The impact of age on thyroid cancer staging

Thyroid cancer epidemiology in Ireland from 1994 to 2019 - Rising diagnoses without mortality benefit

BACKGROUND

The epidemiology and management of thyroid cancer has changed radically in the recent past, with rising international incidence of early-stage papillary thyroid cancer (PTC) in particular. In this paper, we review the epidemiology of thyroid cancer in Ireland.

METHODS

A retrospective cohort study of National Cancer Registry of Ireland data, 1994-2019.

RESULTS

Records from 4158 patients were analysed. 73 % (n = 3040) were female. The average age was 50.4 years. Patient sex did not change over time (p = 0.662), while age decreased significantly (p < 0.0001). The most common diagnoses were PTC (n = 2,905, 70 %) and follicular thyroid carcinoma (n = 549, 13 %). Incidence rose over threefold (1.8-6.2 cases/100000 person-years). The incidence of T1 PTC rose over twelvefold (0.169-2.1 cases/100000 person-years), while the incidence of stage III and IV disease did not change significantly. Five-year disease-specific survival (DSS) was 85 % and varied significantly by diagnosis - 97 % for PTC versus 5 % for anaplastic thyroid carcinoma. Survival did not change significantly over time. Male sex was a risk factor for more advanced disease (p < 0.0001) but did not independently predict overall survival except in PTC (HR 1.6, p = 0.03). The use of radioactive iodine declined markedly from 49 % to 12.5 %. RAI improved DSS for PTC patients aged over 55 years (p = 0.02) without a notable effect on survival for those under 55 years (p = 0.99).

CONCLUSION

The epidemiology and management of thyroid cancer in Ireland has changed dramatically in a manner reflective of international trends.

The survival after thyroidectomy versus lobectomy in multifocal papillary thyroid microcarcinoma patients

BACKGROUND

The extent of thyroid surgery for multifocal papillary thyroid microcarcinoma (PTMC) remains controversial. Studies on the optimal surgical approach for a multifocal PTMC are scarce. This study aimed to compare the effectiveness of thyroidectomy and lobectomy for the treatment of multifocal PTMC.

METHODS

A population-based retrospective cohort of patients with multifocal PTMC was analyzed using the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2017, and divided into two groups (thyroidectomy, lobectomy) based on the surgical approach. The clinicopathologic features and survival outcomes were compared between the two groups. Cox proportional hazards regression analysis to explore prognostic factors of survival. Propensity score matching (PSM) was used to balance covariates.

RESULTS

Overall, a total of 9387 multifocal PTMC patients were included in the study. Among them, 8,107 (86.36%) patients received thyroidectomy, and 1280 (13.64%) patients underwent lobectomy. Compared to patients in the thyroidectomy group, patients in the lobectomy group were diagnosed with older age (50.47 years vs. 49.32 years, p = 0.003), a higher proportion of males (20.47% vs. 14.99%, p < 0.001), larger tumors (6.22 mm vs. 4.97 mm, p < 0.001), and more frequently underwent radiotherapy (35.40% vs. 10.16%, p < 0.001). Multivariate Cox regression analysis revealed that age was the only independent prognostic factor for thyroid cancer-specific survival (TCSS), and the determinants of overall survival (OS) were age and gender. Unadjusted survival analysis revealed no difference between the two treatment groups in TCSS (p = 0.598) and OS (p = 0.126). After 1:1 Propensity Score Matching (PSM), there was still no difference in TCSS (p = 0.368) or OS (p = 0.388). The stratified analysis revealed that for patients aged under or above 55, thyroidectomy was not associated with superior BCSS or OS (p > 0.05).

CONCLUSIONS

Thyroidectomy was not associated with improved survival compared to thyroid lobectomy for patients with multifocal PTMC.

Multi-omics data analysis reveals the complex roles of age in differentiated thyroid cancer

Aims

Age is a major risk factor for differentiated thyroid cancer (DTC); however, the mechanisms underlying aging-regulated progression of DTC remains unclear.

Methods

Based on multi-omics data (transcriptional files, somatic mutation files, methylation files) derived from the TCGA database, we comprehensively investigated the genomic and biological features associated with aging in patients with DTC.

Results

We confirmed that age was an independent risk factor for overall survival and progression-free survival of patients with DTC, and confirmed that 55 years of age (adopted in the 8th AJCC staging system) is an appropriate cutoff for patients with DTC rather than 45 years (adopted in the 7th AJCC staging system). Using 55 years as the cutoff, we demonstrated DNA methylation-driven transcriptional regulation during aging, and identified the landscape of somatic mutations in young and old patients with DTC along with two aging-related mutations: TTN and EIF1AX. Subsequently, we investigated the infiltration of immune cells in DTC, and found that old patients exhibited decreased CD8+ T cells infiltration with lower cytotoxicity. Finally, we constructed a prognosis prediction model based on three age-related genes (PTK2B, E2F1, and GHR) that showed satisfactory performance in predicting patients prognosis.

Conclusions

We comprehensively investigated the complex interplay between age and biological features of DTC, which may provide new insights into the role of aging in DTC.

Survival Prognostication in Patients with Differentiated Thyroid Cancer and Distant Metastases: A SEER Population-Based Study

Background: For patients with thyroid cancer, distant metastasis is a significant predictor of poor outcome. Since distant metastasis occurs in less than 10% of patients with differentiated thyroid cancer, correlates of survival in this vulnerable patient population remain understudied. This study aimed to identify prognostic groups among patients with differentiated thyroid cancer and distant metastases and to determine the role of, and interactions between, patient and tumor characteristics in determining survival. Methods: We identified adult patients diagnosed with differentiated thyroid cancer with distant metastases from the U.S. SEER-17 cancer registry (2010-2019). Analyses were performed using Cox proportional hazards regression, survival trees, and random survival forest. Relative importance of patient and tumor factors important for disease-specific and overall survival was assessed based on the random survival forest analyses. Results: Cohort consisted of 2411 patients with differentiated thyroid cancer with distant metastases followed for a median of 62 months. Most common histopathologic subtype (86.0%) was papillary thyroid cancer, and the most common sites of distant metastasis were the lungs (33.7%) and bone (18.9%). Cox proportional hazards model illustrated significant associations between survival and the following: patient age (p < 0.001), tumor size (p < 0.01), and site of distant metastasis (p < 0.05). Survival tree analyses identified three distinct prognostic groups based on disease-specific survival (DSS) (5-year survival of the prognostic groups was 92%, 64%, and 41%; p < 0.001) and four distinct prognostic groups based on overall survival (OS) (5-year survival of the prognostic groups was 96%, 84%, 57%, and 31%; p < 0.001). The first split in the survival trees for DSS and OS was by age at diagnosis (≤57 years vs. ≥58 years) with subsequent splits based on presence/absence of lung metastases, tumor size (≤4 cm vs. >4 cm), and patient age. A total of 558 patients (23.1%) died from thyroid cancer, and 757 patients (31.4%) died from all causes during the study period. Conclusions: This study identifies distinct prognostic groups for patients with differentiated thyroid cancer with distant metastases and highlights the importance of patient age, lung metastases, and tumor size for determining both disease-specific and overall survival. These findings inform risk stratification and treatment decision-making in this understudied patient population.

Machine learning algorithms for identifying contralateral central lymph node metastasis in unilateral cN0 papillary thyroid cancer

Purpose

The incidence of thyroid cancer is growing fast and surgery is the most significant treatment of it. For patients with unilateral cN0 papillary thyroid cancer whether to dissect contralateral central lymph node is still under debating. Here, we aim to provide a machine learning based prediction model of contralateral central lymph node metastasis using demographic and clinical data.

Methods

2225 patients with unilateral cN0 papillary thyroid cancer from Wuhan Union Hospital were retrospectively studied. Clinical and pathological features were compared between patients with contralateral central lymph node metastasis and without. Six machine learning models were constructed based on these patients and compared using accuracy, sensitivity, specificity, area under the receiver operating characteristic and decision curve analysis. The selected models were then verified using data from Differentiated Thyroid Cancer in China study. All statistical analysis and model construction were performed by R software.

Results

Male, maximum diameter larger than 1cm, multifocality, ipsilateral central lymph node metastasis and younger than 50 years were independent risk factors of contralateral central lymph node metastasis. Random forest model performed better than others, and were verified in external validation cohort. A web calculator was constructed.

Conclusions

Gender, maximum diameter, multifocality, ipsilateral central lymph node metastasis and age should be considered for contralateral central lymph node dissection. The web calculator based on random forest model may be helpful in clinical decision.

Impact of age on central lymph nodes involvement in papillary thyroid cancer

BACKGROUND

Total thyroidectomy is the main line of treatment for papillary thyroid cancer. Central lymph node dissection (CLND) is still debatable. In this study, we aimed to correlate the central lymph node status with the age of patients.

METHODS

This is a retrospective study including patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy and CLND at a tertiary cancer center during the period from January 2012 to September 2022. Patients were subdivided into 3groups: patients younger than 20 years old, patients between 20 and 40 years old, and patients older than 40 years old. Correlation between central lymph node status, lateral lymph node status, and harvest count with each other and between age groups was done.

RESULTS

315 patients were included. The younger the age group the higher the possibility of harboring positive central nodes, however, the positivity of lateral nodes was similar. Neither central nodal harvest nor positive central node count significantly differed between groups. The lateral nodal harvest was significantly higher in the < 20 years group with no affection to the number of positive nodes retrieved. The younger the age group the longer the disease-free survival (DFS).

CONCLUSION

We can conclude that patients younger than twenty years had a higher probability of harboring malignancy in central nodes and higher lateral node harvest on dissection. In contrast, they do have a lower incidence of recurrence.

Expression and prognosis analysis of integrin subunit α3 (ITGA3) in papillary thyroid cancer

Integrin subunit α3 (ITGA3) is a member of the integrin family and interacts with extracellular matrix proteins. However, there have been few reports regarding the role of ITGA3 in papillary thyroid cancer. The expression levels of ITGA3 were firstly analyzed by bioinformatics tools and in vitro experiments, followed by evaluating its prognostic significance in papillary thyroid cancer patients using Kaplan-Meier, receiver operating characteristic, and Cox regression analyses. Then, cBioportal and GSCA databases were applied to evaluate genetic alterations of ITGA3. Functional enrichment analysis was conducted and the upstream miRNAs of ITGA3 were determined. The results showed that the ITGA3 mRNA and protein levels were higher in the papillary thyroid cancer group than those in the normal group (all P < 0.05). Moreover, ITGA3 performed well in distinguishing the recurrence-free survival (RFS) status and served as an independent prognostic factor of papillary thyroid cancer patients (P < 0.01). Besides, significant relations between ITGA3 and genetic alterations were observed (FDR <0.01). Functional enrichment analysis indicated ECM-receptor interaction and cell adhesion molecules were the shared regulatory pathways. Moreover, ITGA3 might be the target gene of hsa-miR-3129, hsa-miR-181d, hsa-miR-181b, hsa-miR-199a, and hsa-miR-199b. Of note, the ITGA3 mRNA level was reduced after has-miR-199b-3p/5p was overexpressed. In conclusion, ITGA3 could be a reliable biomarker and have potential value in predicting the RFS status of papillary thyroid cancer patients.

Natural History and Prognostic Model of Untreated Papillary Thyroid Cancer: A SEER Database Analysis

PURPOSE

This investigation leveraged the SEER database to delve into the progression patterns of PTC when left untreated. Furthermore, it aimed to devise and authenticate a nomogram for prognosis prediction for such patients.

METHODS

We extracted data from the SEER database, focusing on PTC-diagnosed individuals from 2004-2020. To discern disease progression intervals, median survival times across stages were gauged, and the disease progression time was estimated by subtracting the median survival time of a more severe stage from its preceding stage. Prognostic determinants in the training set were pinpointed using both univariate and multivariate Cox regression. Using these determinants, a prognostic nomogram was crafted.

RESULTS

In untreated PTC patients, those in stages I and II had a favorable prognosis, with 10-year overall survival rates of 86.34% and 66.03%, respectively. Patients in stages III and IV had a relatively poorer prognosis. The median survival time of stage III, stage IVA, stage IVB and stage IVC patients was 108months, 43 months, 20 months and 8 months, respectively. The deduced progression intervals from stages III-IVC were 65, 23, and 12 months. In the training set, age, tumor stage, gender, and marital status were identified as independent risk factors influencing the prognosis of untreated PTC, and a nomogram was constructed using these variables.

CONCLUSION

In the absence of treatment intervention, early-stage PTC progressed slowly with an overall favorable prognosis. However, in mid to advanced-stage PTC, as tumor stage increased, disease progression accelerated, and prognosis gradually worsened. Age, tumor stage, marital status, and gender were independent risk factors influencing the prognosis of untreated PTC, and the nomogram based on these factors demonstrated good prognostic capability.

Development and validation of nomograms for predicting the risk of central lymph node metastasis of solitary papillary thyroid carcinoma of the isthmus

BACKGROUND

This study was conducted to develop nomograms and validate them by assessing risk factors for the development of central lymph node metastasis (CLNM) in patients with solitary papillary thyroid carcinoma of the isthmus (PTCI) for predicting the probability of CLNM.

METHODS

Demographic and clinicopathological variables of patients with solitary papillary thyroid carcinoma (PTC) from May 2018 to May 2023 at the First Hospital of Shanxi Medical University were retrospectively analyzed, and the lobar group and the isthmus group were divided according to tumor location. Patients with the same sex, age difference of less than 3 years, and equal gross tumor diameter were selected from the lobar group and compared with the paraisthmic tumor group. Independent risk factors were determined using univariate and multivariate logistic regression analysis. On this basis, clinical predictive nomograms were developed and validated.

RESULTS

Clinical data from 326 patients with solitary PTCI and 660 cases of solitary lobar PTC were used for analysis in our study. The incidence of solitary tumors CLNM located in the median isthmus, paracentral isthmus, and lobes was 69.8%, 40.9%, and 33.6%, respectively. Statistical analysis revealed that gender, age, isthmus location, maximum nodal diameter, the presence of possible CLNM in advance on preoperative ultrasound, chronic lymphocytic thyroiditis, and the lymphocyte/monocyte ratio were independent risk factors for preoperative CLNM in patients with solitary PTCI. Age, isthmus location, chronic lymphocytic thyroiditis, gross tumor diameter, presence of intraoperative extrathyroidal extension, and presence of metastasis in the Delphian lymph node on frozen section were independent risk factors for intraoperative CLNM. The concordance indices of nomograms for preoperative and intraoperative are 0.871 and 0.894 in the training set and 0.796 and 0.851 in the validation set, calibration curve and decision curve analysis also demonstrated the strong reliability and clinical applicability of this clinical prediction model.

CONCLUSION

In this study, we concluded that solitary PTCI is more aggressive compared to solitary lobar PTC, and we constructed nomograms and risk stratification to accurately identify patients with solitary PTCI who are at high risk of developing CLNM, which will help clinicians in personalized decision making.

Neutrophil extracellular traps and neutrophil-related mediators in human thyroid cancer

Background

Polymorphonuclear neutrophils (PMNs) are the main effector cells in inflammatory responses and play multiple roles in thyroid cancer (TC). PMNs contain and release a plethora of mediators, including granular enzymes [e.g., myeloperoxidase (MPO), pentraxin-3 (PTX3) and matrix metalloproteinase-9 (MMP-9)], and neutrophil extracellular traps (NETs). The aim of this study was to evaluate NETs and neutrophil-derived mediators as possible biomarkers in TC patients.

Methods

20 patients with differentiated thyroid cancer (DTC), 26 patients with dedifferentiated thyroid cancer (De-DTC), 26 patients with multinodular goiter (MNG) and 22 healthy controls (HCs) were recruited. Serum concentrations of free DNA (dsDNA), nucleosomes, citrullinated histone H3 (CitH3) and MPO-DNA complexes were evaluated as NET biomarkers. Neutrophil-related mediators such as MPO, PTX3, MMP-9, CXCL8, and granulocyte-monocyte colony-stimulating factor (GM-CSF) were measured by ELISA.

Results

Serum levels of all four NET biomarkers were increased in DeDTC patients compared to HCs. CitH3 serum levels were selectively increased in both DeDTC and DTC patients compared to HCs and MNG patients. MPO-DNA complexes and nucleosomes were selectively increased only in DeDTC patients compared to HCs and MNG patients. Moreover, MPO-DNA complexes were selectively increased in DeDTC patients compared to DTC patients also. MPO circulating levels were selectively increased in the DeDTC patient subgroup compared to HCs. Circulating levels of PTX3, MMP-9 and GM-CSF were increased in DTC and DeDTC patients compared to HCs. Nucleosomes positively correlated with dsDNA, CitH3, MPO and CXCL8. MPO-DNA complexes positively correlated with dsDNA, CitH3, CXCL8, MPO and nucleosome levels. Moreover, three out of the four NET biomarkers (i.e., dsDNA, nucleosomes and MPO-DNA complexes) were increased in elderly patients compared to young patients and in patients with metastatic disease at diagnosis compared to non metastatic patients. Nucleosomes were higher in males compared to females.

Conclusion

MPO-DNA complexes, nucleosomes and, to some extent, CitH3 levels seem to correlate with malignancy and severity of progressive TC. Moreover, serum concentrations of PMN-related mediators (MPO, PTX3, GM-CSF) were increased in TCs compared to MNG and HCs.

Is it Possible to Diagnose "Non-Invasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features" Preoperatively?

There is no accepted consensus or algorithm for the preoperative diagnosis of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in patients with thyroid nodules. In this study, we evaluated the importance of preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in the differential diagnosis of NIFTP. Pathology preparations of 209 patients with a follicular variant of papillary thyroid carcinoma (FVPTC) diagnosed after thyroid surgery in a tertiary health center between January 2010 and January 2020 were re-evaluated. Patients were divided into NIFTP and encapsulated follicular variant papillary thyroid carcinoma (EFVPTC) to compare. Of the patients, 58 (27.7%) were NIFTP, and 151 (72.3%) were EFVPTC. There was no statistically significant difference in terms of age (p = 0.46), tumor size (p = 0.51), gender (p = 0.48), and surgical technique (p = 0.78) between the groups. The probability of the neutrophil-to-lymphocyte ratio (NLR) > 2 is more common in the EFVPTC group. It was statistically significant that the NIFTP group was 1.96 times more likely to have NLR > 2 (OR: 1.96, 95% CI: 1.06-3.63) (p < 0.05). However, there was no risk difference between the groups in terms of the platelet-to-lymphocyte ratio (PLR) (OR: 0.76, 95% CI: 0.41-1.43) (p > 0.05). The diagnosis of NIFTP should be kept in mind in the evaluation of patients whose thyroid fine-needle aspiration (FNA) biopsy results are in the intermediate group. NIFTP exhibits better prognostic findings than classic thyroid papillary cancer and EFVPTC. Therefore, preoperative diagnosis of NIFTP in line with laboratory, ultrasonography, and FNA findings will save the patient from unnecessary overtreatment.

Combined Conventional Ultrasound and Contrast-Enhanced Computed Tomography for Cervical Lymph Node Metastasis Prediction in Papillary Thyroid Carcinoma

OBJECTIVES

This study aimed to evaluate conventional ultrasound (US) combined with contrast-enhanced computed tomography (CT) of the neck to predict central lymph node metastasis (CLNM) in clinical lymph-negative patients with papillary thyroid carcinoma (PTC), establish a simple preoperative risk-scoring model, and validate its effectiveness in a two-center dataset.

METHODS

A total of 423 patients with PTC preoperatively evaluated by US and contrast-enhanced CT were included in the modeling group, and 102 patients from two hospitals were enrolled in the validation group. Independent predictive factors were determined using multivariate logistic regression analysis. Diagnostic performance was evaluated using receiver operating characteristic curve analysis.

RESULTS

The independent predictive factors for CLNM were age ≤45 years (odds ratio [OR] = 3.950), nodule presence in the non-upper pole (OR = 2.385), nodule size >12.5 mm (OR = 2.130), Thyroid Imaging Reporting and Data System score ≥9 (OR = 2.857), normalized enhancement CT value ≥0.75 (OR = 3.132), central enhancement (OR = 0.222), and capsular invasion (OR = 3.478). The area under the curve (AUC) of the model was 0.790 (95% confidence interval [CI]: 0.747-0.834), and the sensitivity and specificity were 70.4% and 73.9%, respectively. The AUC in the validation group was 0.827 (95% CI: 0.747-0.907), and the sensitivity and specificity were 88.9% and 63.2%, respectively.

CONCLUSIONS

We found conventional US combined with contrast-enhanced CT of the neck to be useful in predicting CLNM preoperatively and established a simple risk-scoring model that might help surgeons with appropriate surgical plans and prognostic evaluation.

Disease-Specific Survival Trends for Patients Presenting with Differentiated Thyroid Cancer and Distant Metastases in the United States, 1992-2018

Objective: Differentiated thyroid cancer (DTC) is associated with an excellent prognosis, but patients with distant metastatic DTC have a 10-year disease-specific survival (DSS) of just 50%. The incidence of distant metastatic DTC has steadily increased in the United States since the 1980s. The aim of this study was to examine trends in survival and treatment for patients with distant metastatic DTC. Methods: In this population-based, retrospective cohort study, patients with distant metastatic DTC were identified from the Surveillance, Epidemiology, and End Results-13 cancer registry program. Multivariable logistic and Cox regression analyses were used to examine factors associated with DSS and management. Annual percentage changes in treatment patterns were calculated using log-linear regression. Results: During 1992-2018, 1991 patients (69.7% white, 58.0% female, 47.5% aged ≥65 years) were diagnosed with distant metastatic DTC. Papillary thyroid cancer was the most common histological type (74.5%). While the 10-year DSS for overall DTC increased over time (95.4% for patients diagnosed in 1992-1998, 96.6% in 1999-2008, and 97.3% in 2009-2018; p < 0.01), 10-year DSS for DTC with distant metastases did not change (50.2%, 47.3%, and 52.4%, respectively; p = 0.48). Ten-year DSS rates were reduced for patients aged ≥65 years (28.1%), patients undergoing nonsurgical treatment with external beam radiation therapy and/or systemic therapy (6.0%), and patients undergoing no/unknown treatment (32.8%). On multivariable analysis, oncocytic carcinoma, age 65-79 and ≥80 years, male sex, node-positive disease, larger tumor size, nonsurgical treatment, and no/unknown treatment were associated with increased risk of thyroid cancer death. Between 1992 and 2018, the rate of nonsurgical treatment increased, on average, 1.3% per year (1992-1998: 22.9% vs. 2009-2018: 25.6%; p = 0.03), and the rate of patients receiving no/unknown treatment increased 1.9% per year (1992-1998: 11.3% vs. 2009-2018: 15.6%; p = 0.01). Patients aged 65-79 and ≥80 years were more likely than younger patients to receive nonsurgical management or no/unknown treatment. Conclusion: Patients diagnosed with distant metastatic DTC have experienced no improvement in DSS over the past three decades. An increasing proportion of patients diagnosed with distant metastatic DTC are receiving nonsurgical treatment or no/unknown treatment over time; the proportion was highest among the oldest patients.

A practical dynamic nomogram model for predicting bone metastasis in patients with thyroid cancer

PURPOSE

The aim of this study was to established a dynamic nomogram for assessing the risk of bone metastasis in patients with thyroid cancer (TC) and assist physicians to make accurate clinical decisions.

METHODS

The clinical data of patients with TC admitted to the First Affiliated hospital of Nanchang University from January 2006 to November 2016 were included in this study. Demographic and clinicopathological parameters of all patients at primary diagnosis were analyzed. Univariate and multivariate logistic regression analysis was applied to build a predictive model incorporating parameters. The discrimination, calibration, and clinical usefulness of the nomogram were evaluated using the C-index, ROC curve, calibration plot, and decision curve analysis. Internal validation was evaluated using the bootstrapping method.

RESULTS

A total of 565 patients were enrolled in this study, of whom 25 (4.21%) developed bone metastases. Based on logistic regression analysis, age (OR=1.040, P=0.019), hemoglobin (HB) (OR=0.947, P<0.001) and alkaline phosphatase (ALP) (OR=1.006, P=0.002) levels were used to construct the nomogram. The model exhibited good discrimination, with a C-index of 0.825 and good calibration. A C-index value of 0.815 was achieved on interval validation analysis. Decision curve analysis showed that the nomogram was clinically useful when intervention was decided at a bone metastases possibility threshold of 1%.

CONCLUSIONS

This dynamic nomogram, with relatively good accuracy, incorporating age, HB, and ALP, could be conveniently used to facilitate the prediction of bone metastasis risk in patients with TC.

Aging and cancer epigenetics: Where do the paths fork?

Aging and cancer are clearly associated processes, at both the epidemiological and molecular level. Epigenetic mechanisms are good candidates to explain the molecular links between the two phenomena, but recent reports have also revealed considerable differences, particularly regarding the loss of DNA methylation in the two processes. The large-scale generation and availability of genome-wide epigenetic data now permits systematic studies to be undertaken which may help clarify the similarities and differences between aging and cancer epigenetic alterations. In addition, the development of epigenetic clocks provides a new dimension in which to investigate diseases at the molecular level. Here, we examine current and future questions about the roles of DNA methylation mechanisms as causal factors in the processes of aging and cancer so that we may better understand if and how aging-associated epigenetic alterations lead to tumorigenesis. It seems certain that comprehending the molecular mechanisms underlying epigenetic clocks, especially with regard to somatic stem cell aging, combined with applying single-cell epigenetic-age profiling technologies to aging and cancer cohorts, and the integration of existing and upcoming epigenetic evidence within the genetic damage models of aging will prove to be crucial to improving understanding of these two interrelated phenomena.

A novel prognostic model for papillary thyroid cancer based on epithelial-mesenchymal transition-related genes

BACKGROUND

The frequent incidence of postsurgical recurrence issues in papillary thyroid cancer (PTC) patients is a primary concern considering the low cancer-related mortality. Previous studies have demonstrated that epithelial-mesenchymal transition (EMT) activation is closely related to PTC progression and invasion. In this study, we aimed to develop a novel EMT signature and ancillary nomogram to improve personalized prediction of progression-free interval (PFI).

METHODS

First, we carried out a differential analysis of PTC samples and pairwise normal thyroid samples to explore the differentially expressed genes (DEGs). The intersection of the DEGs with EMT-related genes (ERGs) were identified as differentially expressed EMT-related genes (DE-ERGs). We determined PFI-related DE-ERGs by Cox regression analysis and then established a novel gene classifier by LASSO regression analysis. We validated the signature in external datasets and in multiple cell lines. Further, we used uni- and multivariate analyses to identify independent prognostic characters.

RESULTS

We identified 244 prognosis-related DE-ERGs. The 244 DE-ERGs were associated with several pivotal oncogenic processes. We also constructed a novel 10-gene signature and relevant prognostic model for recurrence prediction of PTC. The 10-gene signature had a C-index of 0.723 and the relevant nomogram had a C-index of 0.776. The efficacy of the signature and nomogram was satisfying and closely correlated with relevant clinical parameters. Furthermore, the signature also had a unique potential in differentiating anaplastic thyroid cancer (ATC) samples.

CONCLUSIONS

The novel EMT signature and nomogram are useful and convenient for personalized management for thyroid cancer.

Factors affecting the health-promoting behavior of thyroid cancer survivors: comparison by stage of cancer survivorship

PURPOSE

The purpose of this study was to identify differences in factors affecting health-promoting behaviors according to the survival stage of thyroid cancer survivors.

METHODS

This descriptive cross-sectional study analyzed data from 354 thyroid cancer survivors after diagnosis. The survivors were divided into three stages: (1) the acute stage (< 2 years after diagnosis), (2) extended stage (2-5 years after diagnosis), and (3) permanent stage (≥ 5 years after diagnosis). To measure health-promoting behavior, the revised Korean version of the Health Promoting Lifestyle Profile questionnaires was used. The factors affecting the health-promoting behavior included social support, self-efficacy, fear of recurrence, and symptoms. Multiple regression analysis was used to analyze factors affecting the health-promoting behavior according to survival stage.

RESULT

The factors affecting the health-promoting behavior of thyroid cancer survivors differed by survival stage. In the acute stage, the factors of health-promoting behavior were self-efficacy (t = 4.76, p < .001) and social support (t = 3.54, p < .001). In the extended stage, symptoms (t =  - 3.65, p < .001), social support (t = 2.61, p = .011), fear of recurrence (t = 2.18, p = .032), and receipt of radioiodine treatment (t =  - 2.18, p = .032) were found to be significant variables that affected health-promoting behaviors. In the permanent stage, social support (t = 2.79, p = .007), receipt of radioiodine treatment (t =  - 3.21, p = .002), and age (t =  - 2.77, p = .007) were significant variables that affected health-promoting behaviors.

CONCLUSION

The experience of thyroid cancer survivors varies as they progress through the survival stages; thus, health-promotion interventions should be tailored to each survival stage.

An Integrative Multi-Omics Analysis of The Molecular Links between Aging and Aggressiveness in Thyroid Cancers

Aging modifies risk in all cancers, but age is used as a clinical staging criterion uniquely in thyroid cancer (TC). The molecular drivers of age-dependent TC onset and aggressiveness remain poorly understood. We applied an integrative, multi-omics data analysis approach to characterize these signatures. Our analysis reveals that aging, independent of BRAF^V600E mutational status, drives a significant accumulation of aggressiveness-related markers and poorer survival outcomes, most noticeably at age 55 and over. We identified that chromosomal alterations in loci 1p/1q as aging-associated drivers of aggressiveness, and that depleted infiltration with tumor surveillant CD8+T and follicular helper T cells, dysregulation of proteostasis- and senescence-related processes, and ERK1/2 signaling cascade are key features of the aging thyroid and TC onset/progression and aggressiveness in aging patients but not in young individuals. A panel of 23 genes, including those related to cell division such as CENPF, ERCC6L, and the kinases MELK and NEK2, were identified and rigorously characterized as aging-dependent and aggressiveness-specific markers. These genes effectively stratified patients into aggressive clusters with distinct phenotypic enrichment and genomic/transcriptomic profiles. This panel also showed excellent performance in predicting metastasis stage, BRAF^V600E, TERT promoter mutation, and survival outcomes and was superior to the American Thyroid Association (ATA) methodology in predicting aggressiveness risk. Our analysis established clinically relevant biomarkers for TC aggressiveness factoring in aging as an important component.

Identifying key genes of classic papillary thyroid cancer in women aged more than 55 years old using bioinformatics analysis

BACKGROUND

The incidence rate of thyroid carcinoma (THCA) markedly increased in the recent few decades and has been likely over-diagnosed, especially papillary thyroid cancer (PTC) in women. However, the incidence of advanced-stage papillary thyroid cancer is also rising. According to earlier studies, tumors with identical pathology might have different clinical outcomes, which implies some variances in papillary thyroid cancer. Although the mortality of thyroid cancer has remained stable or declined, there is still an important problem in estimating whether it is benign or needs surgery for patients with papillary thyroid cancer.

METHODS

After obtaining data from The Cancer Genome Atlas (TCGA) Project-THCA database by R package TCGA bio links, 18 samples (11 at stage IV as high-risk group and 7 at stage I as low-risk group) were obtained using survival package and edgeR to ensure differential expression; ClusterProfiler package was used to carry on gene set enrichment analysis and searched the possible pathways in the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. STRING and Cytoscape were used to construct and modify the protein-protein interaction (PPI) network to get hub genes of differentially expressed genes. Next, the pROC package was used to get the receiver operating characteristic (ROC) curves of hub genes' disease-free survival (DFS). Then, transcription factors (TFs) and miRNAs of key genes were predicted by ENCORI and AnimalTFDB. In the end, TF-target genes-miRNA regulatory network was also constructed by Cytoscape.

RESULTS

Our research obtained the top 9 candidate genes from the whole network (IFNA1, MRC1, LGALS3, LOX, POSTN, TIMP1, CD276, SDC4, and TLR2). According to the ROC results, TIMP1, LOX, CD276, IFNA1, TLR2, and POSTN were considered to play a more critical role in malignant papillary thyroid cancer or immature cancer of papillary thyroid cancer. Our analysis concludes that TIMP1, LOX, CD276, IFNA1, TLR2, and POSTN are identified as thyroid cancer biomarkers, which lead to the different clinical courses of a woman older than 55 years old with papillary thyroid cancer. Especially CD276, POSTN, and IFNA1 may be considered as new biomarkers associated with the prognosis of thyroid cancer.

CONCLUSIONS

TIMP1, LOX, CD276, IFNA1, TLR2, and POSTN have different expressions in PTCs, which lead to the various clinical courses of a woman older than 55 years old with papillary thyroid cancer. Especially CD276, POSTN, and IFNA1 may be considered as new potential biomarkers associated with the prognosis of thyroid cancer. In addition, TF-miRNA-target gene regulatory network may help further reach for PTC.

Prognostic biomarkers for predicting papillary thyroid carcinoma patients at high risk using nine genes of apoptotic pathway

Aberrant expressions of apoptotic genes have been associated with papillary thyroid carcinoma (PTC) in the past, however, their prognostic role and utility as biomarkers remains poorly understood. In this study, we analysed 505 PTC patients by employing Cox-PH regression techniques, prognostic index models and machine learning methods to elucidate the relationship between overall survival (OS) of PTC patients and 165 apoptosis related genes. It was observed that nine genes (ANXA1, TGFBR3, CLU, PSEN1, TNFRSF12A, GPX4, TIMP3, LEF1, BNIP3L) showed significant association with OS of PTC patients. Five out of nine genes were found to be positively correlated with OS of the patients, while the remaining four genes were negatively correlated. These genes were used for developing risk prediction models, which can be utilized to classify patients with a higher risk of death from the patients which have a good prognosis. Our voting-based model achieved highest performance (HR = 41.59, p = 3.36x10^-4, C = 0.84, logrank-p = 3.8x10^-8). The performance of voting-based model improved significantly when we used the age of patients with prognostic biomarker genes and achieved HR = 57.04 with p = 10⁻⁴ (C = 0.88, logrank-p = 1.44x10^-9). We also developed classification models that can classify high risk patients (survival ≤ 6 years) and low risk patients (survival > 6 years). Our best model achieved AUROC of 0.92. Further, the expression pattern of the prognostic genes was verified at mRNA level, which showed their differential expression between normal and PTC samples. Also, the immunostaining results from HPA validated these findings. Since these genes can also be used as potential therapeutic targets in PTC, we also identified potential drug molecules which could modulate their expression profile. The study briefly revealed the key prognostic biomarker genes in the apoptotic pathway whose altered expression is associated with PTC progression and aggressiveness. In addition to this, risk assessment models proposed here can help in efficient management of PTC patients.

Machine learning for the prediction of bone metastasis in patients with newly diagnosed thyroid cancer

OBJECTIVES

This study aimed to establish a machine learning prediction model that can be used to predict bone metastasis (BM) in patients with newly diagnosed thyroid cancer (TC).

METHODS

Demographic and clinicopathologic variables of TC patients in the Surveillance, Epidemiology, and End Results database from 2010 to 2016 were retrospectively analyzed. On this basis, we developed a random forest (RF) algorithm model based on machine-learning. The area under receiver operating characteristic curve (AUC), accuracy score, recall rate, and specificity are used to evaluate and compare the prediction performance of the RF model and the other model.

RESULTS

A total of 17,138 patients were included in the study, with 166 (0.97%) developed bone metastases. Grade, T stage, histology, race, sex, age, and N stage were the important prediction features of BM. The RF model has better predictive performance than the other model (AUC: 0.917, accuracy: 0.904, recall rate: 0.833, and specificity: 0.905).

CONCLUSIONS

The RF model constructed in this study could accurately predict bone metastases in TC patients, which may provide clinicians with more personalized clinical decision-making recommendations. Machine learning technology has the potential to improve the development of BM prediction models in TC patients.

Age Influences the Prognosis of Anaplastic Thyroid Cancer Patients

BACKGROUND

The staging system for patients with anaplastic thyroid cancer (ATC) was updated in the 8^th edition of the American Joint Committee on Cancer Staging Manual. A cut-off age of 55 years was stipulated as a prognostic factor for differentiated thyroid cancer; however, age was not considered for ATC patients. To this end, this study investigated the relationship between age at diagnosis and prognosis of ATC patients.

METHODS

The clinical information on ATC patients was acquired from the Surveillance, Epidemiology, and End Results Program public database. Youden's index and X-tile analyses were used to calculate the high-point age at diagnosis associated with prognosis. Cox proportional hazards models, Kaplan-Meier curves, and 1000-person-year were then used for verifying the accuracy of the high-point age.

RESULTS

After inclusion/exclusion criteria was applied, 586 patients were included in this study. The high-point age was determined to be 70 years by both the Youden's index and X-tile plot methods. The hazard ratio was 1.662 (95% confidence interval [CI]: 1.321-2.092), indicating that there was an increased risk of poor prognosis for patients > 70 years of age. The cancer-specific mortality rates per 1000-person-years for patients ≤ and > 70 years-old were 949.980 (95% CI: 827.323-1090.822) and 1546.667 (95% CI: 1333.114-1794.428), respectively. P-values were < 0.001 for the results shown above.

CONCLUSION

Our study found that age influenced the prognosis of ATC patients. Furthermore, we determined that the high-point age at diagnosis was 70 years and that > 70 years of age was associated with a poor prognosis. These results provide a useful addition to the staging manual and can improve the diagnosis, treatment strategies and prognosis of ATC patients.

The age threshold of the 8th edition AJCC classification is useful for indicating patients with aggressive papillary thyroid cancer in clinical practice

BACKGROUND

Papillary thyroid cancer (PTC) is unique among cancers in that patient age is a consideration in staging. One of the most important modifications in the 8th Edition of the American Joint Committee on Cancer (AJCC) classification is to increase the age cut off for risk stratification in PTC from 45 to 55 years. However, whether this cut off is useful in clinical practice remains controversial. In the present study, we assessed how well this new age threshold stratifies patients with aggressive PTC.

METHODS

We retrospectively analyzed the clinicopathological features and overall survival rate of patients with PTC admitted to and surgically treated at a single surgical center. The study protocol was divided into two series. In each series all patients (n = 523) were divided in 2 groups according to age cut off. In the first series (cut off 45) patients < 45 (n = 193) vs. ≥45 (n = 330) were compared, and in the second series (cut off 55) patients < 55 (n = 306) vs. ≥55 (n = 217) were compared.

RESULTS

The rate of the prevalence of locally advanced disease (pT3 and pT4) was significantly higher in the patients above 55 years old than in those below 55 years old (p = 0.013). No significant differences were found for this parameter in series with cut off point 45 years old. A significantly higher risk of locally advanced disease T3 + T4 (OR = 4.87) and presence of LNM (N1) (OR = 3.78) was observed in ≥45 years old group (p = 0.021 and p < 0.0001, respectively). More expressive results were found for the patients ≥55 years old group, where the risk of locally advanced disease (T3 + T4) was higher (OR = 5.21) and LNM presence was OR = 4.76 (p < 0.001 and p < 0.0001, respectively). None of the patients below 55 years old showed distant metastasis, but 19 patients above 55 years old showed M1 (p < 0.0001). In older patients group (≥55 years old) we observed deaths related thyroid cancer in 11 individuals.

CONCLUSIONS

The age cut off of 55 years old for risk stratification proposed by the 8th Edition of AJCC effectively stratifies PTC patients with a poor prognosis, indicating it is likely to be useful in clinical practice.

Non-coding RNA in thyroid cancer - Functions and mechanisms

Thyroid cancer is the most common endocrine malignant tumor, and its incidence has increased significantly in the past few years. A growing number of noncoding RNAs (ncRNAs) have shown abnormal expression patterns in human thyroid cancer in recent studies. Depending on size, ncRNAs are usually subdivided into two categories: short ncRNAs and long ncRNAs (longer than 200 nucleotides). Short ncRNAs include microRNAs (miRNAs), PIWI-interacting RNAs, small nucleolar RNAs, and endogenous small interfering RNAs, which have been extensively studied due to their roles in developmental and tumor biology. Compared to that of short ncRNAs, the involvement of lncRNAs in human cancers, especially in thyroid cancer, is not as well studied. Here, we reviewed the roles and clinical significance of miRNAs, lncRNAs, and circular RNA in thyroid development, tumorigenesis, and metastasis to offer a new approach to thyroid cancer treatment.

Relationship of patient age to tumor factors and outcomes among patients undergoing sentinel node biopsy for melanoma

INTRODUCTION

Patient age has been intermittently associated with demographics and outcomes in cutaneous melanoma. We looked at the association of age and patient demographics, tumor features, and melanoma-related outcomes in patients undergoing sentinel lymph node (SLN) biopsy for melanoma.

METHODS

We reviewed demographics (age, gender), tumor features (mean Breslow thickness, ulceration, SLN positivity rates), and outcomes (all-site relapse, progression to stage IV, death from melanoma, complications) from a university-based prospective database of 1633 patients. Patients were grouped by decade of age and the impact of age was examined by univariable and multivariable analyses.

RESULTS

Increasing age was directly associated with number of patients referred for SLN biopsy, male gender, head and neck (H&N) tumor location, mean Breslow thickness, tumor ulceration, and with all -site relapse, progression to stage IV, death from melanoma and complication rates. Increasing age was indirectly associated with SLN positivity rates. Comparing ages <30 with ages >60, these trends reached statistical significance for male gender, H&N location, SLN positivity, all-site relapse, progression to stage IV (development of metastases) and death from melanoma.

CONCLUSIONS

Referrals for SLN biopsy increase with increasing patient age, yet increasing age is associated with lower SLN positivity rates. This occurs despite the fact that older patients have thicker, more ulcerated tumors, and higher melanoma-related relapse and death rates.

Lymph node metastasis in young and middle-aged papillary thyroid carcinoma patients: a SEER-based cohort study

BACKGROUND

Lymph node metastasis (LNM) occurs frequently in young papillary thyroid carcinoma (PTC) patients, though the mortality rates are low. We aimed to analyze the relationship between age at diagnosis and LNM in PTC at a population level to elucidate the clinical behavior of PTC.

METHODS

Data of adult patients with surgically treated PTC and follicular thyroid carcinoma (FTC) were identified from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015) to investigate the relationship between age and clinical characteristics by curve estimation. The adjusted odds ratio of age and LNM rate were determined.

RESULTS

A total of 50,347 PTC (48,166) and FTC (2181) (median age: 45 and 50 years, respectively) patients met the inclusion criteria; 44.5% of those with PTC (21,428) had LNM. Rank-sum test analysis indicated differences in distribution of age in LNM-positive and LNM-negative PTC. The relationship between age, tumor size and LNM showed a quadratic curve in PTC. The mean tumor diameter and LNM rate correlated linearly with age in 18-59-year-old patients. LNM rate decreased with age (R² = 0.932, P < .0001), especially women (R² = 0.951, P < .0001).

CONCLUSION

In young and middle-aged PTC patients, LNM may resolve spontaneously with delayed diagnosis and management. Active surveillance of low-risk PTC is justified.

Older patients with differentiated thyroid cancer exhibit more aggressive pathological characteristics than younger patients

Summary

Differentiated thyroid cancer (DTC) has long been recognized as having a worse prognosis in older people. We retrospectively evaluated the clinical and pathological characteristics of 973 sequentially treated patients with primary DTC stratified into 2 age groups, ≥ 55 or < 55 years, based on the current American Joint Committee on Cancer (AJCC) DTC staging system. We found that older patients had a higher frequency of extrathyroidal cancer extension and larger cancers, and that their cancers were less commonly completely resectable.