Identifying risk factors of recurrence for clinically node negative papillary thyroid carcinoma with pathologic N1a

Status of mental and social activities of young and middle-aged patients after papillary thyroid cancer surgery

Background

Papillary thyroid cancer (PTC) is prevalent among younger populations and has a favorable survival rate. However, a significant number of patients experience psychosocial stress and a reduced quality of life (QoL) after surgical treatment. Therefore, comprehensive evaluations of the patients are essential to improve their recovery.

Methods

The present study enrolled 512 young and middle-aged patients diagnosed with PTC who underwent surgery at our institution between September 2020 and August 2021. Each participant completed a series of questionnaires: Generalized Anxiety Disorder 7 (GAD-7), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Thyroid Cancer-Specific Quality of Life Questionnaire (THYCA-QoL), and Readiness to Return-to-Work Scale (RRTW).

Results

GAD-7 data showed that almost half of the study subjects were experiencing anxiety. Regarding health-related quality of life (HRQoL), participants reported the highest levels of fatigue, insomnia, voice problems, and scarring, with patients in anxious states reporting worse symptoms. Based on RRTW, more than half of the subjects had returned to work and had better HRQoL compared to the others who were evaluating a possible return to work. Age, gender, BMI, education, diet, residence, health insurance, months since surgery, monthly income, and caregiver status were significantly correlated with return to work. Additionally, having a caregiver, higher monthly income, more time since surgery, and living in a city or village were positively associated with return to work.

Conclusion

Young and middle-aged patients with PTC commonly experience a range of health-related issues and disease-specific symptoms following surgery, accompanied by inferior psychological well-being, HRQoL, and work readiness. It is crucial to prioritize timely interventions targeting postoperative psychological support, HRQoL improvement, and the restoration of working ability in PTC patients.

The risk of central nodal metastasis based on prognostic factors of the differentiated thyroid carcinoma: a systematic review and meta-analysis study

BACKGROUND AND AIM

Despite improving the 10-year disease-free-survival, prophylactic central neck dissection (pCND) in differentiated thyroid carcinoma (DTC) should only be considered in patients with high risk factors for lymph node (LN) metastasis due to the increases in the risk of postoperative complications. Our aim was to identify the risk factors for central lymph node metastasis (CLNM) in DTC.

METHOD

We searched PubMed, Scopus, Web of science, Cochrane library for eligible studies from inception to November 1, 2021 and a systematic review and meta-analysis were carried out to identify the risk factors for CLNM in DTC.

RESULTS

We included 41 studies with total of 27,741 patients in this study. The pooled results in this meta-analysis showed that these risk factors were significantly associated with CLNM: age < 45 years (odds ratio (OR) 1.64, 95% confidence interval (CI) 1.34-1.99, p < 0.00001), male sex (OR 1.73, 95% CI 1.54-1.93, p < 0.00001), multifocality (OR 1.87, 95% CI 1.59-2.19, p < 0.00001), bilateral disease (OR 1.43, 95% CI 1.15-1.78, p < 0.001), capsular invasion (OR 1.67, 95% CI 1.10-2.54, p < 0.02), lymphovascular invasion (OR 4.89, 95% CI 2.76-8.66, p < 0.00001) and extra-thyroidal extension (OR 2.43, 95% CI 1.97-3.00, p < 0.00001). In addition, young age (< 45 years), male sex, multifocality, and extra-thyroidal extension were significantly associated with large-volume CLNM in clinically N0 DTC patients. However, the presence of Hashimoto's thyroiditis was not a predictors of large-volume CLNM.

CONCLUSION

Young age (< 45 years), male sex, bilateral disease, multifocality, capsular invasion, lymphovascular invasion and extra-thyroidal extension are significantly associated with CLNM and pCND would be expected to have a higher yield in patients with these risk factors.

Construction of prediction models for determining the risk of lateral lymph node metastasis in patients with thyroid papillary carcinoma based on gender stratification

BACKGROUND

Lateral lymph node metastasis (LLNM) is associated with poor prognosis in patients with papillary thyroid cancer (PTC). The purpose of this study was to determine the risk factors for LLNM and establish prediction models that could individually assessed the risk of LLNM.

METHODS

A total of 619 PTC patients were retrospectively analyzed in our study. Univariate and multivariate analysis were performed for male and female patients, respectively, to assess relationships between clinicopathological features and LLNM. By integrating independent predictors selected by binary logistic regression modeling, preoperative and postoperative nomograms were developed to estimate the risk of LLNM.

RESULTS

LLNM was detected in 80 of 216 male patients. Of 403 female patients, 114 had LLNM. The preoperative nomogram of male patients included three clinical variables: the number of foci, tuner size, and echogenic foci. In addition to the above three variables, the postoperative nomogram of male patients included extrathyroidal extension (ETE) detected in surgery, central lymph node metastasis (CLNM) and high-volume CLNM. The preoperative nomogram of female patients included the following variables: age, chronic lymphocytic thyroiditis (CLT), BRAF V600E, the number of foci, tumor size and echogenic foci. Variables such as CLT, BRAF V600E, the number of foci, tumor size, ETE detected in surgery, CLNM, high-volume CLNM and central lymph node ratio were included in the postoperative nomogram. Above Nomograms show good discrimination.

CONCLUSIONS

Considering the difference in the incidence rate of LLNM between men and women, a separate prediction system should be established for patients of different genders. These nomograms are helpful in promoting the risk stratification of PTC treatment decision-making and postoperative management.

A systematic review and meta-analysis comparing tumor progression and complications between radiofrequency ablation and thyroidectomy for papillary thyroid carcinoma

BACKGROUND

Papillary thyroid cancer (PTC) is the most frequent thyroid cancers worldwide. The efficacy and acceptability of radiofrequency ablation (RFA) in the treatment of PTC have been intensively studied. The aim of this study is to focus on extra detailed that may influent for PTC or papillary thyroid microcarcinoma (PTMC).

MATERIALS AND METHODS

We identified a total of 1,987 records of a primary literature searched in PubMed, Embase, Cochrane Library, and Google Scholar by key words, from 2000 to 2022. The outcome of studies included complication, costs, and local tumor progression. After scrutiny screening and full-text assessment, six studies were included in the systematic review. Heterogeneity was estimated using I2, and the quality of evidence was assessed for each outcome using the GRADE guidelines.

RESULTS

Our review enrolled 1,708 patients reported in six articles in the final analysis. There were 397 men and 1,311 women in the analysis. Two of these studies involved PTC and four focused on PTMC. There were 859 patients in the RFA group and 849 patients in the thyroidectomy group. By contrast, the tumor progression of RFA group was as same as that surgical groups [odds ratio, 1.31; 95% CI, 0.52-3.29; heterogeneity (I2 statistic), 0%, p = 0.85]. The risk of complication rates was significantly lower in the RFA group than that in the surgical group [odds ratio, 0.18; 95% CI, 0.09-0.35; heterogeneity (I2 statistic), 40%, p = 0.14].

CONCLUSIONS

RFA is a safe procedure with a certain outcome for PTC. RFA can achieve a good efficacy and has a lower risk of major complications.

Nomograms for the prediction of lateral lymph node metastasis in papillary thyroid carcinoma: Stratification by size

Background

Lateral lymph node metastasis (LLNM) is a risk factor of poor prognosis in papillary thyroid cancer (PTC). We aimed to determine predictive factors and develop the nomograms for LLNM in patients with papillary thyroid microcarcinoma (PTMC) and macro-PTC.

Methods

We reviewed the medical records of 1,106 patients who underwent surgery between January 2019 and January 2022. Patients were divided into a PTMC and a macro-PTC group. We developed preoperative and postoperative nomograms for predicting LLNM based on results of multivariate analysis. Internal calibration was performed for these models.

Results

The number of metastatic lymph nodes in lateral compartment was higher in macro-PTC patients. LLNM was independently associated with gender, the number of foci, location, shape, and central lymph node metastasis (CLNM) in PTMC patients. For macro-PTC patients, chronic lymphocytic thyroiditis, the number of foci, location, margin, CLNM, and central lymph node ratio were all independent predictors for LLNM. All the above factors were incorporated into nomograms, which showed the perfect discriminative ability.

Conclusion

The diameter of the tumor has an impact on the rate of LLNM. Separate predictive systems should be used for PTMC and macro-PTC patients for more accurate clinical assessment of lateral lymph node status. Through these nomograms, we can not only detect high-risk patients with occult LLNM preoperatively, but also form appropriate treatment protocols for postoperative management of PTC patients with different risks.

Lymph node ratio is superior to AJCC N stage for predicting recurrence in papillary thyroid carcinoma

OBJECTIVE

Recently, lymph node ratio (LNR) has emerged as an alternative to American Joint Committee on Cancer (AJCC) N stage, with superior prognostic value. The utility of LNR in Middle Eastern papillary thyroid carcinoma (PTC) remains unknown. Therefore, we retrospectively analyzed a large cohort of 1407 PTC patients for clinicopathological associations of LNR.

METHODS

Receiver operating characteristics (ROC) curve was used to determine the cut-off for LNR. We also performed multivariate logistic regression analysis to determine whether LNR or AJCC N stage was superior in predicting recurrence in PTC.

RESULTS

Based on ROC curve analysis, a cut-off of 0.15 was chosen for LNR. High LNR was significantly associated with adverse clinicopathological characteristics such as male sex, extrathyroidal extension, lymphovascular invasion, multifocality, bilateral tumors, T4 tumors, lateral lymph node (N1b) involvement, distant metastasis, advanced tumor stage, American Thyroid Association (ATA) high-risk category and tumor recurrence. On multivariate analysis, we found that LNR was a better predictor of tumor recurrence than AJCC N stage (odds ratio: 1.96 vs 1.30; P value: 0.0184 vs 0.3831). We also found that LNR combined with TNM stage and ATA risk category improved the prediction of recurrence-free survival, compared to TNM stage or ATA risk category alone.

CONCLUSIONS

The present study suggests LNR is an independent predictor of recurrence in Middle Eastern PTC. Integration of LNR with 8th edition AJCC TNM staging system and ATA risk stratification will improve the accuracy to predict recurrence in Middle Eastern PTC and help in tailoring treatment and surveillance strategies in these patients.

Male Sex Is an Independent Predictor of Recurrence-Free Survival in Middle Eastern Papillary Thyroid Carcinoma

BACKGROUND

Disparity between sexes with regard to incidence, disease aggressiveness, and prognosis has been documented in several cancers. Although various reports have documented the association between male sex and aggressive papillary thyroid carcinoma (PTC), the prognostic impact of sex on PTC has been inconsistent. The role of sex in PTC aggressiveness and outcome in Middle Eastern PTC remains unknown. Therefore, our study retrospectively analyzed the data of a large cohort of Middle Eastern PTC patients to address this issue.

METHODS

We compared men and women with respect to clinico-pathological characteristics, disease persistence, structural recurrence, risk stratification, and prognosis. We included 1,430 patients-1,085 (75.9%) women and 345 (24.1%) men.

RESULTS

The median follow-up was 9.3 years. At diagnosis, 27% (93/345) of men were ≥55 years, compared with 17.8% (193/1085) of women (p = 0.0003). Men had significantly more advanced disease at presentation: higher stage (p = 0.0074), larger tumor size (p = 0.0069), higher rates of lymphovascular invasion (p = 0.0129), extrathyroidal extension (p = 0.0086), regional lymph node metastasis (p = 0.0279), and distant metastasis (p = 0.0101). There was a higher rate of recurrence (p < 0.0001) and TERT mutations (p = 0.0003) in male PTC patients than in female patients. Additionally, radioiodine refractoriness was higher in male PTC patients (p = 0.0014). In multivariate analysis, male sex was an independent prognostic factor for poor recurrence-free survival (RFS) (hazard ratio = 1.58; 95% confidence interval = 1.20-2.06; p = 0.0011).

CONCLUSIONS

Men with PTC are more likely to present with more advanced and aggressive disease. Importantly, male sex was an independent prognostic factor for RFS. Thus, men may benefit from more aggressive management and therapeutic interventions.

The effect of intraoperative neuromonitoring on the number of lymph nodes excised and recurrence when applied during neck dissection in cases of papillary thyroid cancer

Purpose

The aim of this study was to evaluate the effect of neuromonitoring on the number of lymph nodes (LNs) removed when applied during neck dissection.

Methods

A total of 166 patients receiving neck dissection due to papillary thyroid cancer were separated into 2 groups (monitoring group, n = 76; non-monitoring group, n = 90).

Results

The number of LNs dissected was observed to be statistically significantly higher in the monitoring group (P = 0.001), and the difference between the groups in the number of positive LNs was significant (P = 0.031). There was seen to be a negative relationship between the number of positive LNs dissected and recurrence (r = –0.404, P = 0.005).

Conclusion

Intraoperative neuromonitoring during neck dissection makes a positive contribution to the prevention of the development of recurrence by increasing the number of LNs excised and the number of metastatic LNs.

Microscopic Extrathyroidal Extension Results in Increased Rate of Tumor Recurrence and Is an Independent Predictor of Patient’s Outcome in Middle Eastern Papillary Thyroid Carcinoma

Background

Papillary Thyroid Cancer (PTC) is the most common endocrine malignancy, with recurrence rate as high as 30%. A great deal of controversy surrounds the significance of microscopic extrathyroidal extension (m-ETE) as a prognostic factor. The most recent edition (8^th) of American Joint Committee on Cancer (AJCC) staging system has removed m-ETE from the definition of pT3, which suggests that m-ETE may lack prognostic impact in PTC patients. Moreover, data about m-ETE prevalence and clinical impact on Middle Eastern PTC remains unknown. We therefore investigate the prevalence of m-ETE and its clinico-pathological correlation and prognostic impact in Middle Eastern PTC. We also compared the AJCC 7^th and 8^th staging systems and their prognostic performance.

Methods

PTCs from 1430 consecutive adult (> 18 years) patients from single tertiary care hospital were included in this study. A retrospective analysis of PTC patients’ survival and recurrence were compared between AJCC 8^th and AJCC 7^th staging systems using Proportion of Variation Explained (PVE) and Harrell’s C-index.

Results

Median follow up of the study cohort was 9.3 years. 31.2% (446/1430) of patients had m-ETE. In the overall cohort, m-ETE was associated with multiple adverse features such as older age (p < 0.0001), male sex (p = 0.0245), tall cell variant (p < 0.0001), bilateral tumors (p < 0.0001), multifocality (p < 0.0001), lymphovascular invasion (p < 0.0001), lymph node metastasis (p < 0.0001), distant metastasis (p = 0.0166), tumor recurrence (p < 0.0001), radioactive iodine refractoriness (p < 0.0001), BRAF mutation (p < 0.0001) and reduced recurrence-free survival (RFS; HR = 1.75; 95% CI = 1.30 – 2.35; p < 0.0001) irrespective of tumor size. Of the 611 patients with T3 disease based on AJCC 7^th edition, 359 (58.8%) were down-staged in AJCC 8^th edition classification. Overall, the prognostic performance of AJCC 8^th edition was inferior to AJCC 7^th on the basis of lower PVE (3.04% vs. 3.73%) and lower C-index (0.40 vs. 0.48).

Conclusions

In Middle Eastern PTC, m-ETE is significantly associated with compromised survival and acts as an independent predictor of RFS. Given these findings, m-ETE should be included in the thyroid cancer treatment guidelines.

Impacto del fenómeno de migración de estadio ganglionar en la supervivencia y la recurrencia de pacientes con cáncer papilar de tiroides sometidos a vaciamiento ganglionar profiláctico

Introducción. Dado que un ensayo clínico aleatorio es irrealizable, el rol del vaciamiento ganglionar profiláctico en pacientes con cáncer papilar de tiroides sin comprobación clínica de compromiso ganglionar metastásico (cN0) es controversial. El vaciamiento ganglionar profiláctico acarrea un proceso de reclasificación de pacientes, al hacer evidente la positividad ganglionar micrometastásica antes ignorada, lo que genera una aparente pero falsa mejoría en los desenlaces de los grupos de estadificación, mientras el pronóstico individual y total de la población no cambia, fenómeno conocido como migración de estadio o fenómeno de Will Rogers. Métodos. Se ejecutaron simulaciones de poblaciones con cáncer papilar de tiroides con compromiso ganglionar metastásico clínicamente evidente (cN+) y cN0, para determinar el impacto del fenómeno de migración de estadio en los pacientes sometidos a vaciamiento ganglionar profiláctico. Resultados. Con la simulación de las poblaciones y sus estadios ganglionares, se observa cómo la migración de estadio ganglionar genera una aparente mejoría en los desenlaces de recurrencia loco regional y supervivencia, sin cambiar los desenlaces de la población total ni individuales. Discusión. El fenómeno de migración de estadio es uno de los sesgos más importantes que limitan el uso de grupos históricos de control en ensayos de tratamiento experimental. De acuerdo con nuestros resultados, este fenómeno podría explicar los beneficios observados con el vaciamiento ganglionar profiláctico en algunos de los estudios agregativos publicados hasta el momento, hallazgos que no han sido documentados para el cáncer papilar de tiroides.

Clinical Relevance and Management of Recurrent Laryngeal Nerve Inlet Zone Lymph Nodes Metastasis in Papillary Thyroid Cancer

BACKGROUND

Recurrent nodal disease often occurs in recurrent laryngeal nerve inlet zone (RLNIZ), leading to difficult surgical management.

METHODS

Medical records of 947 patients with PTC and 33 patients with recurrent PTC were retrospectively reviewed. Totally 169 sides of RLNIZ dissection in 152 patients (17 cases were bilateral and 135 cases were unilateral) with primary surgery and 4 patients with structural recurrent disease were included for the analysis.

RESULTS

The rate of lymph node metastasis in RLNIZ was 31.3% (47/150). The incidence of transient hypoparathyroidism was 5.9% and no RLN injury and permanent hypoparathyroidism occurred. RLNIZ lymph nodes metastasis (LNM) was significantly associated with age <45 years, larger tumor size, number of CNLNM, and lateral node metastasis. CNLNM and lateral node metastasis were independent risk factors for RLNIZ LNM. Recurrent nodal disease in RLNIZ was identified in four of 33 patients and permanent recurrent laryngeal nerve (RLN) injury was observed in one of four patients.

CONCLUSION

Lymph nodes in RLNIZ are usually involved in patients with heavy tumor burden and can be removed safely at initial surgery. Once central or lateral LNM was confirmed preoperatively or intraoperatively, RLNIZ lymph node dissection should be carefully performed to reduce the rate of structural recurrence in the central compartment.

Completion Total Thyroidectomy Is Not Necessary for Papillary Thyroid Microcarcinoma with Occult Central Lymph Node Metastasis: A Long-Term Serial Follow-Up

Simple Summary

The necessity of completion total thyroidectomy is unclear in patients with papillary thyroid microcarcinoma (PTMC) with only pathological central lymph node metastasis (pCLNM). The aim of our study was to determine the necessity of completion total thyroidectomy after an initial surgery by comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We retrospectively compared the pathological central lymph node (pCLN)-positive group of 165 patients who underwent thyroid lobectomy with the pCLN-negative group of 711 patients and found no difference between the two groups in the recurrence rate and disease-free survival rates. Therefore, PTMC patients who underwent thyroid lobectomy with prophylactic central compartment neck dissection and were diagnosed with pCLNM after surgery do not require completion total thyroidectomy.

Abstract

The necessity of completion total thyroidectomy in patients with papillary thyroid microcarcinoma (PTMC) and pathological central lymph node metastasis (pCLNM) who underwent thyroid lobectomy with central compartment neck dissection (CCND) is unclear. We determined the necessity of completion total thyroidectomy by retrospectively comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We enrolled 876 patients with PTMC who underwent thyroid lobectomy with prophylactic CCND from January 1986 to December 2009. Patients were divided according to central lymph node (CLN) metastasis: 165 (18.8%) and 711 (81.2%) in the CLN-positive and CLN-negative groups, respectively. Medical records were reviewed retrospectively, and clinicopathologic characteristics and recurrence rates were analyzed. The CLN-positive group was associated with male sex (p = 0.001), larger tumor size (p < 0.001), and more microscopic capsular invasion (p < 0.001) compared with the CLN-negative group. There was no significant difference between the two groups’ recurrence (p = 0.133) or disease-free (p = 0.065) survival rates. Univariate and multivariate analyses showed no factors associated with tumor recurrence except male sex (hazard ratio = 3.043, confidence interval 1.117–8.288, p = 0.030). Patients who were diagnosed with pCLNM after undergoing thyroid lobectomy with prophylactic CCND do not require completion total thyroidectomy; however, frequent follow-up is necessary for patients with PTMC and pCLNM.

Extent of thyroid surgery for clinically node-negative papillary thyroid carcinoma with confirmed nodal metastases after prophylactic central neck dissection: a 15-year experience in a single center

PURPOSE

The use of prophylactic central neck dissection (PCND) and the extent of thyroid surgery in clinically node-negative (cN0) papillary thyroid carcinoma (PTC) are controversial. This study aimed to investigate whether the extent of thyroid surgery influences the prognosis of patients with PTC with central lymph node metastasis (N1a), which was cN0 but pathologically confirmed after PCND.

METHODS

This was a single-center retrospective study using medical records. Patients who underwent thyroid surgery with PCND for the treatment of PTC between 2004 and 2019 were included. Predictive factors and local recurrence rates were analyzed.

RESULTS

Of 2,274 patients with cN0 PTC, 436 were confirmed to have pathologic N1a disease after PCND. Among them, 340 patients (78.0%) underwent total thyroidectomy (TT) and 96 patients (22.0%) underwent less than TT. Of the 374 patients who were followed up for >6 months, 5 (1.3%) experienced recurrence. The 15-year recurrence-free survival (RFS) rate was 98.2%. No clinicopathologic factor was predictive of tumor recurrence. RFS tended to be lower in patients who underwent less than TT than in those who underwent TT; however, the difference was not statistically significant.

CONCLUSION

Our study showed low recurrence rates in patients with cN0 PTC pathologically confirmed as N1a after PCND. The RFS did not differ according to the extent of thyroid surgery. Considering the low recurrence rate and the surgical morbidity associated with thyroid surgery, less than TT with PCND may be considered for patients with cN0 unilateral PTC even with a pathologic staging of N1a after PCND.