Thyroid cancer: trends in incidence, mortality and clinical-pathological patterns in Zhejiang Province, Southeast China

CD147 protein molecule expression and chromosomal instability in the pathogenesis and prognosis of thyroid cancer

Low-coverage whole genome sequencing was performed for tissue samples from thyroid patients who received surgery treatment from 2015 to 2021. The potential biological significance of CD147 protein in thyroid cancer was explored through correlation analysis of CD147 protein expression level and clinical features of thyroid cancer patients. Low coverage whole genome sequencing was performed on the extracted DNA samples. The copy number analysis software was used to analyze the sequencing data, calculate the copy number of CD147 gene, further verify the expression of CD147 gene, and analyze its association with clinical features. The relationship between CIN and high risk was evaluated in the internal cohort. The association of CIN with the disease-free survival was validated in the cohort from The Cancer Genome Atlas Program. Thyroglobulin plays a key role in regulating thyroid function and maintaining normal metabolic rate. By sequencing tissue samples from this study, we can gain a deeper understanding of the association between cin and thyroid disease. The percentage of high risk patients in the multiple CIN group (77.8 %) was significantly higher than that in the 22q negative group (31.3 %), BRAF V600E group (22.2 %) and all negative group (25.0 %; p = 0.043).

Treatment and management of medullary thyroid microcarcinoma: a 10-year retrospective study from a single center

OBJECTIVE

To explore individualized treatment and management methods for medullary thyroid microcarcinoma (MTMC).

METHODS

Clinical data of patients with medullary thyroid carcinoma with a diameter ≤1 cm admitted to the First Affiliated Hospital of Kunming Medical University from June 2013 to June 20× were collected. Combined with different treatment guidelines for medullary thyroid carcinoma, factors affecting lymph node metastasis and postoperative disease status were analyzed.

RESULTS

Twenty-nine patients with MTMC were included in the analysis, including 24 patients who underwent total thyroidectomy, 5 who underwent thyroid gland lobectomy, and 13 who experienced postoperative lymph node metastasis. Multifocal tumor and calcitonin (Ctn) were the influencing factors, while multifocal tumor, Ctn, lymph node metastasis, and AJCC stage affected the dynamic risk stratification of postoperative disease.

CONCLUSION

Calcitonin detection is an important method for detecting MTMC. A tumor diameter ≤1 cm does not indicate that the tumor is in the early stage. The presence of multifocal tumors and Ctn should be used as important indicators for preoperative evaluation. Dynamic stratified risk assessment is critical in postoperative follow-up.

Prognostic prediction of patients having classical papillary thyroid carcinoma with a 4 mRNA-based risk model

The dysregulation of protein-coding genes involved in various biological functions is closely associated with the progression of thyroid cancer. This study aimed to investigate the effects of dysregulated gene expressions on the prognosis of classical papillary thyroid carcinoma (cPTC). Using expression profiling datasets from the Cancer Genome Atlas (TCGA) database, we performed differential expression analysis to identify differentially expressed genes (DEGs). Cox regression and Kaplan-Meier analysis were used to identify DEGs, which were used to construct a risk model to predict the prognosis of cPTC patients. Functional enrichment analysis unveiled the potential significance of co-expressed protein-encoding genes in tumors. We identified 4 DEGs (SALL3, PPBP, MYH1, and SYNDIG1), which were used to construct a risk model to predict the prognosis of cPTC patients. These 4 genes were independent of clinical parameters and could be functional in cPTC carcinogenesis. Furthermore, PPBP exhibited a strong correlation with poorer overall survival (OS) in the advanced stage of the disease. This study suggests that the 4-gene signature could be an independent prognostic biomarker to improve prognosis prediction in cPTC patients older than 46.

Exploring temporal trends and influencing factors for thyroid cancer in Guangzhou, China: 2004-2018

PURPOSE

Describe and analyze the trends of thyroid cancer incidence and mortality in Guangzhou, explore the potential influencing factors, and provide evidence for the government to formulate prevention and treatment measures.

METHODS

Incident and death cases of thyroid cancer were retrieved from the Guangzhou cancer registry. The joinpoint regression models were used to estimate the incidence and mortality trends. Age-period-cohort models were used to estimate the age, period, and cohort effects on the time trends. Grey correlation analysis was performed to explore possible connections between thyroid cancer and social factors.

RESULTS

A total of 15,955 new cases of thyroid cancer were registered in Guangzhou during 2004-2018, the age-standardized incidence rate (ASIR) of thyroid cancer increased from 4.29/105 in 2004 to 22.36/105 in 2018, with the average annual percentage change (AAPC) of 13.40%. The overall increase can be attributed to the increase in the incidence of papillary thyroid carcinoma (PTC), which was dominated by tumors <2 cm. The ASIR was higher in women (16.12/105) compared to men (5.46/105), and young and middle-aged individuals had higher incidence rates than older people. The number of thyroid cancer deaths registered between 2010 and 2018 was 356, and the age-standardized mortality rates (ASMRs) were stable (approximately 0.42/105). Men's ASMR (0.34/105) and women's (0.49/105) were similar, and those 60 and older had greater mortality. The period and cohort relative risks showed an overall increasing trend. Furthermore, there was a strong positive correlation between the ASIRs and social determinants.

CONCLUSIONS

During the study period, the incidence rate of thyroid cancer among young and middle-aged people in Guangzhou showed a rapidly increasing trend, and the mortality was relatively stable. In the future, more effective preventive measures should be taken for this age group to reduce the burden of disease and avoid overdiagnosis.

Subgroup analysis of steadily increased trends in medullary thyroid carcinoma incidence and mortality in the USA, 2000-2020: a population-based retrospective cohort study

The incidence rate of medullary thyroid carcinoma (MTC) continues to grow, along with its mortality rate in the USA. However, the subgroup trends in MTC have not yet been established. This population-based retrospective cohort study was based on the Surveillance, Epidemiology, and End Results (SEER) 17/12 registry database. Subgroup analysis was performed through clinicopathological and treatment-related characteristics. Annual average percentage change (AAPC) was calculated using joinpoint regression analysis. A total of 3833 MTC patients and 536 death cases were diagnosed in the SEER database. Between 2000 and 2019, the incidence (AAPC = 1.64) and mortality (AAPC = 3.46) rates of MTC continued to rise. Subgroup analysis showed the proportion of elderly patients (65-84 years) gradually increased in incidence between 2000 and 2020. Patients with early-stage tumors, such as tumors ≤20 mm, showed the same trends. Aspects of treatment, the implementation rate of total thyroidectomy (AAPC = 0.38) and lymph node dissection (AAPC = 1.06) also increased persistently in almost all of the age subgroups. The incidence and mortality of MTC consistently increased from 2000 to 2019. Subgroup analysis indicated a significant increase in elderly patients and early-stage patients, and more attention should be paid to the management of these increased subgroups.

Lateral lymph node metastasis in papillary thyroid cancer: Is there a difference between PTC and PTMC?

Papillary thyroid carcinoma (PTC) and papillary thyroid microcarcinoma (PTMC) are generally characterized as less invasive forms of thyroid cancer with favorable prognosis. However, once lateral cervical lymph node metastasis takes place, the prognosis may be significantly impacted. The purpose of this study was to evaluate whether there is a difference in the pattern of lateral lymph node metastasis between PTC and PTMC. A retrospective analysis was performed for PTC and PTMC patients that underwent central area dissection and unilateral lateral neck lymph node dissection (II-V area) between January 2020 and December 2021. Compared with PTMC group, the PTC group exhibited higher incidence of capsule invasion, extrathyroid invasion and lymphatic vessel invasion. Both the number and rate of central lymph nodes metastasis were elevated in the PTC group. While the number of lateral cervical lymph node metastasis was higher, the metastasis rate did not demonstrate significant difference. No significant differences were identified in the lymph node metastasis patterns between the 2 groups. The determination of the extent of lateral neck lymph node dissection solely based on the tumor size may be unreliable, as PTC and PTMC showed no difference in the number and pattern of lateral neck metastasis. Additional clinical data are warranted to reinforce this conclusion. For patients categorized as unilateral, bilateral, or contralateral cervical lymph node metastasis (including level I, II, III, IV, or V) or retropharyngeal lymph node metastasis who require unilateral lateral neck dissection, the size of the primary tumor may not need to be a central consideration when assessing and deciding the extent of lateral neck dissection.

Predicting central cervical lymph node metastasis in papillary thyroid microcarcinoma using deep learning

Background

The aim of this study is to design a deep learning (DL) model to preoperatively predict the occurrence of central lymph node metastasis (CLNM) in patients with papillary thyroid microcarcinoma (PTMC).

Methods

This research collected preoperative ultrasound (US) images and clinical factors of 611 PTMC patients. The clinical factors were analyzed using multivariate regression. Then, a DL model based on US images and clinical factors was developed to preoperatively predict CLNM. The model's efficacy was evaluated using the receiver operating characteristic (ROC) curve, along with accuracy, sensitivity, specificity, and the F1 score.

Results

The multivariate analysis indicated an independent correlation factors including age ≥55 (OR = 0.309, p < 0.001), tumor diameter (OR = 2.551, p = 0.010), macrocalcifications (OR = 1.832, p = 0.002), and capsular invasion (OR = 1.977, p = 0.005). The suggested DL model utilized US images achieved an average area under the curve (AUC) of 0.65, slightly outperforming the model that employed traditional clinical factors (AUC = 0.64). Nevertheless, the model that incorporated both of them did not enhance prediction accuracy (AUC = 0.63).

Conclusions

The suggested approach offers a reference for the treatment and supervision of PTMC. Among three models used in this study, the deep model relied generally more on image modalities than the data modality of clinic records when making the predictions.

Choice of management strategy for papillary thyroid microcarcinoma: active surveillance or immediate surgery?

Overdiagnosis of papillary thyroid microcarcinoma (PTMC) is prevalent, and effective management of PTMC is an important matter. The high incidence and low mortality rate of papillary thyroid carcinoma (PTC) justify the preference for active surveillance (AS) over immediate surgery (IS), particularly in cases of low-risk PTMC. Japan began AS in the 1990s as an alternative surgical option for PTMC and it has shown promising results. The safety and efficacy of AS management in PTMC have been verified. However, AS may not be suitable for all PTMC cases. How to find the balance between the decision-making of AS and IS requires careful consideration. Therefore, we collected and analyzed the relevant evidence on the clinical strategies for PTC and discussed AS and IS from the perspectives of health, economic, and psychological aspects, to help clinicians in choosing a more appropriate clinical strategy for PTC.

Exploring the clinical utility of angioinvasion markers in papillary thyroid cancer: a literature review

Papillary thyroid cancer (PTC) is the most common type of thyroid cancer, and angioinvasion, the invasion of blood vessels by cancer cells, is a crucial pathological feature associated with disease progression and poor prognosis. Thus, a comprehensive search of scientific databases was conducted to identify relevant studies investigating angioinvasion markers in PTC. The selected studies were reviewed and analyzed to assess the clinical significance and potential utility of these markers in predicting angioinvasion and guiding treatment decisions. Numerous studies have investigated various markers associated with angioinvasion in PTC, including oxidative stress, vascular endothelial growth factor (VEGF), matrix metalloproteinases (MMPs), and other angiogenic factors. The results indicate that increased expression of these markers is correlated with the presence and extent of angioinvasion in PTC. Moreover, some studies suggest that these markers can serve as prognostic indicators and guide therapeutic strategies, such as selecting patients for more aggressive treatment approaches or targeted therapies. The findings from the reviewed literature highlight the potential clinical utility of angioinvasion markers in PTC. The identification and validation of reliable markers can aid in assessing the risk of angioinvasion, predicting disease progression, and optimizing treatment decisions for patients with PTC. However, further research and validation on larger patient cohorts are necessary to establish the robustness and generalizability of these markers in clinical practice.

Deep Learning-Based Differential Diagnosis of Follicular Thyroid Tumors Using Histopathological Images

Deep learning systems (DLSs) have been developed for the histopathological assessment of various types of tumors, but none are suitable for differential diagnosis between follicular thyroid carcinoma (FTC) and follicular adenoma (FA). Furthermore, whether DLSs can identify the malignant characteristics of thyroid tumors based only on random views of tumor tissue histology has not been evaluated. In this study, we developed DLSs able to differentiate between FTC and FA based on 3 types of convolutional neural network architecture: EfficientNet, VGG16, and ResNet50. The performance of all 3 DLSs was excellent (area under the receiver operating characteristic curve = 0.91 ± 0.04; F1 score = 0.82 ± 0.06). Visual explanations using gradient-weighted class activation mapping suggested that the diagnosis of both FTC and FA was largely dependent on nuclear features. The DLSs were then trained with FTC images and linked information (presence or absence of recurrence within 10 years, vascular invasion, and wide capsular invasion). The ability of the DLSs to diagnose these characteristics was then determined. The results showed that, based on the random views of histology, the DLSs could predict the risk of FTC recurrence, vascular invasion, and wide capsular invasion with a certain level of accuracy (area under the receiver operating characteristic curve = 0.67 ± 0.13, 0.62 ± 0.11, and 0.65 ± 0.09, respectively). Further improvement of our DLSs could lead to the establishment of automated differential diagnosis systems requiring only biopsy specimens.

Diagnostic Value and Challenges of BRAF V600E Molecular Testing and Thyroid Fine-Needle Aspiration Cytology: A Retrospective Study from a Tertiary Institution in Southern Hunan Province, China

INTRODUCTION

Combined thyroid fine-needle aspiration (FNA) cytology and valine-to-glutamate substitution at codon 600 of B-Raf proto-oncogene, serine/threonine kinase (BRAF V600E) mutation detection are procedures used for diagnosing thyroid nodules in many Chinese tertiary institutions. This retrospective study at our institution aimed to explore the effectiveness and challenges of the combined approach in diagnosing thyroid nodules and the correlation between BRAF V600E mutation status and behavior of papillary thyroid carcinoma.

METHODS

Thyroid FNA cytology and BRAF V600E mutation detection results were reviewed between November 2020 and July 2022. A total of 623 patients, each of whom underwent thyroidectomy and final pathological examination after FNA cytology diagnosis, were included in the study. The relationship between the BRAF V600E mutational status and pathological parameters was analyzed using the χ2 test. The effectiveness and challenges of FNA cytology alone and the combined procedure were also evaluated based on the final pathology.

RESULTS

Of 623 patients, 591 were diagnosed with papillary thyroid carcinoma (PTC), of which 456 were positive for the BRAF V600E mutation. It demonstrated near-perfect specificity for identifying PTC, and its incidence rate showed an age-specific curve with an inverted U-shaped distribution. The final pathological examination showed that the combined procedure had a higher sensitivity (83.91%) than FNA cytology alone (63.45%) for distinguishing PTC from other lesions (p < 0.001). Mutational status was associated with a larger maximum tumor diameter (p = 0.003) and a tendency of capsular invasion (p = 0.0542) but possibly unrelated to central lymph node metastasis (p = 0.1846). Nodular goiters accounted for most benign entities initially designated as Bethesda categories III-V.

CONCLUSION

BRAF V600E mutational analysis complements cytopathology and improves the PTC detection rate in FNA cytology samples due to the high prevalence of the mutation in China. BRAF V600E mutation does not show a statistical correlation with tumor aggressiveness. Morphological pitfalls such as histocyte aggregation, cystic-lining cells in nodular goiters, and oncocytes in Hashimoto's thyroiditis, were overwhelmingly found in BRAF V600E-negative specimens.

Association between iodine nutrition and cervical lymph node metastasis of papillary thyroid microcarcinoma

We aimed to investigate the association between iodine intake and nodal metastasis stratified by central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) of papillary thyroid microcarcinoma (PTMC). Urinary iodine concentration (UIC) and clinicopathological characteristics were used to identify factors associated with CLNM and LLNM using logistic regression analysis. A sum of 3,858 PTMC patients were enrolled. The median UIC (MUI) of patients with CLNM or LLNM was not statistically different from those without nodal metastasis. Male patients had a higher MUI than females (183.4 μg/L vs. 173.6 μg/L). Female patients with extracapsular extension had a higher MUI than those without it (210.0 μg/L vs. 172.1 μg/L). Male patients with LLNM had a significantly lower MUI than those without LLNM (134.7 μg/L vs. 187.9 μg/L). Female patients with more than adequate iodine intake were more likely to present with CLNM and extrathyroidal extension than those with adequate iodine intake with an odds ratio (95% confidence interval) of 1.23 (1.01-1.51) and 1.59 (1.09-2.32) after adjustment. Iodine nutrition was not found to be associated with LLNM. In addition, patients with a younger age, larger tumors, extrathyroidal extension, and intrathyroidal spread were more likely to be CLNM, whereas nodular goiter presented with a protective factor; CLNM was the only factor associated with LLNM of PTMC in both genders. In conclusion, iodine nutrition has a much closer association with female than male patients, and high iodine intake may be associated with CLNM and extrathyroidal extension in female PTMC patients.

Initial ablation ratio predicts the recurrence of low-risk papillary thyroid microcarcinomas treated with microwave ablation: a 5-year, single-institution cohort study

Objective

To assess the long-term efficacy and safety of microwave ablation (MWA) in treating low-risk papillary thyroid microcarcinomas (PTMC) and to identify predictive factors for the postoperative local tumor progression of PTMC.

Methods

A total of 154 low-risk PTMC patients treated with MWA who were followed up for at least 3 months were retrospectively recruited. Ultrasonography was performed after MWA to assess the local tumor progression. Adverse events associated with MWA were recorded. The ablated volume (Va) and initial ablation ratio (IAR) were measured to assess their influences on the recurrence risk of PTMC.

Results

The mean tumor volume of PTMC before MWA was 0.071 (0.039, 0.121) cm3, with a maximum diameter of 0.60 ± 0.18 cm. All PTMC patients were followed up for 6 (3, 18) months. Va increased immediately after MWA, then gradually decreased over time, till significantly smaller at 12 months than that before MWA (P < 0.05). The median volume reduction ratio at 24 months reached 100%, which was maintained during a 60-month follow-up. A total of 7 (4.55%) cases of local tumor progression were recorded during the follow-up. Kaplan-Meier survival analysis revealed that the rate of local tumor progression was significantly lower in PTMC patients with a maximum tumor diameter < 0.70 cm than in those with ≥0.70 cm (P = 0.031). A significant better prognosis was achieved in PTMC patients with IAR ≥ 15 than in those with IAR < 15 (P = 0.015). Sex, age (<55 years) and preoperative thyroid-stimulating hormone (>2.0 mU/L) of PTMC patients were not correlated with local tumor progression.

Conclusion

MWA is an effective therapeutic strategy for low-risk PTMC with high safety. The maximum tumor diameter and IAR are predictive factors for the local tumor progression of PTMC after MWA.

Predictive nomogram for central lymph node metastasis in papillary thyroid microcarcinoma based on pathological and ultrasound features

Background

Central lymph node metastases (CLNM) in papillary thyroid microcarcinoma (PTMC) are common, but management through prophylactic central lymph node dissection (pCLND) remains controversial. In this study, the independent predictors of CLNM in PTMC were retrospectively studied based on ultrasound and pathological data, and we aim to establish the prediction model to predict CLNM in PTMC.

Methods

This study included a total of 1,506 patients who underwent thyroid surgery for PTMC at the First Affiliated Hospital of Chongqing Medical University from 2015 to 2018. Ultrasound and clinicopathological features were summarized and analyzed. Univariate and multivariate analyses were performed to determine the risk factors associated with CLNM. The prediction model is established and verified according to the multivariate analysis results. The Kaplan-Meier curve was used to evaluate the effect of CLNM on survival.

Results

The CLNM rate was 44.5% (670/1,506). Multivariate analysis showed that men, younger age, smaller diameter, ETE, microcalcification, without Hashimoto's thyroiditis, and multifocal were independent risk predictors of CLNM. Nomogram has a good discriminative ability (C-index: 0.755 in the validation group), and the calibration effect is good. In the DCA curve, the CLNM prediction model performed better net benefit given any high-risk thresholds. The median follow-up time was 30 months (12-59 months), 116 cases were lost, and the follow-up rate was 92.8% (1,506/1,622). Of the 1,506 patients included, 12 (0.8%) experienced recurrence.

Conclusion

The likelihood of CLNM can be objectively quantified before surgery by using this reliable and accurate nomogram that combines preoperative ultrasound with clinicopathological features. Clinicians can use this nomogram to assess central lymph node status in patients with PTMC and consider prophylactic CND in patients with high scores.

Integrated analysis of circulating and tissue proteomes reveals that fibronectin 1 is a potential biomarker in papillary thyroid cancer

Papillary thyroid cancer (PTC) is the most frequent subtype of thyroid cancer, but 20% of cases are indeterminate (i.e., cannot be accurately diagnosed) based on preoperative cytology, which might lead to surgical removal of a normal thyroid gland. To address this concern, we performed an in-depth analysis of the serum proteomes of 26 PTC patients and 23 healthy controls using antibody microarrays and data-independent acquisition mass spectrometry (DIA-MS). We identified a total of 1091 serum proteins spanning 10-12 orders of magnitude. 166 differentially expressed proteins were identified that participate in complement activation, coagulation cascades, and platelet degranulation pathways. Furthermore, the analysis of serum proteomes before and after surgery indicated that the expression of proteins such as lactate dehydrogenase A and olfactory receptor family 52 subfamily B member 4, which participate in fibrin clot formation and extracellular matrix-receptor interaction pathways, were changed. Further analysis of the proteomes of PTC and neighboring tissues revealed integrin-mediated pathways with possible crosstalk between the tissue and circulating compartments. Among these cross-talk proteins, circulating fibronectin 1 (FN1), gelsolin (GSN) and UDP-glucose 4-epimerase (GALE) were indicated as promising biomarkers for PTC identification and validated in an independent cohort. In differentiating between patients with benign nodules or PTC, FN1 produced the best ELISA result (sensitivity = 96.89%, specificity = 91.67%). Overall, our results present proteomic landscapes of PTC before and after surgery as well as the crosstalk between tissue and the circulatory system, which is valuable to understand PTC pathology and improve PTC diagnostics in the future.

Comparison of diagnostic performance and FNA management of the ACR-TIRADS and Chinese-TIRADS based on surgical histological evidence

Background

The sonography-based risk stratification of thyroid nodules is based on the different sonographic features of benign and malignant thyroid nodules. The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) and the Chinese-TIRADS define different risks for malignancy categories and the size criteria for fine-needle aspiration (FNA). Few studies have compared their diagnostic performance and FNA management approaches. Thus, we sought to compare the diagnostic performance and FNA management approaches of the ACR-TIRADS and Chinese-TIRADS based on surgical histological evidence.

Methods

This retrospective study included patients with complete thyroid ultrasound images and histologic evidence who were consecutively selected from The Affiliated Hospital of Nanjing University of Chinese Medicine. A total of 333 nodules from 252 patients with definitive surgical histological findings were examined. Ultrasonography categories and FNA management proposals were assigned according to the ACR-TIRADS and Chinese-TIRADS. The thyroid nodules were divided into 2 groups based on a cut-off size of 1 cm. The diagnostic performance and recommended and unnecessary FNA rates for each group were compared for both systems.

Results

Overall, 280 malignant thyroid nodules (84.1%) and 53 benign nodules (15.9%) were analyzed. Across all groups, the ACR-TIRADS had higher sensitivity, specificity, positive and negative predictive values, and accuracy, and a higher area under the curve (AUC) than the Chinese-TIRADS. However, there was a significant difference in the negative predictive value between the ACR-TIRADS and Chinese-TIRADS of <1 and ≥1 cm, and the overall AUCs differed significantly (39.5% vs. 35.1%, P=0.007 for <1 cm; 70.0% vs. 62.8%, P=0.014 for ≥1 cm; 0.843 vs. 0.806, P=0.037 for all). The rate for recommending the FNA of the nodules in the ACR-TIRADS was lower than that in the Chinese-TIRADS (25.2% vs. 56.5%, P<0.0001), but there was no significant difference between the ACR-TIRADS and Chinese-TIRADS in terms of the unnecessary FNA rate (14.3% vs. 13.8%, P=0.931). The kappa statistics for the consistency of the ACR-TIRADS and Chinese-TIRADS FNA recommendations for nodules sized ≥1.0 to <1.5, ≥1.5 to <2.5, and ≥2.5 cm were 0.084, 0.635, and 0.909, respectively.

Conclusions

The ACR-TIRADS had slightly better diagnostic performance and a lower recommended FNA rate than the Chinese-TIRADS for thyroid nodules. For thyroid nodules ≥1.5 cm in size, the FNA recommendations of the 2 guidelines had good consistency.

Active surveillance of low-risk papillary thyroid microcarcinoma

Recently, the incidence of thyroid carcinoma has been increasing rapidly worldwide. This is interpreted as an increase in the incidental detection of small papillary thyroid carcinomas by the widespread use of high-resolution imaging techniques such as ultrasonography. However, the mortality rates of thyroid carcinoma have not changed, suggesting that small papillary thyroid carcinomas may be overdiagnosed and overtreated. Active surveillance management has been introduced from Japan since the 1990s, as one of the measures to prevent overtreatment of low-risk papillary thyroid microcarcinoma. Based on the favorable outcomes, active surveillance has been gradually adopted worldwide as an alternative to immediate surgery. The management should be carried out with strict eligibility criteria and close monitoring for cancer progression, under a multidisciplinary team. In addition, an adequate shared decision-making is mandatory for individual patients. Papillary thyroid microcarcinomas with clinically apparent lymph node metastasis, distant metastasis, or invasion to adjacent organs should have surgery.

A machine learning-based approach to predicting the malignant and metastasis of thyroid cancer

Background

Thyroid Cancer (TC) is the most common malignant disease of endocrine system, and its incidence rate is increasing year by year. Early diagnosis, management of malignant nodules and scientific treatment are crucial for TC prognosis. The first aim is the construction of a classification model for TC based on risk factors. The second aim is the construction of a prediction model for metastasis based on risk factors.

Methods

We retrospectively collected approximately 70 preoperative demographic and laboratory test indices from 1735 TC patients. Machine learning pipelines including linear regression model ridge, Logistic Regression (LR) and eXtreme Gradient Boosting (XGBoost) were used to select the best model for predicting deterioration and metastasis of TC. A comprehensive comparative analysis with the prediction model using only thyroid imaging reporting and data system (TI-RADS).

Results

The XGBoost model achieved the best performance in the final thyroid nodule diagnosis (AUC: 0.84) and metastasis (AUC: 0.72-0.77) predictions. Its AUCs for predicting Grade 4 TC deterioration and metastasis reached 0.84 and 0.97, respectively, while none of the AUCs for Only TI-RADS reached 0.70. Based on multivariate analysis and feature selection, age, obesity, prothrombin time, fibrinogen, and HBeAb were common significant risk factors for tumor progression and metastasis. Monocyte, D-dimer, T3, FT3, and albumin were common protective factors. Tumor size (11.14 ± 7.14 mm) is the most important indicator of metastasis formation. In addition, GGT, glucose, platelet volume distribution width, and neutrophil percentage also contributed to the development of metastases. The abnormal levels of blood lipid and uric acid were closely related to the deterioration of tumor. The dual role of mean erythrocytic hemoglobin concentration in TC needs to be verified in a larger patient cohort. We have established a free online tool (http://www.cancer-thyroid.com/) that is available to all clinicians for the prognosis of patients at high risk of TC.

Conclusion

It is feasible to use XGBoost algorithm, combined with preoperative laboratory test indexes and demographic characteristics to predict tumor progression and metastasis in patients with TC, and its performance is better than that of Only using TI-RADS. The web tools we developed can help physicians with less clinical experience to choose the appropriate clinical decision or secondary confirmation of diagnosis results.

Transoral endoscopic thyroidectomy vestibular approach for papillary thyroid microcarcinoma: an analysis of clinical outcomes

OBJECTIVE

To analyze the influence of transoral endoscopic thyroidectomy vestibular approach (TOETVA) on the clinical outcomes of patients with papillary thyroid microcarcinoma (PTMC).

METHODS

The clinical data of PTMC patients (n=90) who visited the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University from July 2019 to July 2021 were retrospectively analyzed. Patients who underwent endoscopic thyroidectomy via the transthoracic-areola approach were included in the control group (CG; n=42) and those with TOETVA were assigned to the observation group (OG; n=48). The operative time (OT), length of hospital stay (LOS), postoperative drainage volume, and complications were recorded. Besides, C-reactive protein (CRP), white blood cell count (WBC), erythrocyte sedimentation rate (ESR), as well as scores of the Visual Analogue Scale (VAS), Vancouver Scar Scale (VSS), postoperative patient satisfaction, and the Short-Form 36 Item Health Survey (SF-36) were compared between the two groups.

RESULTS

The data showed that the OT and LOS of the OG were not statistically different from those of the CG, and the postoperative drainage volume was less than that of the CG (P<0.05). The two cohorts of patients showed a similar incidence of complications such as postoperative hematoma, transient hoarseness, infection, temporary recurrent laryngeal nerve injury and transient hypothyroidism (all P>0.05). CRP, WBC and ESR increased in both groups after treatment but showing no evident difference between groups. The OG had statistically lower VAS and VSS scores at two days after surgery, a statistical higher satisfaction rate than the CG, and a statistically higher score of SF-36 at three months after surgery than in the CG (all P<0.05).

CONCLUSIONS

While ensuring the therapeutic effect, TOETVA can significantly reduce the pain degree of patients and scarring, as well as provide better cosmetic effect, higher patient satisfaction, and better quality of life, which is worthy of clinical promotion.

BRCA2 gene mutation in cancer

Breast cancer susceptibility gene 2 (BRCA2) is the main gene associated with hereditary breast cancers. However, a mutation in BRCA2 has also been found in other tumors, such as ovarian, pancreatic, thyroid, gastric, laryngeal, and prostate cancers. In this review, we discuss the biological functions of BRCA2 and the role of BRCA2 mutations in tumor progression and therapy.

A Comparison of the Performances of Artificial Intelligence System and Radiologists in the Ultrasound Diagnosis of Thyroid Nodules

AIMS

The purpose of this paper is to prospectively evaluate the performance of an artificial intelligence (AI) system in diagnosing thyroid nodules and to assess its potential value in comparison with the performance of radiologists with different levels of experience, as well as the factors affecting its diagnostic accuracy.

BACKGROUND

In recent years, medical imaging diagnosis using AI has become a popular topic in clinical application research.

OBJECTIVE

This study aimed to evaluate the performance of an AI system in diagnosing thyroid nodules and compare it with the performance levels of different radiologists.

METHODS

This study involved 426 patients screened for thyroid nodules at the First Affiliated Hospital of Guangzhou Medical University between July 2017 and March 2019. All of the nodules were evaluated by radiologists with various levels of experience and an AI system. The diagnostic performances of two junior and two senior radiologists, an AI system, and an AI-assisted junior radiologist were compared, as were their diagnostic results with respect to nodules of different sizes.

RESULTS

The senior radiologists, the AI system, and the AI-assisted junior radiologist performed better than the junior radiologist (p < 0.05). The area under the curves of the AI system and the AI-assisted junior radiologist were similar to the curve of the senior radiologists (p > 0.05). The diagnostic results concerning the two nodule sizes showed that the diagnostic error rates of the AI system, junior radiologists, and senior radiologists for nodules with a maximum diameter of ≤1 cm (Dmax ≤ 1 cm) were higher than those for nodules with a maximum diameter of 1 cm (D_max > 1 cm) (23.4% vs. 12.1%, p = 0.002; 26.6% vs. 7.3%, p < 0.001; and 38.3% vs. 14.6%, p < 0.001).

CONCLUSION

The AI system is a decision-making tool that could potentially improve the diagnostic efficiency of junior radiologists. Micronodules with Dmax ≤ 1cm were significantly correlated with diagnostic accuracy; accordingly, more micronodules of this size, in particular, should be added to the AI system as training samples. Other: The system could be a potential decision-making tool for effectively improving the diagnostic efficiency of junior radiologists in the community.

A Significance of Concomitant BRAFV600E and TERT Mutations in Polish Patients with Papillary Thyroid Microcarcinoma: A Retrospective Cohort Study Based on 430 Cases

Background: The incidence of papillary thyroid cancer is increasing worldwide due to more frequent pathological detection of papillary thyroid microcarcinomas (PTMC), which are cancers measuring 1 cm or less in diameter. In rare cases, the course of PTMC can be aggressive, with an increased risk of recurrence/persistent disease. The aim of this study of Polish patients diagnosed with PTMC was to assess the impact of concomitant B-type Raf kinas-activating mutation in codon 600 of exon 15 (BRAF^V600E) and telomerase reverse transcriptase (TERT) hotspot mutations on clinicopathological features, response to treatment, potential recurrence, and the final outcome. Methods: A retrospective analysis of the 430 PTMC cases diagnosed during 2001-2020 at a single center was performed. All PTMC cases were assessed histopathologically, and analyses of BRAF^V600E and TERT promoter were performed based on DNA isolated from tumor blocks. Results: There were 29/430 (6.7% [confidence interval: 4.6-9.5]) patients in whom the TERT^C228T and/or TERT^C250T mutations coexisted with the BRAF^V600E mutation. A statistical comparison between PTMC cases with concomitant BRAF^V600E and TERT hotspot mutations and those without any of those mutations revealed no significant differences between the two groups with respect to risk stratification, response to primary treatment, clinical course, or final disease status. Conclusion: Regardless of the molecular background of PTMC, the overall response to therapy is excellent, and long-term disease-free survival rates can be achieved by most patients.

Predictive features of central lymph node metastasis in papillary thyroid microcarcinoma: Roles of active surveillance in over-treatment

Background

Low-risk papillary thyroid microcarcinoma (PTMC) without clinically evident lymph nodes, extrathyroidal expansions, and distant metastases may be candidates for active monitoring.

Objective

The purpose of this research is to identify risk factors for papillary thyroid microcarcinoma (PTMC) metastasis to central cervical lymph nodes (CLNM) and to discuss the viability of an active surveillance strategy to minimize unnecessary therapy for patients.

Methods

This single-center retrospective study was conducted on the data and medical records of the patients who were diagnosed with PTMC and underwent surgery at the Baotou Cancer Hospital, China, between January 1, 2018, and December 31, 2019. Both lobectomy and complete thyroid resections were performed, and central lymph node dissections (CLND) were used in all patients. Comparisons and analyses were conducted on the preoperative ultrasound (US) characteristics, the post-operation pathological results, and lymph node metastasis.

Results

We analyzed 172 patients with PTMC with average age 48.32 ± 10.59 years old, with 31 males and 142 females. US testing showed 74 (43.0%) patients had suspicious lymph nodes; 31 (41.9%) had capsular invasion and 52 (30.2%) patients were confirmed to have CLNM. Based on logistic regression analysis, central lymph node metastasis was shown to be more common in individuals with PTMC who were older than 45 years old, male, and had tumors that lacked micro-calcification on US imaging. Postoperative pathology assessments suggested that 58 cases (33.7%) were more suitable candidates for active surveillance cohorts.

Conclusions

While active surveillance might benefit many PTMC patients, treatments for the patients should also encompass occult lymph node metastasis, especially in patients with over 45 years old, male, tumor without micro-calcification in the US imaging. Furthermore, the prediction of lymph nodes in the central cervical via the preoperative US and the PTMC risk stratification accuracy need to be improved. Our findings showed about 30% of the patients with PTMC had no active surveillance high-risk factors but required surgical treatment. Fear of cancer in the PTMC patients, although informed of the details, is still the main reason for choosing surgical treatment over active surveillance.

Translation and validation of M.D. Anderson Symptom Inventory-Thyroid Cancer module in Chinese thyroid cancer patients: a cross-sectional and methodological study

Aim

To translate and validate the Chinese version of the MDASI-THY among thyroid cancer patients.

Background

The M.D. Anderson Symptom Inventory-Thyroid Cancer module (MDASI-THY) is one of well-validated instruments for thyroid-specific symptom assessment. To date, the instrument has not been used in China.

Methods

After standard forward- and back-translation procedures, two instruments, the Chinese version of MDASI-THY and the European Organization for Research and Treatment of Cancer QLQ C30, were answered by 309 thyroid patients. The content, convergent discriminant validity and reliability of the MDASI-THY were evaluated.

Results

The scale of content validity index (S-CVI) and the item of content validity index (I-CVI) of the instrument were over 0.80. There were significant relationships between MDASI-THY and EORTC QLQ-C30 (r range, 0.139 ~ 0.766, -0.759 ~ -0.461, p < 0.001). Symptoms were severer for patients underwent surgical treatment (Z = -9.999, p < 0.001). The Cronbach’s alpha was 0.966 (between 0.954 and 0.827 for subscales). Most symptom items had moderate to high interitem correlations (r range, 0.297 ~ 0.773).

Conclusions

The Chinese version of MDASI-THY demonstrated favorable validity and reliability. It can be used in development of symptom management program in thyroid cancer patients in China.

Relevance to clinical practice

Healthcare providers can apply this instrument to assess Chinese thyroid cancer patients to increase the understanding of their symptom experience, resulting in a better symptom management.

Quantification and Pattern of Central Compartment Lymph Nodes in pN1a Papillary Thyroid Cancer Patients

Background: The background is to investigate the results of central compartment lymphadenectomy for pN1a papillary thyroid carcinoma (PTC) with regard to quantification and pattern of resected lymph nodes thereby providing basis for future compartment VI surgical intervention. Methods: The study comprised 443 pN1a PTC patients whose clinicopathological characteristics and central compartment lymphadenectomy results were compared and correlated with the primary thyroid cancer and lymph node metastasis (LNM) features. Ultimately, multivariate analysis was conducted to identify statistically significant impact factors for a high metastatic ratio (MR). Results: Dissected lymph nodes (DLNs) were more frequently identified in right level VI than left (P < .05) although there was no difference in in the number of resected metastatic lymph nodes (MLNs). Male sex, multifocality, extrathyroidal extension (ETE), and fewer DLNs were related to a high MR. There was a positive correlation between DLN and MLN, and a negative correlation between DLN and MR. Disease multifocality and ETE were identified more frequently in the left than the right thyroid lobe. Conclusion: The outcome of central compartment lymphadenectomy in pN1a PTC patients is associated with several factors, and a thorough dissection of lymph nodes improves the rate of metastatic lymph node resection.

Cell migration inducing hyaluronidase 1 promotes growth and metastasis of papillary thyroid carcinoma

Cell migration inducing hyaluronidase 1 (CEMIP) mediates catabolism of hyaluronan, and participates in the cell metastasis, invasion, and motility. Dysregulated CEMIP expression was associated with progression and prognosis of tumors. The role of CEMIP in papillary thyroid carcinoma (PTC) remains unknown. Our study showed that CEMIP was upregulated in both tissues and cells of PTC. Silencing of CEMIP reduced cell proliferation and suppressed migration and invasion of PTC. Protein expression of phosphorylated STAT3 (Signal Transducer And Activator Of Transcription 3) (p-STAT3), AKT (p-AKT) and p65 (p-p65) were decreased by CEMIP silencing in PTC cells. Pyruvate dehydrogenase kinase 4 (PDK4) over-expression attenuated CEMIP silencing-induced decrease in p-STAT3, p-AKT and p-p65. Silencing of CEMIP-induced decrease in cell proliferation and metastasis in PTC were restored by over-expression of STAT3. CEMIP functioned as an oncogenic gene in PTC through PDK4-mediated activation of STAT3/AKT/NF-κB pathway.

Assessment of Radiofrequency Ablation for Papillary Microcarcinoma of the Thyroid: A Systematic Review and Meta-analysis

IMPORTANCE

Papillary microcarcinomas of the thyroid (mPTCs) account for an increasing proportion of thyroid cancers in past decades. The use of radiofrequency ablation (RFA) has been investigated as an alternative to surgery. The effectiveness and safety of RFA has yet to be determined.

OBJECTIVE

To evaluate the effectiveness and safety of RFA for low-risk mPTC.

DATA SOURCES

Embase, MEDLINE via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched from inception to May 28, 2021.

STUDY SELECTION

Articles reporting on adult patients with mPTC treated with RFA were included. Studies that involved patients with pre-ablation lymph node or distant metastases, recurrence of disease, or extrathyroidal extension were excluded. Final article selection was conducted by multiple reviewers based on consensus. The proportion of eligible articles was 1%.

DATA EXTRACTION AND SYNTHESIS

This meta-analysis was conducted in accordance with the MOOSE guidelines. Random and fixed-effect models were applied to obtain pooled proportions and 95% CIs.

MAIN OUTCOMES AND MEASURES

The primary outcome was the complete disappearance rate of mPTC. Secondary outcomes were tumor progression and complications.

RESULTS

Fifteen studies were included in this meta-analysis. A total of 1770 patients (1379 women [77.9%]; mean [SD] age, 45.4 [11.4] years; age range, 42.5-66.0 years) with 1822 tumors were treated with RFA; 49 tumors underwent 1 additional RFA session and 1 tumor underwent 2 additional RFA sessions. Mean (SD) follow-up time was 33.0 (11.4) months (range, 6-131 months). The pooled complete disappearance rate at the end of follow-up was 79% (95% CI, 65%-94%). The overall tumor progression rate was 1.5% (n = 26 patients), local residual mPTC in the ablation area was found in 7 tumors (0.4%), new mPTC in the thyroid was found in 15 patients (0.9%), and 4 patients (0.2%) developed lymph node metastases during follow-up. No distant metastases were detected. Three major complications occurred (2 voice changes lasting >2 months and 1 cardiac arrhythmia). Minor complications were described in 45 patients.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that RFA is a safe and efficient method to treat selected low-risk mPTCs. Radiofrequency ablation could be envisioned as step-up treatment after local tumor growth under active surveillance for an mPTC or initial treatment in patients with mPTCs with anxiety about active surveillance.

Thoracoscopy-assisted treatment for mediastinal metastasis of thyroid cancer: a case report

Advanced thyroid cancer with upper mediastinal lymph node metastasis is not rare in the clinical setting. For patients with severe metastasis, a thoracocervical incision is usually performed for dissection of lymph nodes. However, the difficult operation of three-port thoracoscopy to support performance of a cervical incision in the treatment of upper mediastinal lymph node metastasis has rarely been reported to date. We herein describe a case involving the treatment of thyroid cancer with upper mediastinal lymph node metastasis. The lymph node metastasis was severe, closely adhered to the innominate vein, and fused into a mass. Thoracoscopy with a cervical incision was performed and proved to be a highly difficult surgical maneuver. The patient recovered quickly after the operation. Repeat computed tomography showed no swollen metastatic lymph nodes, indicating that the dissection was thorough. Thoracoscopy with a neck incision is more difficult than conventional longitudinal split sternotomy in the treatment of upper mediastinal lymph node metastasis, but its advantages are less severe trauma and faster recovery. This procedure may be performed by surgeons with proficient skill in cervical surgery and thoracoscopy techniques.

Clinicopathological Findings Associated With Cervical Lymph Node Metastasis in Papillary Thyroid Microcarcinoma: A Retrospective Study in China

Objective

The incidence of papillary thyroid microcarcinoma (PTMC) has increased sharply during the past decades. Yet, whether or not nodal dissection should be performed remains controversial. This article aims to assess the high-risk factors associated with cervical lymph node metastasis (LNM) in patients with PTMC, which may potentially guide clinical management decision-making.

Methods

Medical records of 449 PTMC patients who underwent thyroidectomy in our hospital from August 2016 to July 2017 were retrospectively reviewed. Clinical and pathological factors of the patients were anonymously extracted from the charts and analyzed.

Result

The patients were classified into two subgroups according to maximum tumor size measured through post-surgical pathology: smaller PTMC group (≤5 mm) and larger PTMC group (>5 mm). Larger tumor size was found to be associated with a higher rate of LNM (P = .001), particularly central lymph node metastasis (CLNM) (P = .001). Tumor size was also associated with extrathyroidal tumor extension (ETE) (P < .001), bilateral lesions (P = .015), and BRAF^v600e mutation (P = .004). LNM was found to be more common in older patients (>55 y) (P = .030), and those with multifocal cancer (P < .001). In PTMC patients with unilateral lesions without ETE, tumor size was not significantly associated with LNM (P = .121).

Conclusions

For the PTMC population, tumor size was an independent risk factor for LNM, particularly for patients of old age (>55 y), and multifocality. However, in PTMC patients with unilateral lesions without extrathyroidal extension, tumor size was not related to the risk of LNM. These findings may potentially guide clinical decision-making in terms of cervical nodal dissection.

Value of Contrast-Enhanced Ultrasound in Adjusting the Classification of Chinese-TIRADS 4 Nodules

OBJECTIVES

To explore the value of applying contrast-enhanced ultrasound (CEUS) in adjusting the classification of category 4 nodules in the Chinese-Thyroid Imaging Report and Data System (C-TIRADS).

METHODS

The data of preoperative conventional ultrasound and CEUS examinations of 125 C-TIRADS 4 nodules in 109 patients were retrospectively analyzed. We divided the thyroid nodules into two groups based on whether recommend by the guide fine-needle aspiration (FNA). Group I included C-TIRADS 4A nodules with a maximum diameter ≤15 mm and C-TIRADS 4B and 4C nodules with a maximum diameter ≤10 mm, and Group II included C-TIRADS 4A nodules with a maximum diameter >15 mm and C-TIRADS 4B and 4C nodules with a maximum diameter >10 mm. In CEUS, thyroid nodules showing suspicious malignant features such as hypoenhancement or early washout were adjusted to a level higher in the C-TIRADS classification; thyroid nodules showing possible benign features such as iso- or hyperenhancement were adjusted to a level lower; and thyroid nodules showing no enhancement were adjusted to C-TIRADS 3. Taking the pathological results as the gold standard, the receiver operating characteristic (ROC) curves of the C-TIRADS classification before and after the adjustment based on CEUS were plotted, and the diagnostic efficiency was compared.

RESULTS

The sensitivity, specificity, accuracy, and positive and negative predictive values of the C-TIRADS classification for the diagnosis of thyroid nodule malignancy before the adjustment based on the CEUS results were 83.6%, 63.8%, 74.4%, 72.7%, and 77.1%, respectively, and these values were 91.0%, 82.8%, 87.2%, 85.9%, and 88.9%, respectively, after the adjustment. The area under the ROC curve (AUC) was 0.737 and 0.869, respectively, showing a significant difference (Z = 3.288, P=0.001). The diagnostic efficiency of C-TIRADS classification after the adjustment based on the CEUS results in both groups was improved compared with the result before the adjustment, and the difference in Group II was significant (Z = 2.931, P=0.003).

CONCLUSIONS

CEUS significantly improved the diagnostic performance in the adjustment of C-TIRADS 4 nodule classification, especially for the nodules which needs FNA recommended by the C-TIRADS.

Burden of cancer and changing cancer spectrum among older adults in China: Trends and projections to 2030

BACKGROUND

Cancer creates considerable challenges for China with its aging population. This analysis aimed to estimate the burden of cancer and transition in cancer spectrum among older adults in China by 2030.

METHODS

Using data from the National Central Cancer Registry of China, we estimated annual percent change (APC) in cancer incidence and mortality rates among adults aged 60 years and above between 2006 and 2015 using joinpoint regression. We further estimated the number of new cancer cases and deaths from 2020 to 2030 based on the APC and population projections.

RESULTS

Although cancer incidence and mortality rates have been decreasing among older adults in China between 2006 and 2015, there were marked increases in the incidence and mortality rates of cervical (incidence: APC = 9.2%, mortality: APC = 7.6% all p < 0.05) and thyroid cancers (incidence: APC = 9.3%, p < 0.05) in older women. Between 2015 and 2030, the number of new cancer cases is projected to increase by 46% from 2.2 million to 3.2 million; cancer deaths will increase by 31% from 1.6 million to 2.1 million among older Chinese adults. In 2015, the 3 most common cancers were lung, colorectal and breast cancer in women, and lung, colorectal and stomach cancer in men. By 2030, cervical cancer is projected to be the most common cancer in women, followed by lung and thyroid cancer; prostate cancer will surpass stomach cancer to become the third most common cancer in men. In both sexes, lung, liver and stomach cancer were the top 3 leading causes of cancer deaths in 2015. In women, cervical cancer will surpass lung cancer as the leading cause of cancer deaths by 2030.

CONCLUSION

The growing burden of cervical, thyroid and prostate cancer among older Chinese adults represents a major shift in cancer spectrum in this population.

Safety of calcitonin stimulation tests with calcium

INTRODUCTION

Medullary thyroid carcinoma (MTC) is an aggressive form of thyroid cancer. Early detection is essential because only complete resection of the thyroid tumor and any local metastases can cure MTC. Calcitonin (CT) is a marker used for diagnosis of MTC. In controversial cases of slightly elevated CT levels, stimulation tests have shown their utility, but their safety should also be taken into account.

OBJECTIVE

Our aim is to present our own experience regarding the safety of CT stimulating tests.

MATERIALS AND METHODS

We applied a specific protocol of calcium stimulation test in 176 patients after informed consent (115 women with a median age of 46 years, range 21-79; 61 men with a median age of 54 years, range 22-78). We recorded the side effects and a further analysis was performed.

RESULTS

The most frequent side effects noted were hot flashes in 159 out of 176 patients (90.34%), followed by dysgeusia (32/176) and bradycardia (10/176). Severe bradycardia was reported in only one patient (0.568%), which was rapidly reversible. There was no correlation between patients' age, weight, height, body mass index, basal CT or peak stimulated CT, and grade of severity, but men were more likely to develop cardiovascular side effects than women, namely, bradycardia, tachycardia, ventricular or atrial extrasystoles, hypertension, hypotension, or angina (p = 0.024), with an odds ratio of 2.94 (CI: 1.11-7.76). We recommend thyroid surgery in all women with sCT above 285 pg/ml.

CONCLUSION

The calcium stimulation test is well tolerated, with few adverse reactions. The test should be performed with appropriate precautions (i.e., ECG monitoring during and after the test) to minimize the possibility of a serious event.

Characterization of the Immune Cell Infiltration Landscape of Thyroid Cancer for Improved Immunotherapy

Within the endocrine system, thyroid cancer (THCA) is the most typical malignant tumor. Tumor-infiltrating immune cells play vital roles in tumor progression, recurrence, metastasis as well as response to immunotherapy. However, THCA’s immune infiltrative landscape is still not clarified. Therefore, we utilized two statistical algorithms to investigate the immune cell infiltration (ICI) landscape of 505 THCA samples and defined three ICI immune subtypes. The ICI scores were calculated using principal-component analysis. Increased tumor mutation burden (TMB) and immune-related signaling pathways were associated to a high ICI score. The high ICI score group indicated a relatively longer overall survival (OS) than the low ICI score group. Most immune checkpoint-related and immune activation-related genes were considerably upregulated in the ICI high group, which indicates stronger immunogenicity and a greater likelihood of benefiting from immunotherapy. In two cohort studies of patients receiving immunotherapy, high-ICI-score group showed notable therapeutic effects and clinical advantages compared to those with lower ICI scores. These results demonstrate that ICI score acts as an effective prognostic indicator and predictor of response to immunotherapy.

Changes in clinical patterns of Chinese patients with primary hyperparathyroidism in the past 12 years: a single-center experience

The clinical presentation of primary hyperparathyroidism (PHPT) differs between patients from developed and developing countries. In China, the clinical pattern has changed over the past few decades. Our aim was to elucidate general changes in the clinical characteristics of PHPT from 2010 to 2021. We enrolled 343 patients with PHPT at the Qilu Hospital of Shandong University, Jinan, China, from January 2010 to May 2021, including both surgical and non-surgical patients. Patients were divided into two subgroups, 2010-2016 (group A, n = 152) and 2017-2021 (group B, n = 191), based on the time span. We compared clinical manifestations and laboratory result data between these two groups. The mean patient age was 52.59 ± 13.55 years, and the male-to-female ratio was 1:2.54. Of the 343 patients, 183 (53.35%) had symptomatic PHPT; bone pain, urolithiasis, and fatigue were the most common symptoms. Post-operative pathology showed that 96.20% of the patients had parathyroid adenoma, whereas 2.41% had parathyroid carcinoma. Great changes occurred between 2010 and 2021; the percentage of patients with asymptomatic PHPT (aPHPT) increased from 36.18% in group A to 54.97% in group B. Moreover, patients in group B showed significantly lower serum calcium, alkaline phosphatase, parathyroid hormone, and urinary phosphate levels but higher serum 25-hydroxyvitamin D levels than those in group A. Clinical presentations in group B were also milder. In conclusion, the clinical characteristics of Chinese PHPT patients changed dramatically from 2010 to 2021, with asymptomatic PHPT (aPHPT becoming the predominant type over the last 3 years.

Fine Needle Aspiration Cytology Implementation and Malignancy Rates in Children and Adolescents Based on Japanese Guidelines: The Fukushima Health Management Survey

Background: The thyroid ultrasound examination (TUE) program was initiated among the residents of Fukushima Prefecture aged ≤18 years at the time of the Fukushima Dai-ichi Nuclear Power Plant accident. In this program, fine needle aspiration cytology (FNAC) was performed only in cases that conformed to the Japanese guidelines for the management of thyroid nodules. To analyze the suitability of the protocol in the TUE, we analyzed the implementation rate of FNAC and the detection rate of thyroid malignancy. Methods: There were 299,939 and 269,659 voluntary participants in the Preliminarily Baseline Survey (PLBS), first-round survey, and the first Full-scale Survey (FSS), second-round survey, of the TUE, respectively. FNAC is recommended for nodules with diameters 5.1-10.0 mm showing sonographic characteristics that are strongly suspicious for thyroid carcinoma; diameters 10.1-20.0 mm with characteristics that are suspicious for carcinoma; and all nodules with diameters >20 mm. Results: In the PLBS and the first FSS, 1362 and 1382 cases with thyroid nodules sized ≥5.1 mm in diameter were found, respectively. The implementation rates of FNAC in the PLBS were 20.1%, 63.2%, and 87.7% of subjects with nodules sized 5.1-10.0, 10.1-20.0, and ≥20.1 mm in diameter, respectively. In the first FSS, the FNAC implementation rates were 7.3%, 26.0%, and 50.0% in the subjects with nodules with diameters 5.1-10.0, 10.1-20.0, and ≥20.1 mm, respectively. In the subjects who underwent FNAC, the detection rates of malignant and suspected malignant nodules were 21.4% and 34.1% in the PLBS and first FSS, respectively. In the first FSS, malignant or suspected malignant nodules were found in 0.63% and 0.40% of subjects who had nodules of diameters ≤5.0 mm and 5.1-10.0 mm in the PLBS, respectively. In contrast, in the subjects with nodules measuring ≥10.0 mm in diameter in the PLBS, no malignancies were detected. Conclusions: The use of a protocol that conformed to the Japanese guidelines led to a reduction in the FNAC implementation rate and an increase in the malignancy detection rate in smaller nodules. In addition, the use of this strategy enabled us to avoid detection failure of thyroid carcinomas >10.0 mm.

Low Iodine Intake May Decrease Women's Fecundity: A Population-Based Cross-Sectional Study

Salt iodization is one of the most cost-effective strategies to eliminate iodine deficiency disorders (IDD). However, China’s dismantling of salt monopoly has reduced the availability of iodized salt in the susceptible population in pregnancy, which might cause IDD and have adverse health effects on both themselves and their offspring. The aim of our study was therefore to explore the association between IDD and women’s reproductive health. This is a population-based cross-sectional study conducted in 2018 in Zhejiang Province, China. A total of 1653 pregnant women participated in this study. Median urinary iodine concentration (UIC) in the population was used to assess iodine intake. Cox regression analyses were used to estimate the association between iodine intake and time to pregnancy, which was indicated with fecundability ratio (FR) and 95% confidence interval (CI). The percentage of participants with iodine deficiency who had been waiting longer than 13 months to get pregnant (20%; median UIC 119.6 μg/L) was significantly higher than those with iodine sufficiency (14%; median UIC 147.1 μg/L). A significant decrease in fecundity was observed in participants with iodine deficiency (FR, 0.820; 95% CI, 0.725−0.929) than those with iodine sufficiency. These findings indicate the importance of ongoing monitoring of iodine nutrition in women of reproductive age. Keeping a safe and optimal level of iodine nutrition during pregnancy should be emphasized.

A Randomized Comparison of Carbon Nanoparticles in Endoscopic Lymph Node Dissection Via the Bilateral Areola Approach for Papillary Thyroid Cancer

OBJECTIVE

We assess the value of carbon nanoparticles (CNP) staining in patients undergoing endoscopic thyroidectomy and central compartment lymph node (CLN) dissection via the bilateral areola approach [endoscopic thyroidectomy via bilateral areola approach (ETBAA)].

METHODS

This was a prospective randomized study. Three hundred two consecutive early-stage thyroid cancer patients eligible for ETBAA were recruited at the Division of Thyroid Surgery, China-Japan Union Hospital, Jilin University, China. CLN were mapped and retrieved under the guidance of stained or unstained CNP. The location, detection rates, positive nodes, and number of stained lymph nodes were compared.

RESULTS

ETBAA patients were randomly divided into a CNP group (n=152) and a control group (n=150). In the CNP group, the imaging of lymphatic flow could be observed in 1016 (95.9%) lymph nodes, whereas 43 (4.1%) were unstained. The mean number of stained lymph nodes in each procedure was 6.68 (range, 3 to 12). The total number of dissected lymph nodes was 1059 in the CNP group and 872 in the control group (P=0.00). There was a significant difference of inadvertent parathyroidectomy between the 2 groups: 0.5% versus 3.9% in lobectomy (P=0.035) and 0.6% versus 5.2% in total thyroidectomy (P=0.012). However, the rates of hypoparathyroidism were not significantly different (P>0.05). There were no cases of CNP-related adverse effects.

CONCLUSIONS

The lymphatic navigation by CNP increases the number of detected CLN without the involvement of radioactive isotopes. However, CNP did not lower hypocalcemia, did not improve parathyroid hormone range, and there was no significant difference in the percentage of metastatic lymph nodes between the 2 groups.

Constitutive Cytomorphologic Features of Medullary Thyroid Carcinoma Using Different Staining Methods

(1) Background: Accurate preoperative identification of medullary thyroid carcinoma (MTC) is challenging due to a spectrum of cytomorphologic features. However, there is a scarcity of studies describing the cytomorphologic features as seen on fine-needle aspiration (FNA) smears prepared using different staining methods. (2) Methods: We performed a retrospective study on MTC cases with available FNA slides from 13 hospitals distributed across 8 Asia-Pacific countries. The differences in the constitutive cytomorphologic features of MTC with each cytopreparatory method were recorded. A comparative analysis of cytologic characteristics was carried out with appropriate statistical tests. (3) Results: Of a total of 167 MTC samples retrospectively recruited, 148 (88.6%) were interpreted as MTC/suspicious for MTC (S-MTC). The staining methods used were Papanicolaou, hematoxylin-eosin, and Romanowsky stains. Seven out of the eleven cytologic criteria can be readily recognized by all three cytopreparatory methods: high cellularity, cellular pleomorphism, plasmacytoid cells, round cells, dyshesive cells, salt-and-pepper chromatin, and binucleation or multinucleation. An accurate diagnosis was achieved in 125 (84.5%) of the 148 samples whose FNAs exhibited five or more atypical features. Conclusions: The present work is the first study on MTC to compare the morphological differences among the cytologic staining techniques. We investigated the constitutive features and the reliability of diagnostic parameters. A feasible scoring system based upon cytomorphologic data alone is proposed to achieve a high degree of diagnostic accuracy.

Active Surveillance for Papillary Thyroid Microcarcinoma in a Population with Restrictive Diagnostic Workup Strategies

Background: The worldwide incidence of papillary thyroid carcinoma (PTC) has increased. Efforts to reduce overtreatment follow two approaches: limiting diagnostic workup of low-risk thyroid nodules and pursuing active surveillance (AS) after diagnosis of microscopic PTC (mPTC). However, most studies on AS have been performed in countries with a relatively high proportion of overdiagnosis and thus incidental mPTC. The role of AS in a population with a restrictive diagnostic workup protocol for imaging and fine-needle aspiration remains unknown. Therefore, the aim of this study was to describe the proportion and characteristics of patients with mPTC in the Netherlands and to describe the potential candidates for AS in a situation with restrictive diagnostic protocols since 2007. Methods: All operated patients with an mPTC in the Netherlands between 2005 and 2015 were identified from the Netherlands Cancer Registry database. Three groups were defined: (Group 1) mPTC with preoperative distant or lymph node metastases, (Group 2) mPTC in pathology report after thyroid surgery for another indication, and (Group 3) patients with a preoperative high suspicious thyroid nodule or proven mPTC (Bethesda 5 or 6). Only patients in Group 3 were considered potential candidates for AS. Results: A total of 1018 mPTC patients were identified. Group 1 consisted of 152 patients with preoperatively discovered metastases. Group 2 consisted of 667 patients, of whom 16 (2.4%) had lymph node metastases. There were 199 patients in Group 3, of whom 27 (13.6%) had lymph node metastases. After initial treatment in Group 3, 3.5% (7/199) of the patients had recurrence. Conclusions: Restrictive diagnostic workup strategies of patients with small thyroid nodules lead to limited patients eligible for AS and a higher incidence of lymph node metastases. We believe that there is limited additive value for AS in countries with restrictive diagnostic workup guidelines such as in the Netherlands. However, if an mPTC is encountered, AS can be offered on an individual basis.

Fluorescence Image-Guided Surgery for Thyroid Cancer: Utility for Preventing Hypoparathyroidism

Background: Hypoparathyroidism is one of the most frequent complications of thyroid surgery, especially when associated with lymph node dissection in cases of thyroid cancer. Fluorescence-guided surgery is an emerging tool that appears to help reduce the rate of this complication. The present review aims to highlight the utility of fluorescence imaging in preserving parathyroid glands during thyroid cancer surgery. Methods: We performed a systematic review of the literature according to PRISMA guidelines to identify published studies on fluorescence-guided thyroid surgery with a particular focus on thyroid cancer. Articles were selected and analyzed per indication and type of surgery, autofluorescence or exogenous dye usage, and outcomes. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included articles. Results: Twenty-five studies met the inclusion criteria, with three studies exclusively assessing patients with thyroid cancer. The remaining studies assessed mixed cohorts with thyroid cancer and other thyroid or parathyroid diseases. The majority of the papers support the potential benefit of fluorescence imaging in preserving parathyroid glands in thyroid surgery. Conclusions: Fluorescence-guided surgery is useful in the prevention of post-thyroidectomy hypoparathyroidism via enhanced early identification, visualization, and preservation of the parathyroid glands. These aspects are notably beneficial in cases of associated lymphadenectomy for thyroid cancer.

Position paper from the Japan Thyroid Association task force on the management of low-risk papillary thyroid microcarcinoma (T1aN0M0) in adults

The incidence of thyroid carcinoma has been increasing worldwide. This is interpreted as an increase in the incidental detection of papillary thyroid microcarcinomas (PTMCs). However, mortality has not changed, suggesting overdiagnosis and overtreatment. Prospective clinical trials of active surveillance for low-risk PTMC (T1aN0M0) have been conducted in two Japanese institutions since the 1990s. Based on the favorable outcomes of these trials, active surveillance has been gradually adopted worldwide. A task force on the management of PTMC in adults organized by the Japan Thyroid Association therefore conducted a systematic review and has produced the present position paper based on the scientific evidence concerning active surveillance. This paper indicates evidence for the increased incidence of PTMC, favorable surgical outcomes for low-risk PTMC, recommended criteria for diagnosis using fine needle aspiration cytology, and evaluation of lymph node metastasis (LNM), extrathyroidal extension (ETE) and distant metastasis. Active surveillance has also been reported with a low incidence of disease progression and no subsequent recurrence or adverse events on survival if conversion surgery was performed at a slightly advanced stage. Active surveillance is a safe and valid strategy for PTMC, because it might preserve physical quality of life and reduce 10-year medical costs. However, some points should be noted when performing active surveillance. Immediate surgery is needed for PTMC showing high-risk features, such as clinical LNM, ETE or distant metastasis. Active surveillance should be performed under an appropriate medical team and should be continued for life.

Oncosuppressor-Mutated Cell-Based Diagnostic Platform for Liquid Biopsy Diagnoses Benign Head and Neck Masses and Predicts Malignancy in Thyroid Nodules: Results from a Consecutive Cohort of Patients

BACKGROUND

We reported that a novel oncosuppressor-mutated cell (OMC)-based platform has the potential for early cancer detection in healthy individuals and for identification of cancer patients at risk of developing metachronous metastases.

OBJECTIVE

Herein, we sought to determine the diagnostic accuracy of this novel OMC-based platform in a consecutive cohort of patients operated for suspicious head and neck masses.

METHODS

OMCs (BRCA1-deficient fibroblasts) were exposed to blood serum from patients with head and neck nodules before surgical removal. These cells were analyzed for their proliferation and survival. Treated OMCs were inoculated subcutaneously in NOD/SCID mice, and tumor growth was monitored over time.

RESULTS

OMCs exposed to serum from patients with malignant lesions displayed increased proliferation compared to those exposed to serum from patients with benign lesions. Only OMCs exposed to serum from patients diagnosed with malignant thyroid neoplasia generated a cancerous mass. The sensitivity of the test was 92%, with only 1 false negative out of 34 patients. Immunohistochemical staining showed that the cancerous masses were poorly differentiated adenocarcinomas with high proliferative index.

CONCLUSIONS

These data show that liquid biopsy combined with an OMC-based in vivo platform has the potential to diagnose benign head and neck masses and predict whether a thyroid nodule is malignant. These results strengthen the concept that OMCs can be used to detect circulating malignant factors in cancer patients.

Diffuse intrathyroidal dissemination of papillary thyroid carcinoma with no stromal fibrosis at presentation: A pattern of aggressive differentiated thyroid carcinoma

BACKGROUND

Multifocal Papillary thyroid carcinoma (PTC) is a very common condition. In certain cases, it is possible to find tens to hundreds of foci with a diffuse intrathyroidal spread in the whole thyroid with no stromal fibrosis. Herein, PTC with such features was nominated as diffuse disseminate variant (DDV) PTC. The aim of the present study was to investigate the histopathological characteristics, molecular features, and biological behavior of DDV and compare the characteristics of DDV to diffuse sclerosing variant (DSV) PTC.

MATERIALS AND METHODS

Thirty-four DDV and 23 DSV cases were identified from consecutive surgical specimens diagnosed with PTC between 2014 and 2019. Targeted next-generation sequencing (NGS) was applied to investigate the mutation spectrum of DDV and DSV.

RESULTS

DDV was commonly diagnosed in young patients and exhibited high rates of LNM (100 %), ETE (61.8 %), and LVI (44.1 %); however, they did not differ from DSV (P >  0.05). Male patients were more frequently diagnosed with DDV than with DSV (P <  0.001). The size of the largest tumor was significantly greater in DDV than in DSV patients (P =  0.008). In addition, BRAF^V600E mutation was significantly higher in the DDV than in the DSV group (P <  0.001). The RET/PTC rearrangement was more frequent in DSV than in DDV patients; however, the difference was not statistically significant (P =  0.106). Moreover, DDV had a higher rate of recurrence compared to DSV treated with the same protocol (total thyroidectomy followed by radioactive iodine (RAI) treatment) (47.1 % and 8.7 %, P =  0.002).

CONCLUSIONS

DDV should be regarded as a novel aggressive variant of PTC with distinct clinicopathological characteristics, aggressive biological behaviors, and a high recurrence.

Prevalence and predictor for malignancy of contralateral thyroid nodules in patients with unilateral PTMC: a systematic review and meta-analysis

BACKGROUND

The presence of clinically negative nodules on the contralateral lobe is common in patients with unilateral papillary thyroid microcarcinoma (PTMC). The appropriate operational strategies of contralateral thyroid nodules remain controversial. In this study, we analyzed clinical features that could be predictors for malignancy of contralateral thyroid nodules coexisting with diagnosed unilateral PTMC.

METHODS

The literatures published from January 2000 to December 2019 were searched in PubMed, Cochrane Library, Embase, Web of Science, CNKI, and Wan Fang database. Odds ratio (OR) with 95% CI was used to describe categorical variables. Heterogeneity among studies was examined by the Q test and I2 test; potential publication bias was detected by Harbord test and 'trim and fill' method.

RESULTS

In this meta-analysis, 2541 studies were searched and 8 studies were finally included. The results showed that the rate of carcinoma in contralateral nodules was 23% (OR = 0.23, 95% CI = 0.18-0.29). The pooled data indicated that contralateral malignancy was not associated with age, gender, primary lesion size, ipsilateral central lymph node metastasis and multifocality of contralateral lesion. The following variables have correlations with an increased risk of contralateral malignancy: multifocality of primary carcinomas (OR = 3.93, 95% CI = 2.70-5.73, P < 0.0001), capsular invasion (OR = 1.61, 95% CI = 1.10-2.36, P = 0.01), and Hashimoto's thyroiditis (OR = 1.57, 95% CI = 1.13-2.20, P = 0.008).

CONCLUSIONS

Based on our meta-analysis, the rate at which contralateral malignancies are preoperatively misdiagnosed as benign is 23%. The risk factors for contralateral malignancy in unilateral PTMC patients with contralateral clinical negative nodules include multifocality of primary carcinomas, capsular invasion, and Hashimoto's thyroiditis.

Changing incidence and projections of thyroid cancer in mainland China, 1983-2032: evidence from Cancer Incidence in Five Continents

PURPOSE

An increasing incidence of thyroid cancer has been seen in China during the past several decades. The aim of this study was to analyze potential age, period, and cohort effects on the incidence of thyroid cancer in mainland China and to predict new cases up to 2032.

METHODS

We calculated age-adjusted and age-specific incidence rates of thyroid cancer, conducted an age-period-cohort analysis of 35,037 thyroid cancer incidence cases reported to Cancer Incidence in Five Continents from 1983 to 2012 in mainland China, and predicted incidence up to 2032 using the Bayesian age-period-cohort method.

RESULTS

The age-adjusted overall incidence rate of thyroid cancer increased from 1.93/100,000 in 1983-1987 to 12.18/100,000 in 2008-2012 among females and from 0.77/100,000 in 1983-1987 to 3.89/100,000 in 2008-2012 among males, with a female-to-male ratio of approximately 3.0 during the three decades. Strong birth cohort and period effects on the incidence of thyroid cancer were observed for both sexes, and such an increasing trend is predicted to continue for at least the next 20 years. More than 3.7 million new cases are projected in the 2028-2032 period.

CONCLUSION

The increasing trend of thyroid cancer in mainland China will cause a great burden in the future. In addition to the potential impact of improvement in medical diagnostics, potential exposure to risk factors have played a role in the observed rising trend. Further population-based epidemiologic studies are required to identify risk factors to aid in thyroid cancer prevention and control.

Papillary thyroid microcarcinoma with lung metastases: a case report and review of the literature

BACKGROUND

Distant metastasis from papillary thyroid microcarcinoma (PTMC) is rare. Here we report a case of PTMC with multiple lung metastases.

CASE PRESENTATION

A 64-year-old man presented to our hospital with abdominal pain. Computed tomography incidentally revealed multiple lung nodules. The lung tumor was histologically diagnosed as metastasis of papillary thyroid carcinoma (PTC) by core needle biopsy via thoracoscopy. The patient was referred to our department for further examination. Neck ultrasonography revealed a 0.9 cm hypoechoic nodule in the right lobe of the thyroid gland, which was diagnosed as PTC by fine-needle aspiration cytology. Subsequently, total thyroidectomy was performed, followed by radioiodine therapy. Iodine-131 (131-I) scintigraphy showed a strong accumulation in the lung metastasis. The patient presented no evidence of progression of lung metastasis for 25 months after the operation.

CONCLUSIONS

Lymph node metastasis or extraglandular extension has been reported in the few published cases of metastatic PTMC, including the present case, and the average age of these cases was 58.8 ± 12.0 years. Although active surveillance without surgical resection is expected to become a standard of care for PTMC, this case indicates that a subset of PTMC patients with risk factors may develop distant metastases. Hence, careful preoperative screening is required to avoid complications associated with completion thyroidectomy.

Increasing Gap Between Thyroid Cancer Incidence and Mortality in Urban Shanghai, China: An Analysis Spanning 43 Years

OBJECTIVE

To examine the secular trends of thyroid cancer incidence and mortality and to estimate the proportion of thyroid cancer cases potentially attributable to overdiagnosis.

METHODS

Data on thyroid cancer cases from 1973 to 2015 were obtained from the Shanghai Cancer Registry. The average annual percent change (AAPC) was evaluated using the joinpoint regression analysis. The age, period, and birth cohort effects were assessed using an age-period-cohort model. The overdiagnosis of thyroid cancer cases was estimated based on the difference between observed and expected incidences using the rates of Nordic countries as reference.

RESULTS

From 1973 to 2015, the number of thyroid cancer cases was 23 117, and 75% of the patients were women. The age-standardized rates were seven- to eightfold higher from 2013 to 2015 than from 1973 to 1977. Compared with relatively stable mortality, thyroid cancer incidence was dramatically increased from 2002 to 2015 in both sexes, with significant trends (men: AAPC = 21.84%, 95% CI: 18.77%-24.98%, P < .001; women: AAPC = 18.55%, 95% CI: 16.49%-20.64%, P < .001). The proportion of overdiagnosis has gradually increased over time, rising from 68% between 2003 and 2007 to more than 90% between 2013 and 2015. This increasing trend appeared to be similar between men and women.

CONCLUSION

An increasing gap between thyroid cancer incidence and mortality was observed in Shanghai, and overdiagnosis has contributed substantially to the rise of incidence, which calls for an urgent update on the practice of thyroid examination.

Differences in Clinicopathological Characteristics of Papillary Thyroid Carcinoma between Symptomatic and Asymptomatic Patients with Primary Hyperparathyroidism

BACKGROUND

Popularization of cervical ultrasound led to higher detection of papillary thyroid carcinoma (PTC) and primary hyperparathyroidism (PHPT), as well as increasing percentage of asymptomatic PHPT in China. Although the coexistence of PTC and PHPT has been reported, it is unknown whether the clinicopathological features of PTC differ between asymptomatic and symptomatic PHPT patients.

METHODS

We retrospectively reviewed the medical records of 304 PHPT patients treated in our hospital between January 2009 and July 2020, including 217 females and 87 males with the average age of 53.27 ± 13.54 years. Of the 304 patients, 181 were symptomatic PHPT patients and 123 were asymptomatic PHPT patients. We analyzed the laboratory results, postoperative pathology, and the TNM stage of PTC between asymptomatic and symptomatic PHPT patients.

RESULTS

Concurrent thyroid nodules were found in 61.51% of PHPT patients, and the prevalence of PTC in thyroidectomized PHPT patients was 29.89% in our cohort. Lower serum parathyroid hormone (PTH) (p < 0.05) and calcium (p < 0.05) were found in PHPT patients with PTC compared to patients with benign thyroid lesion. Compared with the symptomatic PHPT patients, the asymptomatic PHPT patients showed lower serum calcium (p < 0.05), serum chlorine (p < 0.05), alkaline phosphatase (p < 0.05), PTH (p < 0.05), and bone turnover markers (p < 0.05) but higher prevalence of thyroid nodules (70.73% versus 55.24%, p < 0.05) and PTC (15.44% versus 3.87%, p < 0.05). All the PTC in symptomatic PHPT patients were papillary microcarcinoma limited to the thyroid, while 68.42% and 15.78% of the PTC in asymptomatic PHPT patients showed microscopic extrathyroidal extension and lymph node metastases, respectively. Moreover, 36.84% (7/19) of the PTC patients in asymptomatic group showed multifocality, which was much higher than 14.29% (1/7) in the symptomatic group; however, no statistical significance was found (p=0.24).

CONCLUSIONS

The concomitant PTC in asymptomatic PHPT patients showed a higher rate of microscopic extrathyroidal invasion when compared to symptomatic PHPT patients. So the FNA is essential to the asymptomatic PHPT patients with suspicious thyroid nodules and once the PTC is confirmed, concurrent parathyroidectomy should be performed with thyroidectomy in asymptomatic PHPT patients.