Treatment of advanced medullary thyroid cancer

A Rare Case of Thyroid Metastasis Secondary to Hidden Undiagnosed Lung Adenocarcinoma

The majority of thyroid lesions are primary in origin while secondary metastases to thyroid are considered a rare incidence. However, presentation of such cases with no signs of lung cancer can be extremely challenging to diagnose. Here, we present a 64-year-old man, an ex-smoker of 70 pack-years, who presented with a complaint of hoarseness of voice with associated dyspnea, choking episodes, weight loss, and hemoptysis. With no investigation abnormalities indicating lung adenocarcinoma, he was transferred to the Otolaryngology Department as being suspicious of thyroid cancer. A laryngoscopy demonstrated an immobile right vocal cord and pooling of secretions while a computed tomography (CT) scan showed a right thyroid lobe nodule, upper mediastinal lymphadenopathy, and pleural effusion. The patient underwent a total thyroidectomy. Biopsies from the lymph nodes and lung were obtained, and all demonstrated lung adenocarcinoma. Thus, a diagnosis of primary lung adenocarcinoma with thyroid and mediastinal lymph nodes metastases was established. Despite being a rare clinical presentation, thyroid metastasis should be considered and evaluated for a primary origin according to the associated clinical history and presentation.

Not all that is miliary is tuberculosis: Metastatic medullary thyroid carcinoma mimicking miliary tuberculosis

Medullary carcinoma of the thyroid should be considered in the differential diagnosis of miliary pattern of micronodules on chest imaging, irrespective of clinical features.

The Impact of Transcription Factor Prospero Homeobox 1 on the Regulation of Thyroid Cancer Malignancy

Transcription factor Prospero homeobox 1 (PROX1) is continuously expressed in the lymphatic endothelial cells, playing an essential role in their differentiation. Many reports have shown that PROX1 is implicated in cancer development and acts as an oncoprotein or suppressor in a tissue-dependent manner. Additionally, the PROX1 expression in many types of tumors has prognostic significance and is associated with patient outcomes. In our previous experimental studies, we showed that PROX1 is present in the thyroid cancer (THC) cells of different origins and has a high impact on follicular thyroid cancer (FTC) phenotypes, regulating migration, invasion, focal adhesion, cytoskeleton reorganization, and angiogenesis. Herein, we discuss the PROX1 transcript and protein structures, the expression pattern of PROX1 in THC specimens, and its epigenetic regulation. Next, we emphasize the biological processes and genes regulated by PROX1 in CGTH-W-1 cells, derived from squamous cell carcinoma of the thyroid gland. Finally, we discuss the interaction of PROX1 with other lymphatic factors. In our review, we aimed to highlight the importance of vascular molecules in cancer development and provide an update on the functionality of PROX1 in THC biology regulation.

The added diagnostic value of complementary gadoxetic acid-enhanced MRI to 18F-DOPA-PET/CT for liver staging in medullary thyroid carcinoma

Background

A high proportion of patients with advanced stages of medullary thyroid carcinoma (MTC) present with liver metastasis metastases. The aim of our study was to investigate the added diagnostic value of complementary gadoxetic acid-enhanced MRI to ¹⁸F-DOPA-PET/CT for liver staging in MTC.

Methods

Thirty-six patients (14 female, median age 55 years) with histologically confirmed MTC undergoing gadoxetic acid-enhanced liver MRI within 1 month of matching contrast-enhanced ¹⁸F-DOPA-PET/CT between 2010 and 2016 were selected for this IRB-approved retrospective study. ¹⁸F-DOPA-PET/CT and multiparametric MRI data sets were read consecutively and liver lesions were categorised on a 5-point Likert scale (1–definitely benign; 2–probably benign; 3–intermediate risk for metastasis; 4–probably metastasis; 5–definitely metastasis). It was noted if gadoxetic acid-enhanced MRI detected additional, ¹⁸F-DOPA-PET/CT-occult metastases (category 5) or if gadoxetic acid-enhanced MRI allowed for a definite classification (categories 1 and 5) of lesions for which ¹⁸F-DOPA-PET/CT remained inconclusive (categories 2–4). Follow-up PET/CT and MRI examinations were used as a reference standard.

Results

A total of 207 liver lesions (¹⁸F-DOPA-PET/CT 149, MRI 207; 152 metastases, 37 benign cysts, 18 hemangiomas) were analysed. Fifty-eight additional lesions were detected by MRI, of which 54 were metastases (median diameter 0.5 cm [interquartile range 0.4–0.7 cm]) occult on ¹⁸F-DOPA-PET/CT. MRI allowed for a definite lesion classification (categories 1 and 5) in 92% (190/207) whereas ¹⁸F-DOPA-PET/CT allowed for a definite lesion classification in 76% (113/149). MRI lead to a change in lesion categorisation in 14% (21/149).

Conclusion

Gadoxetic acid-enhanced MRI allows for a more precise liver staging in MTC patients compared to ¹⁸F-DOPA-PET/CT alone, particularly for ¹⁸F-DOPA-negative metastases and lesions < 1 cm.

Management of treatment-related toxicities in advanced medullary thyroid cancer

Progress in the treatment of advanced medullary thyroid cancer (MTC) has resulted from the approval of 2 drugs within the past 5 years, vandetanib and cabozantinib. These multikinase inhibitors (MKIs) possess overlapping specificities for multiple kinase targets implicated in the progression of MTC. Both drugs are associated with toxicities, including hypertension, hemorrhage/perforation, diarrhea and other gastrointestinal events, several dermatologic events, and hypothyroidism. In addition, vandetanib is uniquely associated with QTc prolongation through interaction with myocardial potassium channels, and cabozantinib is uniquely associated with hand-foot skin reaction. Treatment-related toxicities occur frequently and can be severe or life-threatening, and patients undergoing long-term treatment will likely experience adverse events (AEs). Here we offer specific practical recommendations for managing AEs commonly occurring with vandetanib and cabozantinib. The recommended approach relies on early recognition and palliation of symptoms, dose interruption, and dose reduction as necessary in order for the patient to maintain the highest tolerable dose for as long as possible and optimal quality of life. Treatment guidelines do not specify a recommended sequence for treating with vandetanib and cabozantinib; however, most patients will receive both drugs during their lifetime. The choice for first-line therapy is individualized after a risk-benefit assessment and depends on physician preference and patient-related factors, such as comorbid conditions. Because most generalist practices may not be familiar with the intricacies of agents such as vandetanib and cabozantinib, we commend that patients with advanced MTC be managed and treated by a thyroid cancer specialist with coordination of care within a multidisciplinary team.

Prognostic significance and optimal cutoff of age in medullary thyroid cancer

Age has been found to correlate with the prognosis for medullary thyroid cancer (MTC). This study was conducted to investigate whether age can predict long-term unfavorable prognosis and evaluate its predictive accuracy associated with TNM staging, using data of patients diagnosed with MTC between 2000 and 2010 from Surveillance, Epidemiology and End Results database. The relationship between the patients' age at diagnosis and cancer-specific survival (CSS) was evaluated using multivariate Cox regression analysis. Age stratifications were combined into a nomogram model to predict the CSS of MTC. The X-tile program determined 49 and 69 as optimal age cutoff values for CSS. On multivariate analysis, independent factors for survival were age (50-69 years, HR 2.853, 95% CI 1.631-4.991; ≥70 years, HR 5.804, 95% CI 2.91-11.555), race (white, HR 0.344, 95% CI 0.188-0.630), T (T3/4, HR 3.931, 95% CI 2.093-7.381), N (N1a, HR 3.269, 95% CI 1.386-7.710) and M (M1, HR 3.998, 95% CI 2.419-6.606). The C-index for CSS prediction with TNM, age (cutoff of 45)/sex/race/TNM and age (cutoff of 49 and 69)/sex/race/TNM were 0.832 (95% CI 0.763-0.901), 0.863 (95% CI 0.799-0.928), and 0.876 (95% CI 0.817-0.935), respectively. Subgroup multivariate analyses also showed that age significantly increased the risk for CSS in females, non-Hispanic white patients, and those with stage IV MTC. In conclusion, CSS was independently associated with ages between 49 and 69 years, which might be applied for risk stratification in MTC patients.

Recurrent spinal metastasis of a sporadic medullary carcinoma of the thyroid after radiation therapy: a case report and review of the literature

Sporadic Medullary Carcinoma of the Thyroid is a relatively uncommon entity and at the time of diagnosis, most already present loco-regional metastasis. Therapy should be aggressive to reduce recurrence and mortality. Follow-up period should continue lifelong and should also include calcium/pentagastrin infusion test, as well as 6-month interval diagnostic imaging.

Introduction to European comments on "Medullary Thyroid Cancer: management guidelines of the American Thyroid Association"

Guest Editors of Thyroid Research supplement devoted to medullary thyroid cancer present the history on how the discussion about "Medullary Thyroid Cancer: management guidelines of the American Thyroid Association" was initiated and subsequently widely commented before and during European Thyroid Association - Cancer Research Network Meeting in Lisbon. It is explained why it has been decided to publish the manuscripts within the supplement - to document voices from the discussion and popularize them.