Nodular Thyroid Disease and Thyroid Cancer in the Era of Precision Medicine

Current practice in intermediate risk differentiated thyroid cancer - a review

Although the overall prognosis for differentiated thyroid cancer (DTC) is excellent, a subset of patients will experience disease recurrence or may not respond to standard treatments. In recent years, DTC management has become more personalized in order to enhance treatment efficacy and avoid unnecessary interventions.In this context, major guidelines recommend post-surgery staging to assess the risk of disease persistence, recurrence, and mortality. Consequently, risk stratification becomes pivotal in determining the necessity of postoperative adjuvant therapy, which may include radioiodine therapy (RIT), the degree of TSH suppression, additional imaging studies, and the frequency of follow-up.However, the intermediate risk of recurrence is a highly heterogeneous category that encompasses various risk criteria, often combined, resulting in varying degrees of aggressiveness and a recurrence risk ranging from 5 to 20%. Furthermore, there is not enough long-term prognosis data for these patients. Unlike low- and high-risk DTC, the available literature is contradictory, and there is no consensus regarding adjuvant therapy.We aim to provide an overview of intermediate-risk differentiated thyroid cancer, focusing on criteria to consider when deciding on adjuvant therapy in the current context of personalized approach, including molecular analysis to enhance the accuracy of patient management.

Surgical management of low-risk papillary thyroid cancer in real life in Spain: a nationwide survey of endocrine neck surgeons and endocrinologists

BACKGROUND

The extent of surgery in patients with papillary thyroid cancer (PTC) is a subject of ongoing debate. We aimed to explore the attitude of Spanish specialists (endocrinologists, surgeons, and otolaryngologists) in real life on the surgical management of low-risk PTC.

METHODS

We designed an anonymous, web-based survey to inquire information regarding the preferences of interviewees for hemithyroidectomy (Hem), total thyroidectomy (TT) and prophylactic central neck dissection (pCND) in one standard patient with PTC and six clinical variants. We differentiated between small (1.1-2.5 cm) and large (2.6-4.0 cm) tumors.

RESULTS

A total of 278 valid responses were received and divided into two groups: group END (n = 135) and group SUR (n = 143, 101 general surgeons and 42 otolaryngologists). The preference for Hem was low in the standard patient and similar between both groups (40.6 vs 49.0%, NS). This preference decreased for tumors measuring 2.6-4.0 cm, multifocal, with risk location, family history of thyroid cancer, or history of irradiation, and increased in patients older than 65 years or with comorbidity. Preference for pCND ranged from 12.6-71.1% in the group END and from 22.4-65.0% in the group SUR, with few differences between the two. In multivariate analysis, being a high-volume specialist was associated with a lower preference for Hem, while having private practice was associated with a more favorable opinion of Hem.

CONCLUSION

The real clinical practice of Spanish specialists is far from what is recommended by the clinical guidelines in patients with low-risk PTC, especially among high-volume professionals.

Differential diagnosis and feature visualization for thyroid nodules using computer-aided ultrasonic diagnosis system: initial clinical assessment

BACKGROUND

To assess the diagnostic efficacy of the computer-aided ultrasonic diagnosis system (CAD system) in differentiating benign and malignant thyroid nodules.

METHODS

The images of 296 thyroid nodules were included in validation sets. The diagnostic efficacy of the CAD system was compared with that of junior physicians and senior physicians, as well as that of the combination diagnosis of the CAD system with junior physicians. The diagnostic efficacy of the CAD system for different sizes of thyroid nodules was compared.

RESULTS

The diagnostic sensitivity and accuracy of the CAD system were higher than those of junior physicians (83.4% vs. 72.2%, 73.0% vs. 69.6%), but the diagnostic specificity of the CAD system was lower than that of junior physicians (62.1% vs. 66.9%). The diagnostic accuracy of the CAD system was lower than that of senior physicians (73.0% vs. 83.8%). However, the combination diagnosis of the CAD system with junior physicians had higher accuracy (81.8%) and AUC (0.842) than those of either the CAD system or junior physicians alone, and comparable diagnostic performance with those of senior physicians. The Kappa was 0.635 in the combination diagnosis of the CAD system with junior physicians, showing good consistency with the pathological results. The accuracy (76.4%) of the CAD system was the highest for nodules of 1-2 cm.

CONCLUSION

The CAD system can effectively assist physicians to identify malignant and benign thyroid nodules, reduce the overdiagnosis and overtreatment of thyroid nodules, avoid unnecessary invasive fine needle aspiration, and improve the diagnostic accuracy of junior physicians.

A Novel Performance-Based Paradigm of Care for Cochlear Implant Follow-Up

OBJECTIVES

Utilize a multi-institutional outcomes database to determine expected performance for adult cochlear implant (CI) users. Estimate the percentage of patients who are high performers and achieve performance plateau.

STUDY DESIGN

Retrospective database study.

METHODS

Outcomes from 9,448 implantations were mined to identify 804 adult, unilateral recipients who had one preoperative and at least one postoperative consonant-nucleus-consonant (CNC) word score. Results were examined to determine percent-correct CNC word recognition preoperatively and at 1, 3, 6, 12, and 24 months after activation. Outcomes from 318 similar patients who also had at least three postoperative CNC word scores were examined. Linear mixed-effects regression was used to examine CNC word performance over time. The time when each patient achieved maximum performance was recorded as a surrogate for time of performance plateau. Patients were assigned as candidates for less intense follow-up if they were high performers and achieved performance plateau.

RESULTS

Among 804 patients with at least one postoperative score, CNC score improved at all time intervals. Average performance after the 3-month time interval was 47.2% to 51.5%, indicating a CNC ≥ 50% cutoff for high performers. Among 318 patients with at least three postoperative scores, performance improved from 1 to 3 (P = .001), 3 to 6 (P = .001), and 6 to 12 (P = .01) months. Scores from the 12- and 24-month intervals did not significantly differ (P = .09). By 12 months after activation, 59.7% of patients were considered candidates for less intense follow-up.

CONCLUSION

Findings suggest that CNC ≥ 50% is a reasonable cutoff to separate high performers from low performers. Within 12 months after activation, 59.7% of patients were good candidates for less intense follow-up.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Thyroid lobectomy in patients with differentiated thyroid cancer: an analysis of the clinical outcomes in a nationwide multicenter study

Background

Total thyroidectomy is the standard initial surgery for differentiated thyroid carcinoma (DTC), but the extent of the thyroidectomy remains controversial. Thyroid lobectomy (TL) has been widely used in eastern countries; however, its use has not been generalized in western countries, including Spain. Our aims were to analyse the clinical outcome of a multicentre nation-wide cohort of DTC patients treated by TL and to assess the proportion of patients who required completion of the thyroidectomy and who presented disease recurrence.

Methods

We retrospectively analyzed patients who underwent TL for DTC and were followed-up for ≥12 months. We collected demographic, clinical, and histopathological data. Dynamic risk stratification (DRS) was performed at 12 months and at last visit.

Results

One hundred and sixty-four patients (128 women, mean age 50.8 years, median follow-up 45.4 months) from 9 hospitals were included. There were 158 cases of papillary and 6 of follicular thyroid carcinoma (FTC). Remission of the disease (excellent response) was shown in 71.6% of the patients at 12 months and in 74.4% at the end of follow-up. At that time, there were 34 patients (20.7%) with indeterminate response, 6 (3.7%) with biochemical incomplete response, and 2 (1.2%) with structural incomplete response. Completion of the thyroidectomy was necessary in 8 patients (4.9%), but only 3 of them (1.8%) had disease recurrence.

Conclusions

These results, obtained in real clinical practice, suggest that TL is a safe operative option for selected patients with DTC and that the intensity of the treatment must be tailored according to the presurgical tumor-associated risk, in line with a personalized medicine.

What does liver elastography measure? Technical aspects and methodology

Elastography can be thought as an extension of the ancient technique of palpation. After giving a short introduction to the history of elastography, the different technologies that are nowadays available and the physics behind them, the article focuses on the assessment of liver stiffness in patients with diffuse liver disease using shear wave elastography (SWE). Practical advices on how to perform the SWE techniques and on the factors that should be considered for a correct interpretation of the results are given. This paper aimed to provide a practical guide for beginners and advanced clinical users to better understand technical aspects, methodologies and terminology.

The extent of surgery for low-risk 1-4 cm papillary thyroid carcinoma: a catch-22 situation. A retrospective analysis of 497 patients based on the 2015 ATA Guidelines recommendation 35

PURPOSE

The adequate extent of surgery for 1-4 cm low-risk papillary thyroid carcinoma (PTC) is unclear. Our objective was to analyze the applicability of the 2015 ATA Guidelines recommendation 35B (R35) for the management low-risk PTC.

METHODS

This multicentre study included patients with low-risk PTC who had undergone total thyroidectomy (TT). Retrospectively we selected those who met the R35 criteria for the performance of a thyroid lobectomy (TL). The aim was to identify the proportion of low-risk PTC patients treated using TT who would have required reintervention had they had a TL in accordance with R35.

RESULTS

We identified 497 patients (400 female; 80.5%). Median tumor size (mm): 21.2 (11-40). A tumor size ≥2 cm was found in 252 (50.7%). Most of them, 320 (64.4%), were in Stage I (AJCC 7th Edition). Following R35, 286 (57.5%) would have needed TT. Thus, they would have required a second surgery had they undergone TL. The indications for reintervention would have included lymph node involvement (35%), extrathyroidal extension (22.9%), aggressive subtype (8%), or vascular invasion (22.5%). No presurgical clinical data predict TT.

CONCLUSIONS

The appropriate management of low-risk PTC is unclear. Adherence to ATA R35 could lead to a huge increase in reinterventions when a TL is performed, though the need for them would be questionable. In our sample, more than half of patients (57.5%) who may undergo a TL for a seemingly low-risk PTC would have required a second operation to satisfy international guidelines, until better preoperative diagnostic tools become available.

LRRC52-AS1 is associated with clinical progression and regulates cell migration and invasion in papillary thyroid cancer

The incidence of thyroid cancer has increased in recent decades. The potential molecular mechanisms of papillary thyroid cancer (PTC) are still to be uncovered. In recent years, a number of studies reported that LRRC super family members are up-regulated in cancer cells. Cancer cells can experience a feature change from an epithelial to a mesenchymal phenotype, which is called epithelial-mesenchymal transition (EMT) during cancer progression. We found that LRRC52-AS1 is highly expressed in PTC cell lines rather than normal tissues and this observation was consistent with The Cancer Genome Atlas (TCGA) cohort. In a word, LRRC52-AS1 is associated with clinical progression in papillary thyroid cancer. In vitro experiments showed that knocking down LRRC52-AS1 significantly decreased the migration and invasion of the PTC cell lines (BCPAP and TPC). Meanwhile, LRRC52-AS1 may influence the progress of papillary thyroid cancer via mesenchymal markers N-cadherin, vimentin and TAZ. The LRRC52-AS1 gene is up-regulated in papillary thyroid cancer, and knockdown of LRRC52-AS1 could restrain cellular migration, and invasion in vitro. This study indicated that LRRC52-AS1 is a gene associated with PTC and might become a potential therapeutic target in PTC.

Ultrasound criteria for risk stratification of thyroid nodules in the previously iodine deficient area of Austria - a single centre, retrospective analysis

Background

We aimed to study the validity of six published ultrasound criteria for risk stratification of thyroid nodules in the former severely iodine deficient population of Austria.

Methods

Retrospective, single centre, observer blinded study design. All patients with a history of thyroidectomy due to nodules seen in the centre between 2004 and 2014 with preoperative in-house sonography and documented postoperative histology were analyzed (n = 195). A board of five experienced thyroidologists evaluated the images of 45 papillary carcinomas, 8 follicular carcinomas, and 142 benign nodules regarding the following criteria: mild hypoechogenicity, marked hypoechogenicity, microlobulated or irregular margins, microcalcifications, taller than wide shape, missing thin halo.

Results

All criteria but mild hypoechogenicity were significantly more frequent in thyroid cancer than in benign nodules. The number of positive criteria was significantly higher in cancer (2.79 ± 1.35) than in benign nodules (1.73 ± 1.18; p < 0.001). Thus, with a cut-off of two or more positive criteria, a sensitivity of 85% and a specificity of 45% were reached to predict malignancy in this sample of thyroid nodules. As expected, the findings were even more pronounced in papillary cancer only (2.98 ± 1.32 vs. 1.73 ± 1.18, p < 0.001). The six ultrasound criteria could not identify follicular cancer.

Conclusion

Our findings support the recently published EU-TIRADS score. Apart from mild hypoechogenicity, the analyzed ultrasound criteria can be applied for risk stratification of thyroid nodules in the previously severely iodine deficient population of Austria.