Differentiated Thyroid Carcinoma in Children and Young Adults: Evaluation of Response to Treatment

Association between different regional lymph node metastases of papillary thyroid carcinoma in adolescents and young adults

Adolescents and young adults (AYA) describe the demographic aged between 15-39 years diagnosed with cancer. This group is particularly at risk of papillary thyroid carcinoma (PTC) with a greater severity compared with other ages. Through comparative design, the present study aimed to quantify central lymph node metastasis (CLNM) risk in AYAs. A total of 463 AYA patients with PTC and 489 patients >39 years old with PTC from Ningbo Medical Center Lihuili Hospital (Ningbo, China) were enrolled. Details such as demographic data, serum indices and fine-needle aspiration from the Electronic Medical Records System were extracted and analyzed. AYA patients had significantly higher rates of ipsilateral Hashimoto thyroiditis, thyroid capsular invasion (TCI), CLNM, larger tumors and more positive central lymph nodes (CLN). Independent risk factors of CLNM in AYA patients were as follows: Male sex, presence of TCI, multifocality, bilateral disease and maximum tumor diameter (MTD) ≥1.0 cm. Independent risk factors of lateral lymph node metastasis in AYAs with CLNM were as follows: MTD ≥1.0 cm, maximum diameter of positive CLN ≥1.0 cm, and presence of ipsilateral nodular goiter. Furthermore, AYA patients with PTC displayed significantly greater aggression in primary tumor invasion and neck lymph node metastasis. Based on these findings, a treatment stratification chart was created to guide the PTC treatment approach for AYAs. The present study is registered at the Chinese Clinical Trials Registry (trial registration no. ChiCTR2200064921) in November 2022.

Radioiodine therapy in the different stages of differentiated thyroid cancer

Differentiated thyroid cancer is the most frequent type of thyroid cancer with an increasing incidence in the last decades. The initial management is represented by surgical treatment followed by radioactive iodine therapy that includes remnant ablation, adjuvant treatment or treatment of metastatic disease. Radioactive iodine treatment is performed only in selected cases based on the risk of recurrence and mortality during follow up, according to American Joint Committee on Cancer Union for international Cancer Control Tumor, Node, Metastasis (AJCC/TNM) staging system and the 2015 American Thyroid Association (ATA) risk stratification system. This article will review the key factors to consider when planning radioactive iodine therapy in differentiated thyroid cancer patients after surgery and during follow up.

Papillary thyroid microcarcinoma with multiple pulmonary metastases following lung cancer surgery: a case report

BACKGROUND

Distant metastasis is extremely rare for papillary thyroid microcarcinoma (PTMC) without lymph node metastasis or extrathyroidal extension, for which active surveillance (AS) is indicated. The evaluation of distant metastases in low-risk PTMC is controversial. A case of PTMC in which AS would have been performed if chest CT and lung surgery had not been performed is reported.

CASE PRESENTATION

The patient was a 71-year-old woman undergoing follow-up in the Department of Thoracic Surgery at our hospital for multiple frosted glass shadows in both lung fields for one and a half years. To make a definitive diagnosis, thoracoscopic right middle lobectomy and left upper partial lobectomy were performed 4 and 6 months earlier, respectively. In both resected specimens, lung adenocarcinoma and small metastasis of papillary thyroid carcinoma (PTC) were found. The patient was transferred to our department for a thorough examination for PTC. Ultrasonography was performed to search for the primary lesion, and it showed an irregular hypoechoic mass of 4 mm and 6 mm in the middle of the right lobe of the thyroid gland. The patient was diagnosed with PTC. Its clinical stage was T1a (m) N0 M1 (stage IVC). Total thyroidectomy and prophylactic central node dissection were performed. The pathological diagnosis was PTC (typical type) pT1a (m) N0. Postoperatively, she received radioactive iodine therapy.

CONCLUSIONS

We experienced an extremely rare case and struggled to determine a treatment plan. We might be aware that lung metastases could develop in low-risk PTMC.

Advanced Differentiated Thyroid Cancer: A Complex Condition Needing a Tailored Approach

Differentiated thyroid cancers (DTCs) are slow-growing malignant tumours, including papillary and follicular carcinomas. Overall, prognosis is good, although it tends to worsen when local invasion occurs with bulky cervical nodes, or in the case of distant metastases. Surgery represents the main treatment for DTCs. However, radical excision is challenging and significant morbidity and functional loss can follow the treatment of the more advanced forms. Literature on advanced thyroid tumours, both differentiated and undifferentiated, does not provide clear and specific guidelines. This emerges the need for a tailored and multidisciplinary approach. In the present study, we report our single-centre experience of 111 advanced (local, regional, and distant) DTCs, investigating the rate of radical excision, peri-procedural and post-procedural complications, quality of life, persistence, recurrence rates, and survival rates. Results are critically appraised and compared to the existing published evidence review.

Radioactive iodine therapy: multiple faces of the same polyhedron

The incidence of differentiated thyroid carcinoma (DTC) has increased in recent decades with early stage, low risk papillary thyroid cancer (PTC) being detected and diagnosed. As a result, the psychological, financial, and clinical ramifications of overdiagnosis and excessively aggressive therapy are being increasingly recognized with many authorities calling for a re-evaluation of the traditional "one size fits all" management approaches. To address these critical issues, most thyroid cancer guidelines endorse a more risk adapted management strategy where the intensity of therapy and follow up is matched to the anticipated risk of recurrence and death from DTC for each patient. This "less is more" strategy provides for a minimalistic management approach for properly selected patients with low-risk DTC. This has re-kindled the long-standing debate regarding the routine use of radioactive iodine therapy (RIT) in DTC. Although recent guidelines have moved toward a more selective use of RIT, particular in patients with low-intermediate risk DTC, the proper selection of patients, the expected benefit, and the potential risks continue to be a source of ongoing controversy and debate. In this manuscript, we will review the wide range of clinical, imaging, medical team, and patient factors that must be considered when evaluating individual patients for RIT. Through a review of the current literature evaluating the potential benefits and risks of RIT, we will present a risk adapted approach to proper patient selection for RIT which emphasizes peri-operative risk stratification as the primary tool that clinicians should use to guide initial RIT management recommendations.

Lung Metastasis in Children with Differentiated Thyroid Cancer: Factors Associated with Diagnosis and Outcomes of Therapy

Background: Lung metastasis from differentiated thyroid cancer (DTC) in children and young adults (CAYA) is estimated at 25%, which is 3-4 times higher than in adults. Lung metastases may respond to radioactive iodine (RAI) therapy and overall survival is excellent. Associations with lung metastasis include lateral lymph node (LN) disease although CAYA data are limited. We investigated factors associated with lung metastasis in children and adolescents and described their presentation and outcome. Methods: A retrospective review of medical records from 1998 to 2017 in patients aged <18 years treated at a tertiary pediatric center was carried out. Data on age, clinical features at diagnosis, histology, biochemistry, imaging, RAI therapy, and outcome were collected. Results: Patients treated for DTC totaled 98 and 19 of 98 (19%) patients had lung metastasis; 17 of 19 (89%) patients were identified within 6 months from thyroidectomy. Patients with lung metastasis were younger (p < 0.001)-40% <13 years old had lung metastasis-and had a larger primary tumor diameter (p = 0.01). Absence of LN disease had negative predictive values ≥90% (p < 0.02). Patients with lung metastasis had a higher postoperative thyrotropin-stimulated thyroglobulin (Tg) (p < 0.001), ≥2 ng/mL in 10 of 11 (91%) patients, and 100% had an elevated preoperative Tg (>60 ng/mL). Post-therapy whole body scan (WBS) identified most metastasis (13 of 17 patients), which were mostly diffuse (11 of 19 patients). Discordant findings were found between WBS and computed tomography (CT) at diagnosis (2 patients), WBS and CT during surveillance (3 patients), and diagnostic and post-therapy WBS (2 patients). Final outcome was "excellent" in 3 of 19 (16%) patients, "biochemically persistent" in 1 of 19 (5%) patients, "structurally persistent" in 13 of 19 (68%) patients-including 1 death-and indeterminate in 2 of 19 (11%) patients. Postoperative Tg correlated with response to therapy. Lung metastasis pattern and RAI cumulative activity were not predictive of response to therapy. Conclusions: Lung metastases are mostly observed at diagnosis of DTC and higher suspicion should be maintained in CAYA who are younger, have LN disease, and have elevated postoperative Tg. Preoperative Tg shows promise as another predictive marker, but limited sample size precludes generalization. "Excellent" response to therapy is uncommon-multiple RAI courses do not necessarily improve outcome-response appears unrelated to RAI activity or metastasis pattern.

Long-term follow-up of differentiated thyroid carcinoma in children and adolescents

Objectives The aims were to analyze the clinical features, response to treatment, prognostic factors and long-term follow-up of children and adolescents with differentiated thyroid carcinoma (DTC). Methods Eighty patients with DTC were studied retrospectively. All underwent total or near-total thyroidectomy, and in 75 cases, ablative iodine therapy was recommended. Patients were assessed periodically by tests for serum thyroglobulin levels and whole-body iodine scans. Age, gender, initial clinical presentation, histology, tumor stage, postoperative complications, radioiodine treatment protocol, treatment response, thyroglobulin (Tg), recurrence and long-term disease progression were evaluated. Results Seventy patients completed >2 years of follow-up (23 males, 47 females; median age: 14 years; range: 3-18 years). Sixty-two patients showed papillary DTC and eight, follicular DTC. Sixty-five percent presented nodal metastasis and 16%, pulmonary metastasis at diagnosis. Six months after first radioiodine treatment, 36.2% of patients were free of disease. Seven recurrences were documented. At the end of follow-up, overall survival was 100%, and 87.2% of patients were in complete remission. Nine patients had persistent disease. We found a significant association between stage 4 and persistent disease. Hundred percent of patients with negative Tg values at 6 months posttreatment were documented free of disease at the end of the follow-up. The analysis of disease-free survival based on radioiodine treatment protocols used showed no statistically significant differences. Conclusions DTC in children and adolescents is frequently associated with presence of advanced disease at diagnosis. Despite this, complete remission was documented after treatment in most cases, with a good prognosis in the long-term follow-up. Negative posttreatment thyroglobulin and stage 4 at diagnosis were significant prognostic variables.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Prognostic Factors for Differentiated Thyroid Carcinoma and Review of the Literature

Objective

Prognostic factors of differentiated thyroid carcinoma (DTC) are analyzed to justify the diagnostic and therapeutic modalities of DTC in current practice.

Methods

Patients undergoing curative resection for histologically diagnosed DTC (n = 150) were consecutively enrolled, and the clinical and pathological data were retrospectively reviewed.

Results

The DTC patient cohort consisted of 113 females (75.3%; mean age at the time of onset, 40.1 ± 12.0 yr) and 37 males (24.7%; 47.5 ± 16.2 yr). The pathological types of DTC included papillary thyroid carcinoma (n = 131, 87.3%) and follicular thyroid carcinoma (n = 19, 12.7%). The follow-up period ranged from 4.2 to 31 years, in which period 140 (93.3%) patients survived, 30 (20.0%) patients relapsed, and 10 (6.7%) patients died of DTC. Surgical procedures used for the curative resection consisted of near-total or subtotal thyroidectomy (n = 83, 55.3%), partial thyroidectomy (n = 64, 42.7%) and total thyroidectomy (n = 3, 2.0%). Out of those patients undergoing concomitant lymph node dissection (n = 63, 42.0%), 45 patients (71.4%) had detectable lymph node metastases. Postoperatively, 12 patients (8.0%) received external beam radiotherapy, 16 patients (10.7%) received chemotherapy, 37 patients (24.7%) received 131I therapy, and 66 patients (44.0%) received additional long-term L-T4 or thyroid hormone treatment. Age of onset, tumor size at initial visit, and rate of early metastasis showed statistically significant differences between the mortality group and the survival group (P <0.05) and between the recurrence group and the recurrence-free group (P <0.05).

Conclusions

Age, tumor size at initial visit, and early metastasis are prognostic factors for DTC, requiring a stratified management in clinical practice.

Selective use of radioactive iodine (RAI) in thyroid cancer: No longer "one size fits all"

A remarkable, evidence-based trend toward de-escalation has reformed the practice of radioactive iodine (RAI) administration for thyroid cancer patients. Updated guidelines have supported both decreased RAI doses for select populations, as well as expanded definitions of low-risk and intermediate-risk patients that may not require RAI. Correspondingly, there is now increased flexibility for hemithyroidectomy without need for RAI, and relaxed TSH suppression targets for low-risk thyroidectomy patients. Clinical judgment remains indispensable where multiple risk factors co-exist that individually are not indications for RAI. This is especially salient in intermediate-risk patients with a less than excellent response to therapy, determined through thyroglobulin and ultrasound surveillance. Such judgment, however, may lead to patterns of inappropriate RAI practices or overuse with little benefit to the patient and unnecessary harm. A multidisciplinary, risk-adapted approach is ever more important and obliges the surgeon to understand the likelihood that their patients will receive RAI. The risks and benefits of RAI, its evolved role in contemporary guidelines, and current patterns of use among endocrinologists are reviewed, as well as the practical implications for thyroid surgeons.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Identification of epistatic interactions through genome-wide association studies in sporadic medullary and juvenile papillary thyroid carcinomas

Background

The molecular mechanisms leading to sporadic medullary thyroid carcinoma (sMTC) and juvenile papillary thyroid carcinoma (PTC), two rare tumours of the thyroid gland, remain poorly understood. Genetic studies on thyroid carcinomas have been conducted, although just a few loci have been systematically associated. Given the difficulties to obtain single-loci associations, this work expands its scope to the study of epistatic interactions that could help to understand the genetic architecture of complex diseases and explain new heritable components of genetic risk.

Methods

We carried out the first screening for epistasis by Multifactor-Dimensionality Reduction (MDR) in genome-wide association study (GWAS) on sMTC and juvenile PTC, to identify the potential simultaneous involvement of pairs of variants in the disease.

Results

We have identified two significant epistatic gene interactions in sMTC (CHFR-AC016582.2 and C8orf37-RNU1-55P) and three in juvenile PTC (RP11-648k4.2-DIO1, RP11-648k4.2-DMGDH and RP11-648k4.2-LOXL1). Interestingly, each interacting gene pair included a non-coding RNA, providing thus support to the relevance that these elements are increasingly gaining to explain carcinoma development and progression.

Conclusions

Overall, this study contributes to the understanding of the genetic basis of thyroid carcinoma susceptibility in two different case scenarios such as sMTC and juvenile PTC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12920-015-0160-7) contains supplementary material, which is available to authorized users.

Are the characteristics of thyroid cancer different in young patients?

BACKGROUND

Thyroid carcinoma in pediatric patients continues to be a rare albeit significant condition because local recurrence or distant metastases may be revealed during its diagnosis, or even years after completion of treatment.

METHODS

This study was prepared by retrospective analysis of patient files to focus on the clinical presentation of thyroid carcinoma in pediatric patients, and proposes to investigate the clinical parameters that differ from, or that correspond to, those in adult patients.

SUBJECTS

A total of 108 patients, of whom 22 were children and adolescents and 86 were adults, and who were operated on for differentiated thyroid carcinoma during the period 2001-2009, were included in the study.

RESULTS

The rate of large thyroid, multinodular goiter, or tumor >1 cm was significantly higher in the adult group than in the pediatric group. Our analysis also revealed that that the frequency of lymph node metastasis was significantly higher in the pediatric group than in the adult group. Moreover, the frequencies of total lymph node and positive lymph node presentations were significantly higher in the pediatric group than in the adult group.

CONCLUSION

Although thyroid carcinoma has a good prognosis in young patients, one must stress that late diagnosis and ineffective treatment are the main criteria for poor prognosis and, most important, that it is advisable to keep the management of thyroid carcinoma on a path that differs from the management of adult thyroid carcinomas, in nearly all aspects from presentation to treatment.

Age and prognosis of papillary thyroid carcinoma: retrospective stratification into three groups

Purpose

We investigated the prognosis according to age in papillary thyroid carcinoma (PTC) patients.

Methods

We retrospectively evaluated 2,890 patients who underwent thyroidectomy due to PTC between May 2004 and Aug 2008. We divided patients into 3 groups: young (≤35 years old), middle (between 35 and 54 years old), and old (≥55 years old).

Results

Median age was 47.0 years old (range, 15 to 82 years). Within a follow-up period median of 50 months, there were 148 (5.1%) locoregional recurrences, 6 (0.2%) PTC-related deaths, and 18 (0.6%) PTC-unrelated deaths. Outcomes were more favorable in the young group, with no PTC-related death despite the frequent locoregional recurrence. In the old group compared to the middle, there was a higher proportion of male, and more aggressive types as T3 or N1b, higher mean tumor number, more multiplicity, and bilaterality. The old group of ≥55 years did not show a significant difference in PTC-related deaths than other age groups in Cox analysis (OR, 0.9; P = 0.677), but a significant cutoff age in PTC-related deaths at 62.5 years was determined in ROC analysis (area under curve = 0.912).

Conclusion

We showed that the ≤35 years group shows favorable prognosis despite the frequent locoregional recurrence and ≥62.5 years group shows a poor prognosis regardless of other factors such as male sex or tumor aggressiveness. Further multiinstitutional studies are needed to elucidate the prognosis according to patient's age.

Update on thyroid cancer treatment

Surgery and radioiodine therapy are usually effective for most patients with differentiated thyroid cancer. However, poorly differentiated and anaplastic thyroid carcinomas represent a challenge to physicians on the basis of the current cancer treatment modalities. These cancer subtypes are often lethal and refractory to radioiodine therapy as well as most of the common chemotherapy drugs. Several kinase inhibitors are promising targeted therapies for these malignancies; however, clinical trials involving these drugs have provided controversial results and their clinical use is still under debate. Advanced medullary thyroid carcinomas may also be refractory to conventional therapies and novel kinase inhibitors may also be useful to control tumor progression in certain patients. Novel evidence is emerging that thyroid cancer is a stem cell disease, thereby implying that the driving force of thyroid cancers is a subset of undifferentiated cells (thyroid cancer stem cells) with unlimited growth potential and resistance to conventional therapeutic regimens. Thyroid cancer stem cells have been proposed as responsible for tumor invasiveness, metastasis, relapse and differentiation. Therefore, drugs that selectively target these cells could serve as a cornerstone in the treatment of poorly differentiated thyroid cancer.

Relationship between prognosis of papillary thyroid carcinoma patient and age: a retrospective single-institution study

Age is an important prognostic factor in papillary thyroid carcinoma (PTC). In this study, we investigated the difference in prognosis of 7 subsets of PTC patients without distant metastasis at presentation or a history of radiation exposure (20 years or younger, 21-30 years, 31-40 years, 41-50 years, 51-60 years, 61-70 years, and older than 70 years). The lymph node recurrence rate was high in patients 20 years or younger and those older than 60 years. Distant recurrence and carcinoma death rates significantly elevated in patients older than 60 years. The incidence of significant extrathyroid extension markedly increased with age, although that of large node metastasis or extranodal tumor extension did not differ much among the 7 subsets. With the Kaplan-Meier method, lymph node recurrence rate was poor in patients 20 years or younger and in those older than 60 years. Poor distant recurrence-free and cause specific survivals of patients older than 60 years were identified in the series of PTC patients with and without these aggressive features. It is therefore suggested that 1) Lymph node recurrence rate was high in patients 20 years or younger and those older than 60 years and 2) prognosis, including distant recurrence-free survival and cause-specific survival, of patients older than 60 years was poor regardless of clinicopathological features of PTC at initial surgery.

Prognosis and prognostic factors of papillary thyroid carcinoma in patients under 20 years

Age is an important prognostic factor of papillary thyroid carcinoma (PTC). In this study, we investigated the prognosis and prognostic factors of PTC in patients younger than 20 years. We enrolled 110 patients who underwent initial surgery at Kuma Hospital between 1987 and 2008. Tumor size > 4 cm, metastatic node ≥ 3 cm, and significant extrathyroid extension were more frequently detected in 8 patients with distant metastasis at diagnosis than in 102 patients without distant metastasis. Ten- and 20-year lymph node recurrence-free survival (LN-RFS) and distant recurrence-free survival (DRFS) rates were 84 and 80%, and 95 and 89%, respectively. Metastatic node ≥ 3 cm, age ≤ 16 years, tumor size > 4 cm, and male gender affected LN-RFS, and the former two had an independent prognostic value in multivariate analysis. Metastastic node ≥ 3 cm, significant extrathyroid extension, age ≤ 16 years, tumor size > 4 cm, and a male gender predicted a poor DRFS, and the former two were independent prognostic factors. To date, only 2 patients have died of PTC. These findings suggest that, in the subset of PTC patients younger than 20 years, metastatic node ≥ 3 cm, significant extension, and age ≤ 16 were important signs of aggressiveness of carcinoma, and careful treatment is necessary for patients with these characteristics, although the cause-specific survival was excellent.

Surgical and pathological characteristics of papillary thyroid cancer in children and adolescents

Background. Thyroid carcinoma is a relatively rare pediatric pathology, comprising around 3% of all childhood tumors. We investigated parameters of tumor aggressiveness, multicentricity, and locoregional metastatic spread patterns in patients up to 18 years of age and made comparison with the older group. All patients were operated upon with total thyroidectomy, with or without lymph-node neck dissection. Results. Patients with papillary carcinoma present with more advanced stage, larger primary tumor, and more commonly present with palpable thyroid and/or neck node. Overall, papillary cancer demonstrated pathological aggressiveness as defined by our criteria in 60%, multicentricity in 40%, and locoregional metastatic foci in 77% of cases. Multicentric tumor foci in both thyroid lobes and tumor aggressiveness were identified as a risk factor for metastatic development. Conclusion. By observing clinicopathological parameters, we demonstrated that papillary thyroid cancer behaves more aggressively in the younger group. We recommend total thyroidectomy with careful intraoperative exploration of thyroid bed and lateral neck in search for possible metastatic spread. In case of positive findings, it is obligatory to perform a standard neck dissection, keeping in mind that neck lymphonodes are primary site of locoregional recurrence. With meticulous attention to technical aspects of operation, perioperative morbidity should be minimal.

Clinical and molecular features of papillary thyroid cancer in adolescents and young adults

BACKGROUND

Age disparities in thyroid cancer incidence and outcome among adolescents and young adults (AYAs) with thyroid cancer are under reported. In this study, the authors compared the molecular and clinical features of papillary thyroid cancer (PTC) in AYAs with the same features among patients in other age groups.

METHODS

One thousand eleven patients underwent initial treatment for PTC at the University of California at San Francisco. Patients were subdivided into 2 age groups: ages 15 to 39 years (the AYA group) and aged ≥40 years. Demographic, clinical, and survival data in the cohort also were compared with data from the National Cancer Instsitute's Surveillance, Epidemiology, and End Results (SEER) Program. In a subset of the study cohort, the primary tumors were analyzed by genome-wide expression analyses, genotyping for common somatic mutations, and pathway-specific gene expression arrays between the age groups.

RESULTS

The percentage of women and the lymph node metastasis rate were significantly higher in the AYA group. In the AYA group, the rate of distant metastasis was lower. Disease-free survival and median overall survival were significantly higher in the AYA group. The better survival in AYA patients also was apparent in the national SEER data. An unsupervised cluster analysis of gene expression data revealed no distinct clustering by age in 96 PTC samples. The frequency and type of somatic mutations in the primary tumors did not differ significantly between age groups (the AYA group vs the group aged ≥40 years). Six genes (extracellular matrix protein 1 [ECM1], v-erb-2 erythroblastic leukemia viral oncogene homolog 2 [ERBB2], urinary plasminogen activator [UPA], 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 2 [PFKFB2], meis homeobox 2 [MEIS2], and carbonic anhydrase II [CA2]) had significant differential expression between age groups.

CONCLUSIONS

The extent of disease at presentation and the survival of patients with PTC differed between AYAs and older patients. The current results indicated that these differences may be caused by several candidate genes and that these genes are expressed differentially and may play an important role in tumor cell biology. However, no distinct gene expression profiles exist for patients with PTC that distinguish between AYAs and patients aged ≥40 years.

Outcomes of children and adolescents with well-differentiated thyroid carcinoma and pulmonary metastases following ¹³¹I treatment: a systematic review

BACKGROUND

The optimal dose and efficacy of ¹³¹I treatment of children and adolescents with well-differentiated thyroid carcinoma (WDTC) and pulmonary metastases are not well established. A therapeutic challenge is to achieve the maximum benefit of ¹³¹I to decrease disease-related morbidity and obtain disease-free survival while avoiding the potential complications of ¹³¹I therapy.

SUMMARY

We systematically reviewed the published literature on children and adolescents with WDTC and pulmonary metastases treated with ¹³¹I to examine outcomes after ¹³¹I administration and the risks and benefits of therapy. After reviewing 14 published articles, 9 articles met our inclusion criteria encompassing 112 pediatric and adolescent patients with WDTC and pulmonary metastases 21 years of age or younger at diagnosis spanning a follow-up period of 0.6–45 years. ¹³¹I therapy after surgery and thyrotropin suppression resulted in complete, partial, and no disease response in 47.32%, 38.39%, and 14.29% of patients, respectively. Five studies provided data on disease response in relation to ¹³¹I dose. In general, nonresponders received the highest ¹³¹I doses and complete responders received a higher dose than partial responders. The disease-specific mortality rate was 2.68%. Survival was 97.32%. A second primary malignancy occurred in one patient. One out of 11 patients studied experienced radiation fibrosis.

CONCLUSIONS

This review confirms that the majority of pediatric and adolescent patients with WDTC and pulmonary metastases treated with ¹³¹I do not achieve complete response to therapy, yet disease-specific morbidity and mortality appear to remain low. It is therefore prudent to use caution in the repeated administration of ¹³¹I to such patients to ensure that adverse effects of therapy do not cause more harm than good in a disease that has an overall favorable natural course. Long-term prospective studies are needed to analyze disease-specific morbidity and mortality, recurrence rate, dose-specific response, and dose-related adverse effects of ¹³¹I in this patient population.

Utilization of total thyroidectomy for differentiated thyroid cancer in children

PURPOSE

Recent recommendations suggest that total thyroidectomy (TT) is the surgical management of choice for differentiated thyroid cancer in children. The objective of this study is to assess trends in extent of surgical resection for differentiated thyroid cancer in children over the past two decades and to identify patient, tumor or hospital factors associated with use of TT.

PATIENTS AND METHODS

Of 8,013 patients (aged 0-21 years) with differentiated thyroid cancer from the National Cancer Data Base (1985-2007), 5,933 (74%) underwent TT. Trends in extent of surgery were examined. Logistic regression was used to identify factors that predict use of TT.

RESULTS

Use of TT increased from 50.6% in 1985 to 84% in 2007 (P < 0.001). Patients were more likely to undergo TT if they had higher household income or had private insurance (P = 0.002 and P = 0.037). Patients were more likely to undergo TT if they had larger tumors or if there were nodal metastases present at time of resection (both P < 0.001). After adjusting for patient and tumor factors, patients treated at high-volume or Children's Oncology Group hospitals were more likely to undergo TT than patients treated at low-volume or non-Children's Oncology Group hospitals (P < 0.001).

CONCLUSIONS

Overall utilization of TT in children with differentiated thyroid cancer has steadily increased over the past 23 years in the USA. Variations in use of TT are not only related to tumor factors including size and nodal involvement, but also are also related to socioeconomic and hospital factors, demonstrating disparities in care.

Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines.

METHODS

Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.

CONCLUSIONS

We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Treatment strategy of papillary thyroid carcinoma in children and adolescents: clinical significance of the initial nodal manifestation

BACKGROUND

Risk factors and treatment strategy in younger patients with papillary thyroid carcinoma are still controversial.

METHODS

We reviewed 120 consecutive papillary thyroid carcinoma patients younger than 20 years who underwent initial surgery between 1977 and 2004 (14 male and 106 female subjects; mean age, 16.3 years; mean follow-up, 11.6 years). Outcomes were evaluated initially, and risk factors for disease-free survival (DFS) were analyzed statistically. Cox proportional multivariate analysis revealed that initial nodal manifestation (P < .001, hazard ratio 2.97) was the most statistically significant risk factor for DFS. The outcomes were then compared between four subgroups on the basis of the initial nodal manifestation and node dissection: 17 patients in group A (no lymphadenopathy, no or only prophylactic central dissection), 30 patients in group B (no lymphadenopathy, prophylactic modified neck dissection, MND), 46 patients in group C (nonpalpable lymphadenopathy detected by radiological or operative findings, therapeutic MND), and 27 patients in group D (palpable lymphadenopathy, therapeutic MND).

RESULTS

Subtotal/total thyroidectomy and radioactive iodine therapy were performed for 47.1 and 0% in group A, 33.3 and 0% in group B, 43.4 and 10.9% in group C, and 85.1 and 48.1% in group D, respectively. In groups A, B, C, and D, 0%, 3.3%, 28.3%, and 48.1% developed recurrence, respectively (P < .001). DFS Kaplan-Meier curves differed significantly among the four subgroups (P < .0005).

CONCLUSIONS

Initial nodal manifestation is useful to predict DFS in younger papillary thyroid carcinoma patients. Our findings will be beneficial to determine the treatment strategy. Conservative therapy is considered acceptable for patients without risk factors.

Outcome after high-dose radioiodine therapy for advanced differentiated thyroid carcinoma in childhood

OBJECTIVE

To evaluate the clinical outcome in childhood patients receiving postoperative high-dose radioiodine therapy for advanced differentiated thyroid carcinoma.

METHOD

Patients under 18 years old with neck diseases (n = 4) or distant metastases (n = 10) received postoperative radioiodine ablation and repeated treatments for a median of 2 (0.8 10) years with an averaged activity of 25.0 (7.0 72.2) GBq.

RESULTS

Partial remission was achieved in 6, stable disease in 6 and progressive disease in 2 patients, without severe side effects except for two Grade 1 and one Grade 2 WHO haematological toxicity. The median survival time from diagnosis to the last treatment sessions was 5.3 (range, 0.7 14.5) years.

CONCLUSION

High-dose radioiodine treatment was well tolerated with satisfactory outcome in childhood patients with advanced differentiated thyroid carcinoma.

Childhood thyroid cancers and radioactive iodine therapy: necessity of precautious radiation health risk management

One of the lessons from Chernobyl's legacy on health impact beyond 20 years is not only how to detect and treat the patients with radiation-associated thyroid cancers but how to follow up those who received radioactive iodine treatment repetitively after surgery in order to monitor any recurrence/worsening and also how to predict the risk of secondary primary cancers for their lifetime period. To evaluate the possibility of second primary tumors after radioactive iodine treatment, we reviewed the reports on risks from both external and internal radiation exposure, especially at high doses during childhood through an internet service of the National Library of Medicine and the National Institutes of Health, PubMed by the end of June, 2007, together with our own experience of Chernobyl childhood thyroid cancers. Children who were internally exposed after Chernobyl accident have a long-term risk of well differentiated thyroid cancers. Once they have disease, ironically radioactive iodine ablation is one of the useful therapies after surgical treatment. Elevated risks of solid cancers and leukemia have been found in radioiodine-treated patients, however, so far precious few reports from Chernobyl thyroid cancer patient were published. To reduce the adverse effects of radioactive iodine therapy on non-target tissues, recombinant human TSH has been applied and proved effective. Period of latency of second primary cancers may be very long. Therefore patients treated with high activities of radioactive iodine, especially children cases, should be carefully followed up during their whole lifespan.

Management of paediatric thyroid carcinoma: recent experience with recombinant human thyroid stimulating hormone in preparation for radioiodine therapy

BACKGROUND

Thyroid carcinoma in children is rare and raises unique management issues. Although metastatic disease is more common in this age group, prognosis remains good with appropriate treatment. The aim of the study was to report recent experience in the management of differentiated thyroid carcinoma in children, especially in the use of radioiodine after recombinant human thyroid stimulating hormone (rhTSH) stimulation.

METHODS

Eight patients, aged 5-17 years (five were boys) presented following total thyroidectomy for thyroid carcinoma between May 2003 and June 2005. Seven had papillary carcinoma and one had follicular carcinoma. Five had known lymph node metastases and one had pulmonary metastases at presentation. Four patients had previously received therapeutic irradiation for malignancy. All eight underwent diagnostic iodine scans, seven with rhTSH stimulation. Seven went on to receive radioiodine treatment as hospital inpatients, comanaged by the paediatric and nuclear medicine units. The dosage of 131I ranged from 1.5 to 3.7 x 10(9) Bq. All except one were prepared by rhTSH stimulation.

RESULTS

Seven of eight patients had significant uptake in the neck on diagnostic scan and two had pulmonary abnormalities. Six of seven evaluable patients achieved complete thyroid ablation. Both patients with pulmonary abnormalities had scan resolution, although one of them only after a second radioiodine treatment. All patients had thyroxine replacement in doses to suppress TSH and all remain alive and well at time of carrying out this study.

CONCLUSION

Optimal management of paediatric thyroid carcinoma necessitates a multidisciplinary approach. Radioiodine therapy under rhTSH is an effective and safe adjuvant treatment in this special subgroup.