of thyroid cancer were age at diagnosis (P < 0.001), N-stage (P < 0.001), number of tumor foci (P = 0.003), tumor extension (P < 0.001) and T-stage (T1 vs T2 (P = 0.803), T3 (P < 0.001) and T4 (P < 0.001)). In multivariate analysis, factors influencing distant metastasis of thyroid cancer were age at diagnosis (P = 0.001), N-stage (P < 0.001) and T-stage (T1 vs T3 (P = 0.036) and T4 (P < 0.001)). Sex, race, year of diagnosis, pathological type, number of tumor foci, tumor extension, surgical procedure and radiation had no significant influence on distant metastasis (all P > 0.05). Furthermore, according to chi-squared test, younger pediatric thyroid cancer patients with higher T- and N-stages are more likely to have distant metastasis. Conclusion Age at diagnosis, T-stage and N-stage influence distant metastasis of thyroid cancer patients aged 2 to 18 years; accordingly, more radical treatments may need to be used for patients with those risk elements.

Pulmonary metastasectomy for thyroid cancer as salvage therapy for radioactive iodine-refractory metastases

OBJECTIVES

Distant metastasis arising from thyroid cancer is rare but has been associated with significantly reduced long-term survival, especially when refractory to radioactive iodine ablation. We provide one of the largest studies worldwide reporting the outcome after salvage pulmonary metastasectomy for this entity, aiming to identify prognostic factors and to analyse surgical indication.

METHODS

We retrospectively analysed the medical records of 43 patients who had undergone pulmonary metastasectomy for radioactive iodine-refractory thyroid cancer from 1985 to 2016.

RESULTS

The median follow-up period was 77 (95% confidence interval 41-113) months. Twenty-three (53%) patients were alive at the time of analysis. The majority of tumours were follicular thyroid cancer by histology, with 23% identified as Hurthle cell subtype. Five- and 10-year disease-specific (DS) survival was 84% and 59%, respectively. Thirty-one (72%) patients underwent R0-resection with a 5- and 10-year DS survival of 100% and 77%, respectively. This was significantly reduced to 62% and 22% (P = 0.013) in case of incomplete resection, respectively. Ten years after R0-metastasectomy, 17 (55%) patients were recurrence-free. Systematic mediastinal lymphadenectomy was performed in 16 (37%) patients and was associated with improved long-term DS survival (10 years 88% vs 46%, P = 0.034). Moreover, a reduction of > 80% in serum thyroglobulin levels post-metastasectomy correlates with better long-term DS survival (10 years 81% vs 36%, P = 0.007).

CONCLUSIONS

Pulmonary metastasectomy is associated with good survival for selected patients with radioactive iodine-refractory metastases of differentiated thyroid cancer, especially if R0-resection can be achieved. Moreover, it is worth considering whether a significant reduction of tumour load, as indicated by thyroglobulin serum levels, seems possible.

Safety of Tyrosine Kinase Inhibitors in Patients With Differentiated Thyroid Cancer: Real-World Use of Lenvatinib and Sorafenib in Korea

Background: Thyroid cancer has become the most common cancer in Korea. Generally, thyroid cancer patients have a good prognosis; however, 15-20% of patients experience recurrence or distant metastasis or are refractory to standard treatment. We assessed the safety of sorafenib and lenvatinib in patients with advanced or metastatic radioactive iodine-refractory differentiated thyroid cancers (DTC) consecutively treated at a tertiary center in South Korea. Methods: We retrospectively reviewed the charts of all consecutive patients with DTC treated during ≥6 months with lenvatinib (February 2016-April 2018) and sorafenib (January 2014-April 2018) at Gangnam Severance Hospital. Patients were treated according to the prescribing information of each drug and were followed up for 2 months. We evaluated the adverse events (AEs) reported with each drug. Results: A total of 71 medical records (lenvatinib, n = 23; sorafenib, n = 48) were reviewed. The most common histological types were papillary thyroid cancer (69.0%) and follicular thyroid cancer (22.5%). All patients (n = 23) started lenvatinib at a dose of 20 mg; 41.7% of sorafenib-treated patients received an initial dose of 800 mg daily. Four (17.4%) lenvatinib-treated patients and 26 (54.2%) sorafenib-treated patients required treatment discontinuation. The most common AEs of any grade in the lenvatinib group were diarrhea (82.6%), hypertension (78.3%), hand-foot skin reaction (56.5%), weight loss (52.2%), proteinuria (47.8%), and anorexia (43.5%). In the sorafenib group, these were hand-foot skin reaction (87.5%), diarrhea (62.5%), anorexia (60.4%), alopecia (56.3%), mucositis (52.1%), weight loss and generalized weakness (each, 50%), and hypertension (43.8%). The incidence of hand-foot skin reaction, alopecia, and rash of any grade was significantly lower (P = 0.003, P = 0.017, and P = 0.017) in patients treated with lenvatinib compared with those treated with sorafenib. The incidence of hypertension, QT prolongation, and proteinuria of any grade was significantly higher (P = 0.006, P = 0.038, and P < 0.001) in patients treated with lenvatinib compared with those treated with sorafenib. Seven deaths occurred, which were attributed to disease progression. Conclusions: No new safety concerns were identified for either drug. Most AEs were managed with dose modification and medical therapy. AEs such as hypertension and proteinuria warrant close monitoring.

Lung Metastases From Papillary Thyroid Cancer With Persistently Negative Thyroglobulin and Elevated Thyroglobulin Antibody Levels During Radioactive Iodine Treatment and Follow-Up: Long-Term Outcomes and Prognostic Indicators

Background: The lung is the most frequent site of distant metastasis from differentiated thyroid cancer (DTC). However, lung metastasis from papillary thyroid cancer (PTC) with persistently negative thyroglobulin (Tg) and elevated Tg antibody (TgAb) levels is an extremely rare entity, and the prognosis is therefore elusive. We investigated the clinical characteristics, long-term outcomes, and prognostic factors of lung metastases in PTC patients with persistently negative thyroglobulin (Tg) and elevated Tg antibody (TgAb) levels during radioactive iodine (¹³¹I) treatment and follow-up. Methods: We retrospectively reviewed 10,482 patients with DTC who underwent postoperative ¹³¹I treatment from 2007 to 2017 at Shanghai Sixth's People's Hospital. The relationships between progression-free survival (PFS) and several variables were assessed by univariate and multivariate analyses using the Kaplan-Meier method and a Cox proportional hazards model, respectively. Results: Forty-seven patients with PTC were enrolled in this study (4.48‰ of all patients with DTC). The median age at the initial diagnosis of lung metastasis was 39.6 ± 15.4 years, and the patients comprised 14 male and 33 female patients (male: female ratio = 1.00:2.36). Twenty-five patients had ¹³¹I avidity and 22 had non-¹³¹I avidity. At the end of the 5-years follow-up, 12 patients exhibited progressive disease (PD), and 2 patients had died. At the end of the 10-years follow-up, 21 patients showed PD and five patients had died. The 5- and 10-year PFS rates were 74.47 and 53.32%, respectively; the 5- and 10-years overall survival (OS) rates were 95.74 and 89.36%, respectively. The timing of diagnosis of lung metastases, maximal size of lung metastases, and ¹³¹I avidity were significantly associated with the 5-years PFS rate (P = 0.035, P = 0.030, and P<0.001, respectively). Only ¹³¹I avidity was associated with the 10-years PFS rate (P < 0.001). The multivariate analyses also showed that non-¹³¹I avidity were the independent poor prognostic factors for 10-years PFS at the end of follow-up (P < 0.001). Conclusions: Lung metastases from PTC in patients with persistently negative Tg and elevated TgAb levels had an excellent prognosis and survival rate during ¹³¹I treatment and follow-up. The loss of ¹³¹I avidity remained the strongest independent predictor of a poor prognosis and survival in these patients.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

miR-199b-5p-Stonin 2 axis regulates metastases and epithelial-to-mesenchymal transition of papillary thyroid carcinoma

Papillary thyroid carcinoma is one of the most fatal malignant endocrine tumors, and the prognosis remains poor because of the lack of effective therapeutic targets. In this study, we demonstrated that the level of miR-199b-5p was markedly downregulated in papillary thyroid carcinoma. The ectopic expression level of miR-199b-5p in papillary thyroid carcinoma cell B-CPAP could inhibit growth, migration, and invasion as well as epithelial-mesenchymal transition (EMT) and decreased cell metastasis in vivo, but silencing miR-199b-5p caused a contradictory outcome. Additionally, Stonin 2 (STON2) was identified as a direct target gene of miR-199b-5p. Consistent with the downregulation of miR-199b-5p, the overexpression of STON2 induced the growth, migration and invasion of B-CPAP cells. It was also demonstrated that miR-199b-5p suppressed papillary thyroid carcinoma cell aggressiveness by targeting STON2. Furthermore, the overexpression of miR-199b-5p inhibited cell proliferation, promoted apoptosis, and increased the chemo-sensitivity of thyroid carcinoma B-CPAP cells toward the chemotherapy drug paclitaxel. Finally, in vivo experiments further demonstrated that miR-199b-5p suppressed tumor growth in nude mice. Thus, this study revealed that miR-199b-5p functions as antioncogene miRNA in papillary thyroid carcinoma cells and that the miR-199b-5p/STON2 axis might be a potential treatment option for papillary thyroid carcinoma. © 2018 IUBMB Life, 71(1):28-40, 2019.

Tertiary Care Experience of Sorafenib in the Treatment of Progressive Radioiodine-Refractory Differentiated Thyroid Carcinoma: A Korean Multicenter Study

BACKGROUND

Sorafenib, a multi-kinase inhibitor, is approved for the treatment of patients with radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC). This study evaluated the efficacy and safety of sorafenib in real-world clinical practice and compared the results to those of the DECISION trial. The clinical features associated with better clinical outcomes after sorafenib treatment were also evaluated.

METHODS

This multicenter, retrospective cohort study evaluated 98 patients with progressive RAI-refractory DTC who were treated with sorafenib in six tertiary hospitals in Korea. The primary objective was the progression-free survival (PFS) according to Response Evaluation Criteria In Solid Tumors v1.1. Overall survival, response rate (defined as the best objective response according to Response Evaluation Criteria In Solid Tumors v1.1), and safety were also evaluated.

RESULTS

The median PFS was 9.7 months; median overall survival was not reached during follow-up. Partial responses and stable disease were achieved in 25 (25%) and 64 (65%) patients, respectively. Stable disease of >6 months was achieved in 41 (42%) patients. Subgroup analyses identified several prognostic indicators of a better PFS: absence of disease-related symptoms (hazard ratio [HR] = 0.5; p = 0.041), lung-only metastasis (HR = 0.4; p = 0.048), a daily maintenance dose ≥600 mg (HR = 0.3; p = 0.005), and a thyroglobulin reduction ≥60% (HR = 0.4; p = 0.012). The mean daily dose of sorafenib was 666 ± 114 mg, and drug withdrawals due to adverse events (AEs) occurred in 13% of patients. AEs and serious AEs were reported in 93 (95%) and 40 (41%) patients, respectively. The most frequent AE was hand-foot skin reaction (76%).

CONCLUSIONS

The PFS of progressive RAI-refractory DTC patients treated with sorafenib was consistent with the findings of the DECISION trial. Disease-related symptoms, lung-only metastasis, a daily maintenance dose, and thyroglobulin reduction were significantly associated with PFS. These results suggest that sorafenib is an effective treatment option for patients with progressive RAI-refractory DTC.

Prognostic indicators of outcomes in patients with lung metastases from differentiated thyroid carcinoma during long-term follow-up

BACKGROUND

Distant metastases, although uncommon, represent maximum disease-related mortality in differentiated thyroid carcinoma (DTC). Lungs are the most frequent sites of metastases. We aimed to evaluate long-term outcomes and identify prognostic factors in metastatic DTC limited to the lungs.

METHODS

This retrospective study included 89 patients with DTC and metastases limited to the lungs, who were treated between 1996 and 2012 at Samsung Medical Center. Progression-free survival (PFS) and cancer-specific survival (CSS) rates were evaluated according to clinicopathologic factors. Cox regression analysis was used to identify independent factors associated with structural progressive disease (PD) and cancer-specific death.

RESULTS

With a median follow-up of 84 months, the 5- and 10-year CSS rates were 78% and 73%, respectively. Older age at diagnosis (≥55 years), radioactive iodine (RAI) nonavidity, preoperative or late diagnosis of metastasis and macro-nodular metastasis (≥1 cm) were predictive of decreased PFS and CSS. Multivariate analysis identified older age (P = .002), RAI nonavidity (P = .045) and preoperative (P = .030) or late diagnosis (P = .026) as independent predictors of structural PD. RAI avidity was also independent predictor of cancer-specific death (P = .025).

CONCLUSION

Patients with DTC and metastatic disease limited to the lungs had favourable long-term outcomes. Age, RAI avidity and timing of metastasis were found to be major factors for predicting prognosis.

Co-existence of BRAFV600E and TERT promoter mutations in papillary thyroid carcinoma is associated with tumor aggressiveness, but not with lymph node metastasis

BACKGROUND

Mutations of BRAF^V600E and TERT promoters are associated with thyroid cancer development. This study further investigated association of these mutations with clinicopathological characteristics from patients with papillary thyroid carcinoma (PTC).

METHODS

Tumor tissues from 342 PTC patients were obtained for DNA extraction and polymerase chain reaction amplification to detect the BRAF^V600E mutation using amplification-refractory mutation system-polymerase chain reaction. TERT promoter mutations were assessed using Sanger DNA sequencing. The association of these gene mutations with clinicopathological characteristics was then statistically analyzed.

RESULTS

Two hundred and seventy of 342 (78.9%) PTC patients harbored the BRAF^V600E mutation, which was associated with older age male patients. Moreover, TERT promoter mutations occurred in 12 of 342 (3.5 %) PTC patients, all of whom also had the BRAF mutation. One hundred thirty-three patients with papillary thyroid microcarcinoma (PTMC) had no TERT mutations. Statistically, the coexistence of BRAF and TERT promoter mutations were significantly associated with older age, larger tumor size, extrathyroidal extension, and advanced tumor stage, but not with central lymph node metastasis, lateral lymph node metastasis, numbers of lymph node metastasis >5, and numbers of involved/harvested lymph nodes (No. of LNs involved or harvested). The multivariate analyses showed older age (odds ratio [OR], 2.194; 95% CI: 1.117-4.311; p=0.023), larger tumor size (OR, 4.100; 95% CI: 2.257-7.450; p<0.001), and multiplicity (OR, 2.240; 95% CI: 1.309-3.831; p=0.003) were all independent predictors for high prevalence of extrathyroidal extension. However, there was no statistical association with any clinicopathological characteristics except for Hashimoto thyroiditis in PTMC.

CONCLUSION

The current study demonstrated that the coexistence of BRAF and TERT promoter mutations were associated with the PTC aggressiveness, although these mutations were not associated with PTC lymph node metastasis or with PTMC.

Therapeutic response and long-term outcome of differentiated thyroid cancer with pulmonary metastases treated by radioiodine therapy

Objective

To explore the therapeutic response (TR) and long-term outcomes of iodine-131 (I-131) treatment for patients with differentiated thyroid cancer and pulmonary metastases (DTC+PM), as well as the association between the assessment of TR and long-term outcomes.

Methods

This retrospective study comprised 151 DTC+PM patients. TR was evaluated by changes in serum levels of thyroglobulin, anatomic imaging and iodine uptake in pulmonary nodules; logistic regression was applied to identify predictors. Overall survival (OS) was calculated using the Kaplan–Meier method and predictive factors of outcome by multivariate analyses.

Results

After I-131 treatment, 17 patients achieved a complete response, 71 a partial response, and 63 no response. Age, pulmonary nodule size, iodine-concentration within PM, extra-PM, frequency and cumulative dose of I-131 treatment were significant for TR. OS was 72.2% at 5, 55.2% at 10 and 51.3% at 15 years. After adjustment for other factors, age, pulmonary nodule size, extra-PM, frequency and cumulative dose of I-131 treatment were significant. A significant difference of survival rate in patients with different TR group was observed.

Conclusions

There was a supportive response and prognosis for I-131 treatment upon DTC+PM patients. Older patients and those with non-I-131-avid PM were more likely to have no response to I-131 treatment, and greater benefits could be achieved by patients who complete treatment. Long-term outcome was better in patients with age <45 years, pulmonary nodule size <2 cm, without extra-PM, and the frequency of iodine treatment ≥5 times. The predictive power of the TR on long-term prognosis was favorable.

Circulating epithelial cell counts for monitoring the therapeutic outcome of patients with papillary thyroid carcinoma

Loco-regional recurrence or distant metastasis usually leads to the death of patients with papillary thyroid carcinoma (PTC). Whether or not circulating epithelial cells (CECs) count is a valuable marker in monitoring the therapeutic outcome of PTC was investigated. Patients with PTC (n=129) were treated in our medical center and were categorized into 4 groups with excellent (n=45), biochemical incomplete (n=15), indeterminate (n=37), and structural incomplete (n=32) responses. CECs were enriched from the peripheral blood by the PowerMag negative selection system. Three subtypes of CECs expressing epithelial cell adhesion molecule (EpCAM), thyroid-stimulating hormone receptor (TSHR, a marker for thyroid cells), and podoplanin (PDPN, a marker related to poor prognosis in patients with PTC) were defined by immunofluorescence staining, respectively. The median number of CECs (cells/mL of blood) expressing EpCAM, TSHR, and PDPN was 23 (interquartile range 10-61), 19 (interquartile range 8-50), and 8 (interquartile range 3-22), respectively, for patients enrolled in this study. The number of EpCAM+-CECs, TSHR+-CECs, and PDPN+-CECs was statistically different among patients in different treatment response groups without interference from anti-thyroglobulin antibody (P<0.0001). Patients with structural incomplete response had higher counts for all three CECs subtypes when compared to other patients. EpCAM+-CECs was better in distinguishing patients with excellent response from structural incomplete response among the three subtypes of CECs. The sensitivity and specificity of the assay was 84.4% and 95.6%, respectively, when the cut off value was 39 EpCAM+-CECs/mL. CECs testing can supplement the current standard methods for monitoring the therapeutic outcome of PTC.

Prognostic markers in well differentiated papillary and follicular thyroid cancer (WDTC)

OBJECTIVES

WDTC (papillary and follicular thyroid cancer) make up around 90% of all thyroid tumours. Overall, the prognosis in patients with WDTC is excellent. However, there are small cohorts of patients who experience a more aggressive form of disease which is often associated with certain poor prognostic factors. Identifying these patients at an early stage is imperative for guiding treatment decisions. With recent developments in this area we plan to discuss the current evidence surrounding prognostic markers.

METHODS

The literature regarding prognostic factors in WDTC was reviewed using an electronic database Medline - Pubmed. Using the MeSH search engine specific prognostic factors including age, size, grade, lymph node involvement, distant metastasis, extension/invasion, ethnic background, radioactive iodine avidity, and thyroglobulin level and their association with WDTC were evaluated. A broader search of prognostic markers in thyroid cancer was also carried out to avoid missing other pertinent markers.

RESULTS

Multiple clinical and pathologic variables have been shown to be poor prognostic factors in WDTC with statistical significance. Extensive extrathyroidal extension and age may be the most important factors when predicting clinical outcomes in WDTC, although the age threshold may be increased from 45 to 55 years in due course.

CONCLUSIONS

Management of WDTC has changed considerably over the last two years as reflected in evolving British and American Thyroid Guidelines. In all cases a combined multi-disciplinary approach, with consideration of the available guidelines and stratification systems should be utilised when planning an individualised treatment program to offer the best contemporary care to WDTC patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

ABBREVIATIONS

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

Growth Kinetics of Macronodular Lung Metastases and Survival in Differentiated Thyroid Carcinoma

BACKGROUND

The clinical course of patients with lung metastases of differentiated thyroid carcinoma (DTC) vary, and cancer-specific survival (CSS) can be associated with tumor burden. This study evaluated the growth kinetics of lung metastases from DTC using serial chest computed tomography for Response Evaluation Criteria in Solid Tumors assessment and its prognostic implications.

METHODS

Forty-four patients with macronodular lung metastases (≥1 cm) of DTC were included. The time intervals to disease progression of lung metastases were measured and compared to CSS rates.

RESULTS

On the basis of the time to progression, 15 (34%), 17 (39%), and 12 (27%) patients were classified into the slow (≥3 years), moderate (1-3 years), and rapid groups (<1 year), respectively. The growth kinetics of lung metastases exhibited a linear pattern in the three groups. The doubling time of tumor burden was 1.8 years (R² = 0.973, p = 0.013) in the rapid group, and the estimated doubling time of the tumor burden in the moderate and slow groups was 5.9 years and 19.3 years, respectively. No independent variable predicted the growth kinetics of lung metastases. In multivariate analysis, disease progression within the first year was an independent predictor of CSS (hazard ratio = 8.6; p = 0.003).

CONCLUSIONS

This is the first study to demonstrate objectively that tumor growth kinetics within the first year are an independent predictor of CSS in patients with macronodular lung metastases. Performing chest computed tomography at least twice a year in the early phase of the disease in patients with macronodular lung metastases may be helpful for identifying high-risk patients who are eligible for treatment with tyrosine kinase inhibitors.

Effects of Coexistent BRAFV600E and TERT Promoter Mutations on Poor Clinical Outcomes in Papillary Thyroid Cancer: A Meta-Analysis

BACKGROUND

The presence of a telomerase reverse transcriptase (TERT) promoter mutation has been suggested as a potential prognostic marker for thyroid cancer, and a synergistic association with the BRAF^V600E mutation has been demonstrated. The aim of this study was to verify the role of this genetic duet in papillary thyroid cancer (PTC).

METHODS

Studies of the association of BRAF^V600E and TERT promoter mutations with clinicopathologic features, recurrence, or PTC-related mortality were included from PubMed and Embase databases (inception to September 2016).

RESULTS

Thirteen eligible studies incorporating 4347 patients with PTC were included, and 283 (median 8.3%) of these patients had coexistent BRAF^V600E and TERT promoter mutations. The coexistence of the two mutations was far more strongly associated with high-risk clinicopathologic features than either mutation alone was, including advanced TNM stage (vs. BRAF^V600E: odds ratio [OR] = 4.19 [confidence interval (CI) 3.07-5.71]; vs. TERT: OR = 4.66 [CI 2.67-8.13]), extrathyroidal extension (vs. BRAF^V600E: OR = 3.1 [CI 2.2-4.37]; vs. TERT: OR = 5.66 [CI 3.02-10.6]), lymph node metastasis (vs. BRAF^V600E: OR = 1.59 [CI 1.16-2.17]; vs. TERT: OR = 2.03 [CI 1.22-3.38]), and distant metastasis (vs. BRAF^V600E: OR = 11.76 [CI 5.63-24.58]). The coexistence of the mutations showed the highest risk of recurrence (coexistence vs. no mutations: hazard ratio [HR] = 6.60 [CI 3.82-11.40]; BRAF^V600E vs. no mutations: HR = 1.31 [CI 0.49-3.46]; TERT vs. no mutations: HR = 3.38 [CI 0.85-13.35]). Moreover, PTC-related mortality was significantly higher with coexistent mutations than in the presence of BRAF^V600E alone (HR = 20.07 [CI 8.37-48.09]).

CONCLUSIONS

Coexistent BRAF^V600E and TERT promoter mutations have a synergistic effect on clinical outcomes in PTC, whereas each mutation alone has a modest effect. Therefore, molecular testing of BRAF^V600E and TERT promoter mutations together is useful in assessing risk stratification of PTC.

Analysis of radioiodine therapy and prognostic factors of differentiated thyroid cancer patients with pulmonary metastasis: An 8-year retrospective study

To assess the efficacy of radioiodine therapy (RIT) and investigate the prognostic factors for patients with pulmonary metastasis secondary to differentiated thyroid carcinoma (DTC) through a retrospective study. A total of 80 patients with radioactive iodine-131 (I)-avid pulmonary metastasis from DTC treated with I from 2007 to 2014 at our institution entered the study. Treatment response was mainly measured by two parameters: serum thyroglobulin (Tg) levels and post-therapeutic I whole-body scan (WBS). Treatment variables were assessed for statistical significance using the univariate and multivariate analyses. A receiver-operating characteristic (ROC) curve was also plotted to verify the accuracy of predictors. Of these 80 patients, the overall effective rate was 72.5% (58/80), the rates for complete response (CR), partial response (PR), and no response (NR) were 20.0%, 52.5%, and 27.5%, respectively. Univariate analysis showed that gender, pulmonary nodule size, absence or presence of extrapulmonary distant metastases, age, and Tg level at diagnosis were significantly associated with I therapy efficacy. Binary logistic regression analysis revealed that older patients (odds ratio [OR]:1.481, 95% confidence interval [CI]: 1.457-2.091, P = .020), subjects with higher Tg levels at diagnosis (OR: 1.046, 95% CI: 1.016-1.119, P = .014), and those with extrapulmonary distant metastases (OR: 1.185, 95%CI: 1.025-1.463, P = .020) had a higher probability of poor prognosis. The optimal cutoffs for age and Tg level to predict I therapy efficacy for DTC with lung metastases were 46 years old and 55.50 ng/mL, respectively, based on ROC analysis. This study indicated that most DTC patients with pulmonary metastases can obtain partial or complete remission after RIT, while older patients with higher Tg levels at diagnosis and extrapulmonary distant metastases more likely show poor prognosis.

Long-term follow-up of papillary and follicular thyroid carcinomas with bone metastasis

The aims of this study were to investigate papillary and follicular thyroid carcinomas with bone metastasis in various clinical presentations and to determine the prognostic factors after multimodality treatment. A retrospective analysis was performed of 3,120 patients with papillary and follicular thyroid carcinoma. Of these patients, 131 (including 97 women, 71.8%) were diagnosed with bone metastasis and underwent follow-up at the Chang Gung Medical Center. Patients with bone metastasis were categorized into two groups. Group A was comprised of patients who were diagnosed with bone metastasis either before thyroidectomy or within 6 months of the initial thyroidectomy (90 patients, 68.7%). Group B was comprised of patients with bone metastasis who received a diagnosis 6 months post-thyroidectomy in the follow-up period (41 patients, 31.3%). After a mean follow-up period of 8.4 ± 7.0 years, there were 88 deaths (67.2%) attributed to thyroid cancer and 13 patients (9.9%) achieved disease-free status. A multivariate analysis showed that older age, early diagnosis, and brain metastasis were each associated with a poor prognosis. The difference in disease-specific mortality rates between groups A and B was significant (p < 0.0001). In conclusion, papillary and follicular thyroid cancers with bone metastasis have a high rate of mortality. Despite this high mortality, 9.9% patients still had an excellent response to treatment.