Prediction Table and Nomogram as Tools for Diagnosis of Papillary Thyroid Carcinoma: Combined Analysis of Ultrasonography, Fine-Needle Aspiration Biopsy, and BRAF V600E Mutation

TERT Promoter Mutations and the 8th Edition TNM Classification in Predicting the Survival of Thyroid Cancer Patients

Simple Summary

In a cohort study involving 393 patients with differentiated thyroid cancer, TERT promoter mutations were found to act as an independent poor prognostic factor based on the American Joint Committee on Cancer (AJCC) tumor-node-metastasis 8th edition (TNM-8) in differentiated thyroid carcinoma (DTC) patients, regardless of the histological types or stage at diagnosis. Since the current AJCC TNM-8 is insufficient to distinguish the risk of mortality in patients with differentiated thyroid cancer, a proposal for a new survival prediction model that includes the TERT promoter mutational state is required.

Abstract

Our research group has previously shown that the presence of TERT promoter mutations is an independent prognostic factor, by applying the TERT mutation status to the variables of the AJCC 7th edition. This study aimed to determine if TERT mutations could be independent predictors of thyroid cancer-specific mortality based on the AJCC TNM 8th edition, with long-term follow-up. This was a retrospective study of 393 patients with pathologically confirmed differentiated thyroid carcinoma (DTC) after thyroidectomy at a tertiary Korean hospital from 1994 to 2004. The thyroid cancer-specific mortality rate was 6.9% (5.2% for papillary and 15.2% for follicular cancers). TERT promoter mutations were identified in 10.9% (43/393) of DTC cases (9.8% of papillary and 16.7% of follicular cancer) and were associated with older age (p < 0.001), the presence of extrathyroidal invasion (p < 0.001), distant metastasis (p = 0.001), and advanced stage at diagnosis (p < 0.001). The 10-year survival rate in mutant TERT was 67.4% for DTC patients (vs. 98% for wild-type; adjusted hazard ratio (HR) of 9.93, (95% CI: 3.67–26.90)) and 75% for patients with papillary cancer (vs. 99%; 18.55 (4.83–71.18)). In addition, TERT promoter mutations were related to poor prognosis regardless of histologic type (p < 0.001 for both papillary and follicular cancer) or initial stage (p < 0.001, p = 0.004, and p = 0.086 for stages I, II, and III and IV, respectively). TERT promoter mutations comprise an independent poor prognostic factor after adjusting for the clinicopathological risk factors of the AJCC TNM 8th edition, histologic type, and each stage at diagnosis, which could increase prognostic predictability for patients with DTC.

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.

High BRAFV600E mutation frequency in Chinese patients with papillary thyroid carcinoma increases diagnostic efficacy in cytologically indeterminate thyroid nodules

To estimate the BRAFV600E mutation frequency in Chinese patients with papillary thyroid carcinoma (PTC), and the diagnostic value of BRAFV600E mutation status in thyroid nodules with indeterminate TBSRTC categories.A total of 4875 consecutive samples for thyroid ultrasound-guided fine-needle aspiration cytology (FNAC) and BRAF mutation analysis were collected from patients at Jiangsu Province Hospital on Integration of Chinese and Western Medicine. Among all the cases, 314 underwent thyroidectomy. According to TBSRTC categories, FNAC was performed for a preoperative diagnosis. ROC of the subject was constructed to evaluate the diagnostic value of these 2 methods and their combination.BRAF mutation in FNAC of thyroid nodules occurred in 2796 samples (57.35%). Of 353 nodule samples from 314 patients with thyroid operation, 333 were pathologically diagnosed as PTC. Of these PTC patients, 292 (87.69%) were found to have BRAF mutation in their preoperative FNAC. In 175 cytologically indeterminate thyroid nodules, BRAF mutation identified 88% of PTC. According to ROC data, BRAF mutation testing had an obviously higher sensitivity (87.69%) and specificity (100.00%) than TBSRTC. Combining BRAF mutation testing and TBSRTC achieved the largest AUC (0.954). For 41 PTC with a negative BRAF mutation in preoperative evaluation, the repeated BRAF mutation testing found out 12 samples with BRAF mutation. The true BRAF mutation rate of Chinese PTC patients was 91.29%.Chinese patients with PTC have a higher frequency of BRAF mutation. The BRAF mutation testing affords a high diagnostic value in thyroid nodules with indeterminate cytology.

The Malignancy Risk Assessment of Cytologically Indeterminate Thyroid Nodules Improves Markedly by Using a Predictive Model

OBJECTIVES

The majority of thyroid nodules are discovered incidentally, and the management may be a challenge if the fine needle aspiration specimen yields indeterminate findings. Our aim was to develop an individualized risk prediction model to provide an accurate estimate of cancer risk in patients with cytologically indeterminate thyroid nodules.

MATERIALS AND METHODS

Clinical records, ultrasound images, and cytopathology reports of patients who underwent thyroidectomy were retrospectively reviewed. Logistic regression analysis was used to identify the predictive ability of each variable for malignancy, and a nomogram was built by integrating patients' age, multiplicity of nodules, cytology results, and suspicious ultrasound features, such as microcalcifications and irregular margins.

RESULTS

For the 233 indeterminate nodules according to the Bethesda System for Reporting Thyroid Cytopathology, the malignancy rates of the subgroups "atypia of undetermined significance," "suspicious follicular neoplasia," and "suspicious for malignancy" were 44.3, 47.7, and 88.0%, respectively. It was found that the Bethesda category "suspicious for malignancy," microcalcifications, and irregular margins were independent risk factors for malignancy. The area under the receiver operating characteristics curve was 0.784, which suggested that the presented nomogram had considerable discriminative performance.

CONCLUSIONS

The nomogram developed in our study accurately predicts the malignancy risk of thyroid nodules with indeterminate cytology by using clinical, cytological, and ultrasonographic features.

Diagnostic value of high b-value (2000 s/mm2) DWI for thyroid micronodules

The aim of the study was to assess the diagnostic value of high b-value (2000 s/mm) diffusion-weighted imaging (DWI) in differentiating malignant from benign thyroid micronodules.Consecutive patients with thyroid micronodules scheduled for Ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) or surgery were underwent high b-value DWI with 3 b-values: 0, 800, and 2000 s/mm. Signal intensity ratios (SIRs) of thyroid micronodules to adjacent normal thyroid tissue on DWI were measured as SIRb0, SIRb800 and SIRb2000. Apparent diffusion coefficients (ADCs) according to the three different b-values were acquired as: ADCb0-800, ADCb0-2000 and ADCb0-800-2000. The 6 diagnostic indicators were evaluated by receiver operating characteristic (ROC) and diagnostic ability was compared between the high b-value DWI and US.Sixty-two malignant thyroid micronodules (48 patients, 13 men and 35 women, aged 44.8 ± 11.7 years) and 57 benign thyroid micronodules (40 patients, 6 men and 34 women, aged 49.6 ± 12.5 years) were enrolled into the final statistical analysis. Among the alone diagnostic indicators, SIRb2000 had the highest diagnostic ability in differentiating malignant from benign thyroid micronodules with area under curve (AUC) of 0.975, sensitivity of 90.32% and specificity of 96.49%. Compared to US, SIRb2000 had a significantly better diagnostic ability US for thyroid micronodules (P < .001) with dramatically raised positive predict value (96.6% vs 78.9%) and reduced false-positive rate (3.51% vs 26.32%).High b-value (2000 s/mm) DWI can contribute to differentiating malignant from benign thyroid micronodules.

Clinical Parameter for Deciding the BRAFV600E Mutation Test in Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance Thyroid Nodules: US Features According to TIRADS

This study aimed to investigate the usefulness of a thyroid imaging reporting and data system (TIRADS) to select thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) cytology for additional BRAF mutation testing. Three hundred three thyroid nodules were included. Statistical analysis was performed at both patient and nodule levels according to BRAF mutation positivity and clinical factors. Univariate and multivariate logistic regression analyses were performed to assess independent associations between BRAF mutation positivity and clinical factors. Of 303 AUS/FLUS nodules, 16 (5.3%) of 303 nodules had the BRAF mutation. The frequency of the BRAF mutation according to the TIRADS was 35.7% for category 5, 10.8% for category 4c, 2.5% for category 4b, 1.1% for category 4a, and 0% for category 3 nodules (P < 0.001). On multivariate analysis, BRAF mutation positivity was significantly associated with high suspicion on the TIRADS (odds ratio, 15.247; P < 0.001). In conclusion, the ultrasonography patterns of the TIRADS can be used as a clinical parameter for deciding the BRAF mutation test in thyroid nodules with AUS/FLUS cytology.

External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Valid and user-friendly prediction models for conversion to open cholecystectomy allow for proper planning prior to surgery. The Cairns Prediction Model (CPM) has been in use clinically in the original study site for the past three years, but has not been tested at other sites.

METHODS

A retrospective, single-centred study collected ultrasonic measurements and clinical variables alongside with conversion status from consecutive patients who underwent laparoscopic cholecystectomy from 2013 to 2016 in The Townsville Hospital, North Queensland, Australia. An area under the curve (AUC) was calculated to externally validate of the CPM.

RESULTS

Conversion was necessary in 43 (4.2%) out of 1035 patients. External validation showed an area under the curve of 0.87 (95% CI 0.82-0.93, p = 1.1 × 10^-14).

CONCLUSIONS

In comparison with most previously published models, which have an AUC of approximately 0.80 or less, the CPM has the highest AUC of all published prediction models both for internal and external validation.

Predicting Factors for Bilaterality in Papillary Thyroid Carcinoma with Tumor Size <4 cm

BACKGROUND

In the 2015 American Thyroid Association guidelines, either lobectomy or total thyroidectomy was recommended for thyroid cancer <4 cm without extrathyroidal extension (ETE) and lymph node (LN) metastasis. Therefore, the purpose of this study was to investigate factors predictive of bilaterality in papillary thyroid carcinoma (PTC) patients with tumor size <4 cm.

METHODS

This study retrospectively reviewed 3296 conventional PTC patients who underwent total thyroidectomy with central neck dissection and/or lateral neck dissection between January 2008 and June 2015.

RESULTS

In overall conventional PTC patients, per 10-year age increment (adjusted odds ratio [OR] = 1.153, p < 0.001), BRAF mutation positivity (adjusted OR = 1.447, p = 0.002) and multifocality (adjusted OR = 3.895, p < 0.001) were independent predictors for bilaterality. In conventional PTC patients with tumor size 1-4 cm, per 10-year age increment (adjusted OR = 1.289, p < 0.001), BRAF mutation positivity (adjusted OR = 1.560, p = 0.012), multifocality (adjusted OR = 4.220, p < 0.001), and N1b (adjusted OR = 1.570, p = 0.007) were independent predictors for bilaterality. In conventional PTC patients with tumor size <1 cm, BRAF mutation positivity (adjusted OR = 1.327, p = 0.042) and multifocality (adjusted OR = 3.530, p < 0.001) were found to be independent predictors for bilaterality.

CONCLUSIONS

When multifocality and BRAF mutation positivity are observed in PTC patients with tumor size <4 cm, total thyroidectomy may be considered. If lobectomy is performed in PTC patients with multifocality and BRAF mutation positivity, meticulous follow-up is needed to detect hidden malignancies in the contralateral lobe.

Novel and Practical Scoring Systems for the Diagnosis of Thyroid Nodules

Objective

The clinical management of patients with thyroid nodules that are biopsied by fine-needle aspiration cytology and yield indeterminate results remains unsettled. The BRAF V600E mutation has dubious diagnostic value due to its low sensitivity. Novel strategies are urgently needed to distinguish thyroid malignancies from thyroid nodules.

Design

This prospective study included 504 thyroid nodules diagnosed by ultrasonography from 468 patients, and fine-needle aspiration cytology was performed under ultrasound guidance. Cytology and molecular analysis, including BRAF V600E, RET/PTC1 and RET/PTC3, were conducted simultaneously. The cytology, ultrasonography results, and mutational status were gathered and analyzed together. Predictive scoring systems were designed using a combination of diagnostic parameters for ultrasonography, cytology and genetic analysis. The utility of the scoring systems was analyzed and compared to detection using the individual methods alone or combined.

Result

The sensitivity of scoring system^a (ultrasonography, cytology, BRAF V600E, RET/PTC) was nearly identical to that of scoring system^b (ultrasonography, cytology, BRAF V600E); these were 91.0% and 90.2%, respectively. These sensitivities were significantly higher than those obtained using FNAC, genetic analysis and US alone or combined; their sensitivities were 63.9%, 70.7% and 87.2%, respectively. Scoring system^c (ultrasonography, cytology) was slightly inferior to the former two scoring systems but still had relatively high sensitivity and specificity (80.5% and 95.1%, respectively), which were significantly superior to those of single cytology, ultrasonography or genetic analysis. In nodules with uncertainty cytology, scoring system^a, scoring system^b and scoring system^c could elevate the malignancy detection rates to 69.7%, 69.7% and 63.6%, respectively.

Conclusion

These three scoring systems were quick for clinicians to master and could provide quantified information to predict the probability of malignant nodules. Scoring system^b is recommended for improving the detection rate among nodules of uncertain cytology.

Personalized Estimate of Chemotherapy-Induced Nausea and Vomiting: Development and External Validation of a Nomogram in Cancer Patients Receiving Highly/Moderately Emetogenic Chemotherapy

Chemotherapy-induced nausea and vomiting (CINV) is presented in over 30% of cancer patients receiving highly/moderately emetogenic chemotherapy (HEC/MEC). The currently recommended antiemetic therapy is merely based on the emetogenic level of chemotherapy, regardless of patient's individual risk factors. It is, therefore, critical to develop an approach for personalized management of CINV in the era of precision medicine.A number of variables were involved in the development of CINV. In the present study, we pooled the data from 2 multi-institutional investigations of CINV due to HEC/MEC treatment in Asian countries. Demographic and clinical variables of 881 patients were prospectively collected as defined previously, and 862 of them had full documentation of variables of interest. The data of 548 patients from Chinese institutions were used to identify variables associated with CINV using multivariate logistic regression model, and then construct a personalized prediction model of nomogram; while the remaining 314 patients out of China (Singapore, South Korea, and Taiwan) entered the external validation set. C-index was used to measure the discrimination ability of the model.The predictors in the final model included sex, age, alcohol consumption, history of vomiting pregnancy, history of motion sickness, body surface area, emetogenicity of chemotherapy, and antiemetic regimens. The C-index was 0.67 (95% CI, 0.62-0.72) for the training set and 0.65 (95% CI, 0.58-0.72) for the validation set. The C-index was higher than that of any single predictor, including the emetogenic level of chemotherapy according to current antiemetic guidelines. Calibration curves showed good agreement between prediction and actual occurrence of CINV.This easy-to-use prediction model was based on chemotherapeutic regimens as well as patient's individual risk factors. The prediction accuracy of CINV occurrence in this nomogram was well validated by an independent data set. It could facilitate the assessment of individual risk, and thus improve the personalized management of CINV.