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Park J, An S, Bae JS, Kim K, Kim JS. Impact of Tumor Size on Prognosis in Differentiated Thyroid Cancer with Gross Extrathyroidal Extension to Strap Muscles: Redefining T3b. Cancers (Basel) 2024; 16:2577. [PMID: 39061216 PMCID: PMC11274482 DOI: 10.3390/cancers16142577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/10/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
The prognostic significance of tumor size in T3b differentiated thyroid cancer (DTC) remains debated and underexplored. This study aimed to examine the varying impact of T3b based on tumor size, analyzing disease-specific survival, disease-free survival, and overall survival. A retrospective review of 6282 DTC patients who underwent thyroid surgery at Seoul St. Mary's Hospital from September 2000 to December 2017 was conducted. T3b was classified into three subcategories, T3b-1 (≤2 cm), T3b-2 (2-4 cm), and T3b-3 (>4 cm), using the same size criteria for T1, T2, and T3a. T3b-1 showed no significant difference in disease specific survival compared to T1, and both disease-free and disease-specific survival curves were sequentially ranked as T1, T3b-1, T2, T3a, T3b-2, and T3b-3. The modified T category, reclassifying T3b-1 as T1, demonstrated superior staging performance compared to the classic T category (c-index: 0.8961 vs. 0.8959 and AUC: 0.8573 vs. 0.8518). Tumors measuring 2 cm or less within the T3b category may require downstaging, and a modified T category could improve the precision of prognostic staging compared to the current T category.
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Affiliation(s)
| | | | - Ja Seong Bae
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.P.); (S.A.); (K.K.); (J.S.K.)
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Peng L, Zheng X, Xue Y, Huang C, Su X, Yu S. Central lymph nodes in frozen sections can effectively guide extended lymph node resection for papillary thyroid carcinoma. Ann Med 2023; 55:2286337. [PMID: 38061392 PMCID: PMC10836250 DOI: 10.1080/07853890.2023.2286337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES The scope of lateral neck lymph node dissection (LND) in papillary thyroid carcinoma (PTC) remains controversial. Our research aimed to explore the value of central lymph node metastasis (CLNM) in frozen sections for predicting neck lateral lymph node metastasis (NLLNM) and to guide clinical surgeons in performing surgical lymph node dissection. PATIENTS A total of 275 patients with PTC with suspected 'Cervical lymph node metastasis (LNM, including CLNM and NLLNM)' underwent unilateral or bilateral thyroidectomy and an intraoperative frozen diagnosis of central lymph nodes (LNs), as well as central and neck lateral LND. Validity indices and consistency of central LNs in frozen sections were calculated. In total, 216 patients then met the inclusion criteria and were enrolled in the follow-up study. The clinical and pathological data of the patients were retrospectively analyzed. The relationship between the number, metastatic diameter, and the ratio of CLNM to NLLNM was investigated. RESULTS CLNM in frozen and paraffin-embedded sections was associated with NLLNM. Univariate and multivariate analyses revealed the following risk factors for NLLNM metastasis: maximum diameter, total number, and ratio of metastatic LNs. A significant result was obtained when a cut-off value of 2.050 mm for the maximum metastatic diameter, 5.5 in the total number, and 0.5342 for the CLNM ratio level was used. Interaction term analyses showed that the association between the number of CLNM and NLLNM differed according to maximum diameter. CONCLUSION Central LNs in frozen sections accurately predicted NLLNM. In patients with PTC with >5 CLNMs, ≥2 and ≤5 CLNMs and maximum metastatic diameter > 2 mm, neck lateral LND should be considered. Our findings will facilitate the identification of patients who are likely to benefit from extended lateral neck LND.
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Affiliation(s)
- Li Peng
- Department of Pathology, College of Basic Medicine, Molecular Medicine Diagnostic and Testing Center, Chongqing Medical University, Chongqing, China
| | - Xiaoya Zheng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Xue
- Department of Pathology, College of Basic Medicine, Molecular Medicine Diagnostic and Testing Center, Chongqing Medical University, Chongqing, China
| | - Chun Huang
- Department of Thyroid and Breast Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - XinLiang Su
- Department of Thyroid and Breast Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shanshan Yu
- Department of Pathology, College of Basic Medicine, Molecular Medicine Diagnostic and Testing Center, Chongqing Medical University, Chongqing, China
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Qusty NF, Albarakati AJA, Almasary M, Alsalamah S, Alharbi L, Alharthi A, Al Sulaiman IN, Baokbah TAS, Taha M. Thyroid Cancer Knowledge and Awareness in Saudi Arabia: A Cross-Sectional Study. Cureus 2023; 15:e47888. [PMID: 38034267 PMCID: PMC10681848 DOI: 10.7759/cureus.47888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 12/02/2023] Open
Abstract
Background Thyroid cancer incidence has been increasing worldwide over the last few decades. It is the most common endocrine cancer and is most common among females. The study contributes to filling the knowledge gap among Saudi people regarding thyroid cancer. Objectives This research aims to investigate the level of thyroid cancer knowledge and awareness in Saudi Arabia, identify potential knowledge gaps, and develop targeted strategies for enhancing public awareness and education. Methods A cross-sectional, voluntary online survey was conducted from 1st August 2023 to 1st October 2023 among residents living in Saudi Arabia over 18 years of age. The participants included were 2030 respondents. Data analysis was performed using RStudio (R version 4.3.0; R Foundation for Statistical Computing, Vienna, Austria). Results Among the participants, the majority were female (60.4%). A total of 49.7% of the individuals reported having a moderate to high level of knowledge about thyroid cancer. While 63.9% knew the association of a lump in the neck to thyroid cancer, 82.6% affirmed to consult a doctor upon discovering a lump, 72.1% knew that regular monitoring of neck lumps is crucial for early diagnosis and treatment of precancerous conditions, 38.7% were aware of females being prone to thyroid cancer, and 59.2% were aware of the link between lifestyle and increased risk. Higher awareness scores were positively associated with female gender, previously having thyroid function tests done, and previously undergoing a US scan of the thyroid. Conclusion In this study, Saudi individuals are reported to lack some aspects of knowledge and perception of thyroid cancer. This study emphasizes filling the existing knowledge gap in thyroid cancer awareness in the Saudi population.
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Affiliation(s)
- Naeem F Qusty
- Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, SAU
| | | | - Manal Almasary
- Medicine, Faculty of Medicine, Umm Al-Qura University, Al-Qunfudah, SAU
| | - Seham Alsalamah
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Lama Alharbi
- Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Amnah Alharthi
- Medicine, College of Medicine, King Khalid University, Abha, SAU
| | | | - Tourki A S Baokbah
- Medical Emergency Services, College of Health Sciences, Umm Al-Qura University, Al-Qunfudah, SAU
| | - Medhat Taha
- Anatomy, College of Medicine, Umm Al-Qura University, Al-Qunfudah, SAU
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Alibrahim IS, Alnafei KH, Atwah RH, Altwyjri OA, Bassas RB, Alqurashi RO, Alsairafi RA. Thyroid Cancer Knowledge and Awareness Among Women in Makkah Region, Saudi Arabia. Cureus 2023; 15:e37739. [PMID: 37213993 PMCID: PMC10192656 DOI: 10.7759/cureus.37739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
INTRODUCTION Thyroid cancer (TC) is the most prevalent endocrine cancer, and it has shown a rapid rise in incidence across the globe in recent decades. This study aimed to evaluate the level of knowledge about TC among women in the Makkah Region, Saudi Arabia. METHODS A cross-sectional study was conducted between 28 December 2022 and 20 January 2023 among women in the Makkah Region via a self-administrated online questionnaire using Google Forms. Our inclusion criteria were women aged 18 years and older from the Makkah Region, and we excluded healthcare professionals and women who declined to participate in the study. The collected data were analyzed using the SPSS program. RESULTS The sample included 1219 participants. The majority (64%, n = 784) were 18 to 35. Of the participants, 362 (29.7%) had poor knowledge of TC, and only 94 (7.7%) possessed good knowledge. Forty-four percent of the participants (n = 541) believed that TC was incurable, and 86% (n = 1050) did not watch or participate in TC campaigns. Age, marital status, and family members or friends working in the medical field all significantly impacted the participants' knowledge scores. CONCLUSION According to our study, women in the Makkah Region in Saudi Arabia do not fully comprehend the risk factors and symptoms of TC or the diagnostic methods and treatment for it. The results emphasize the value of health campaigns focused on women-in public places and on social media platforms to increase awareness of TC.
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Lam AK. Concepts of Pathological Staging and Prognosis in Papillary Thyroid Carcinoma. Methods Mol Biol 2022; 2534:109-119. [PMID: 35670971 DOI: 10.1007/978-1-0716-2505-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (AJCC/UICC) staging and American Thyroid Association (ATA) risk predication system are the best predicators of mortality and cancer recurrence, respectively, in patients with differentiated thyroid carcinoma, including papillary thyroid carcinoma. In ATA risk stratification of differentiated thyroid carcinomas, clinical features, nodal features, and pathological features are assessed. Many of the features are also assessed in pathological staging. The prognostic stage grouping of papillary thyroid carcinoma in AJCC/UICC depends on the age of the patients as well as the standard parameters-extent of tumor (T), lymph node status (N), and presence of distant metastasis (M). Major changes noted in the current pathological staging protocol include the cut-off age from 45-year to 55-year in grouping of patients, use of gross invasion of strap muscles instead of minimal microscopic extrathyroidal extensions as T3b and downstage of many prognostic groups such as those with lymph node metastases (without distant metastases) from Stage III to Stage II. The staging protocol have moved many patients with papillary thyroid carcinoma into good prognostic groups for better predication of patients' survival rates and to avoid unnecessary treatment. This new approach has been verified by different groups globally, although modifications could be expected in the future for better prognostic assessment in patients with papillary thyroid carcinoma.
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Affiliation(s)
- Alfred K Lam
- Cancer Molecular Pathology of School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.
- Pathology Queensland, Gold Coast University Hospital, Southport, QLD, Australia.
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia.
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Preoperative Ultrasonographic Staging of Papillary Thyroid Carcinoma With the Eighth American Joint Committee on Cancer Tumor-Node-Metastasis Staging System. Ultrasound Q 2019; 36:158-163. [PMID: 31478984 DOI: 10.1097/ruq.0000000000000469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the performance of preoperative ultrasonography (US) in the staging of papillary thyroid carcinoma (PTC) according to the eighth AJCC TNM classification system, to determine the effect of the preoperative US staging in the management of PTC. PATIENTS AND METHODS Preoperative US was performed by 2 highly trained sonographers in 665 consecutive patients with PTC, and the T and N categories were determined preoperatively. The accuracy of preoperative US in clinical staging was evaluated based on the histopathological specimens according to the eighth AJCC TNM classification. Further analysis was performed to identify the high-risk factors of N1b stage. RESULTS Overall accuracy of preoperative US for T stage was 92.5% (615/665). The accuracy of sonographic evaluation for T was high except for the T4a. Overall accuracy of preoperative US for N stage was 59% (426/655). The accuracies of sonographic evaluation for N0, N1a, and N1b were 81.8% (274/335), 33.3% (70/250), and 87.5% (70/80), respectively. Of 250 N1a patients, 164 (65.6%) were underestimated by US. Univariate and multivariate analyses showed that larger tumor diameter, multifocality, and higher T stage significantly increase the risk of N1b stage (P < 0.01). CONCLUSIONS Preoperative US was useful for the evaluation in staging of PTC, but some limitations still existed. For higher-risk patients of N1b (larger tumor size, multifocality, and higher T stage), preoperative US examination for lateral neck region should be further emphasized, and prophylactic lateral nodal dissection should be determined based on both preoperative imaging results and intraoperative evaluation.
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Ozmen S, Timur O, Calik I, Altinkaynak K, Simsek E, Gozcu H, Arslan A, Carlioglu A. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) may be superior to C-reactive protein (CRP) for predicting the occurrence of differentiated thyroid cancer. Endocr Regul 2019; 51:131-136. [PMID: 28858848 DOI: 10.1515/enr-2017-0013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES NLR (neutrophil-lymphocyte ratio) and PLR (platelet-lymphocyte ratio) are prognostic markers of differentiated thyroid cancers. In our study, we evaluated NLR, PLR and C-reactive protein (CRP) for predicting the occurence of differentiated thyroid cancer. This is the first study that compares NLR and PLR to C-reactive protein indifferantiated thyroid cancer not only papillary cancer but also folliculer cancer. METHODS This study includes 51 papillary carcinoma, 42 papillary microcarcinoma and 31 folliculer carcinoma patients attending to our outpatient Endocrinology Clinic at Erzurum Region Training and Research Hospital between 2009 and 2014. The control group include 50 age, sex and body mass index matched healty subjects. Blood counts and CRP were measured at the day before surgery. Thyroglobulin was measured after 6 months of operation. RESULTS There were positive correlations between tumor diameter, age, white blood cell (WBC) and thyroglobulin levels. There were also positive correlation between NLR, PLR and CRP levels. CONCLUSION In our study, we found out that higher NLR and PLR was associated with higher levels of thyroglobulin which indicates worse survival. CRP levels were also associated with poorer tumor profile but the determining rate was lower according to ROC analysis.
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Kauffmann RM, Hamner JB, Ituarte PHG, Yim JH. Age greater than 60 years portends a worse prognosis in patients with papillary thyroid cancer: should there be three age categories for staging? BMC Cancer 2018; 18:316. [PMID: 29566662 PMCID: PMC5865378 DOI: 10.1186/s12885-018-4181-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/06/2018] [Indexed: 02/08/2023] Open
Abstract
Background Age is an important prognostic factor in papillary thyroid cancer (PTC), with better survival observed in patients < 45 years of age, regardless of stage. Although the impact of increasing age on PTC-related survival is well-known, previous studies have focused on survival relative to age 45 years only. As the number of patients entering their 7th decade of life increases, PTC-related survival in this demographic becomes increasingly important. Survival in patients ≥ 60 years specifically compared to other groups has not previously been examined. We sought to determine whether age ≥ 60 years is an adverse prognostic factor for disease-specific survival and recurrence in patients with PTC. Methods The California Cancer Registry database was linked to inpatient and ambulatory patient records from the Office of Statewide Health Planning and Development for the years 2000–2011. This linked database was queried for patients diagnosed with papillary thyroid cancer and treated with surgery. We then identified prognostic factors related to both 5-year and 10-year disease-specific survival and disease-free survival in patients ≤ 45, 45–59, and ≥ 60 years. Multivariable Cox proportional hazard models were created to test the effect of age ≥ 60 on disease-specific and disease-free survival, controlling for clinical, treatment, and demographic factors. Results The final cohort included 15,675 patients. Of the group, 46.3% were between 18 and 44 years of age, 33.6% were 45–59 years, and 20.1% were ≥ 60. Univariate analysis showed that compared to other groups, patients ≥ 60 were more likely to be male (p < 0.001), present with tumors > 5 cm (p < 0.001), more likely to have metastatic disease (p < 0.001), less likely to receive radioactive iodine (p < 0.001), and more likely to receive external beam radiation therapy (p < 0.001). In multivariable Cox proportional hazards models for 5 and 10-year disease-free survival, age ≥ 60 was associated with higher risk of disease at 5 and 10-years (HR 2.3 and 1.9 respectively, p < 0.001). Similar results were observed for 5 and 10-year disease-specific survival (HR 38.0 and 30.0 respectively, p < 0.001) after controlling for gender, race, co-morbidity, stage, surgical procedure, radioactive iodine, insurance, and hospital volume. Conclusions Patients ≥ 60 years of age have worse DSS and DFS after a diagnosis of PTC, across all stages of disease. Given that patients over the age of 45 years have progressively worse survival as they age, these data support having three age groups, 18–44 years of age, 45–59 years, and ≥ 60 as an independent predictor of survival and recurrence to current staging guidelines.
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Affiliation(s)
- Rondi M Kauffmann
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA, 91010-8113, USA
| | - J Blair Hamner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA, 91010-8113, USA
| | - Philip H G Ituarte
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA, 91010-8113, USA
| | - John H Yim
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA, 91010-8113, USA.
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Risk of recurrence in a homogeneously managed pT3-differentiated thyroid carcinoma population. Langenbecks Arch Surg 2018; 403:325-332. [PMID: 29445865 DOI: 10.1007/s00423-018-1657-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/29/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND International guidelines for the management of differentiated thyroid cancers are based on the 7th TNM classification: pT3 tumors are defined as differentiated thyroid cancers (DTCs) measuring more than 4 cm in their greatest dimension that are limited to the thyroid or any tumor with minimal extrathyroidal extension (ETE; sternothyroid muscle or perithyroid soft tissues). Differences in clinicohistological features and prognosis among patients with pT3 tumors remain controversial, and studies regarding pT3 subgroups are lacking. OBJECTIVE To analyze the prognosis of four subgroups of pT3 DTCs (papillary, PTC; or follicular, FTC). DESIGN AND SETTING The data of patients who underwent surgery for pT3 DTC between 1978 and 2015 in a surgical department specialized in endocrine surgery were reviewed. Patients were classified into four groups as follows: the pT3a (≤ 10 mm with ETE), pT3b (10-40 mm with ETE), pT3c (> 40 mm without ETE), and pT3d groups (> 40 mm with ETE). Recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method. RESULTS One thousand eighty-eight patients with pT3 DTC were included, of whom 311 (29%) had pT3a; 548 (50%), pT3b; 165 (15%), pT3c; and 64 (6%), pT3d. For the 916 patients with lymph node (LN) dissection, metastatic LNs were more frequent in the pT3b and pT3d groups (61 and 61%, respectively) than in the other groups (44% pT3a and 10% pT3c; p < 0.001). During the median follow-up period of 9 years (range, 2-38 years), recurrence occurred in 169 patients with T3 tumors (16%), including 18 with pT3a (6%), 100 with pT3b (18%), 20 with pT3c (12%), and 31 with pT3d (48%). In a multivariate analysis, LN metastases (< 0.0001), extranodal extension (p = 0.03), FTC (vs. PTC) (p = 0.006), pT3b (p = 0.016), and pT3d (p = 0.047) were associated with an increased risk of recurrence. The 5-year RFS rates were 94.5, 82.2, 91.1, and 50.3% for the pT3a, pT3b, pT3c, and pT3d groups, respectively (p < 0.01). CONCLUSION Except for microcarcinoma, the risk of LN involvement is high and similar for the DTC patients with minimal ETE, regardless of the size of the tumor. The association of a tumor size of > 4 cm and ETE are associated with a poor prognosis and should justify the classification of these cases as a high-risk group. Other pT3 patients with no LN metastases could be individualized as a low-risk group.
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Meixner M, Hellmich M, Dietlein M, Kobe C, Schicha H, Schmidt M. Disease-free survival in papillary and follicular thyroid carcinoma. Nuklearmedizin 2017; 52:71-80. [DOI: 10.3413/nukmed-0530-12-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 01/21/2013] [Indexed: 12/16/2022]
Abstract
SummaryT stage was redefined for patients with differentiated thyroid carcinoma (DTC) between the 5th and 7th versions of the UICC tumour classification system. Patients, methods: 636 patients (486 women, 150 men; mean age 49.1 ± 15.6 years, mean follow-up 4.6 years) who had been treated with ablative radioiodine therapy after thyroidectomy for papillary (PTC) or follicular thyroid carcinomas (FTC) were retrospectively assessed on occurrence of locoregional recurrent disease, or cervical lymph node or distant metastases. Disease-free survival was calculated from initial T stage, classified according to both versions of the UICC staging system and compared with the prognostic value of primary tumour size. Kaplan-Meier method and two measures of explained variation, (1) R2 based on the (partial) likelihood ratio statistic of the Cox proportional hazards model and (2) a model-free variant of a distance measure proposed by Schemper had the aim to detect the most advantageous classification. Results: Of the 508 patients with PTC, 11 (2.2%) developed a local recurrence, 37 (7.3%) cervical lymph node and 23 (4.5%) distant metastases, 3 (2.3%), 8 (6.3%), and 18 (14.1%) were the numbers for the 128 FTC patients respectively. The two classification systems yielded an equal count of statistically significant differences regarding disease-free survival in patients with PTC while UICC 7th classification appeared slightly advantageous in patients with FTC. Regarding explained variation the UICC 7th classification tended to be superior to the UICC 5th classification, both in PTC and FTC, however statistical significance was not reached. Conclusion: The primary tumour size significantly added to the prognosis regarding local cervical and distant metastases.
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Triviño Ibáñez EM, Muros MA, Torres Vela E, Llamas Elvira JM. The role of early 18F-FDG PET/CT in therapeutic management and ongoing risk stratification of high/intermediate-risk thyroid carcinoma. Endocrine 2016. [PMID: 26224589 DOI: 10.1007/s12020-015-0708-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Little is known about the role in ongoing risk stratification of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) performed early after radioactive iodine (RAI) ablation in differentiated thyroid carcinoma (DTC). The aim of the study is to investigate whether 18F-FDG PET/CT performed early after RAI ablation is useful to detect disease and to influence therapy and ongoing risk stratification. Patients with high/intermediate risk of recurrent DTC were included. 18F-FDG PET/CT scan was performed within 6 months after RAI ablation. We confirmed results with other imaging techniques, pathology reports, or follow-up. We classified the patient response as excellent, acceptable, or incomplete. Modified Hicks criteria were used to evaluate clinical impact. We included 81 patients with high/intermediate risk of recurrent DTC. Forty-one (50.6%) had positive uptake in 18F-FDG PET/CT, with negative (131)I whole-body scan ((131)I WBS). Sensitivity, specificity, and diagnostic accuracy of 18F-FDG PET/CT were 92.5, 90.2, and 91.4%, respectively. 18F-FDG PET/CT results had an impact on therapy in 38.3% of patients. One year after initial therapy, 45.7% showed excellent response, 8.6% acceptable response, and 45.7% incomplete response. A statistically significant relationship was found between negative 18F-FDG PET/CT and excellent response (80 vs. 12.2%, p < 0.001; OR 52.8). 18F-FDG PET/CT scan performed early in surveillance of patients with high/intermediate-risk thyroid carcinoma provides important additional information not available with conventional follow-up methods and had a high impact on therapy. A negative 18F-FDG PET/CT predicts an excellent response to therapy in the new ongoing risk stratification.
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Affiliation(s)
- E M Triviño Ibáñez
- Department of Nuclear Medicine, Virgen de las Nieves University Hospital, Granada, Spain.
| | - M A Muros
- Department of Nuclear Medicine, Virgen de las Nieves University Hospital, Granada, Spain
| | - E Torres Vela
- Department of Endocrinology and Metabolism, San Cecilio University Hospital, Granada, Spain
| | - J M Llamas Elvira
- Department of Nuclear Medicine, Virgen de las Nieves University Hospital, Granada, Spain
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Tanase K, Thies ED, Mäder U, Reiners C, Verburg FA. The TNM system (version 7) is the most accurate staging system for the prediction of loss of life expectancy in differentiated thyroid cancer. Clin Endocrinol (Oxf) 2016; 84:284-291. [PMID: 25740466 DOI: 10.1111/cen.12765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/10/2015] [Accepted: 02/26/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Many prognostic systems have been developed for differentiated thyroid cancer. It is unclear which one of these performs 'best'. Our aim was to compare staging systems applicable to our patient database to identify which best predicts DTC-related loss of life expectancy and DTC-specific mortality. DESIGN Database study of patients with DTC treated in our centre between 1978 (earliest available data) up to and including 1 July 2014. All were staged in accordance with the AMES, Clinical Class, Memorial Sloan Kettering, Ohio State University, TNM versions 5 and 6/7, University of Alabama, University of Münster and qTNM systems. PATIENTS A total of 2257 patients with differentiated thyroid cancer. MEASUREMENTS Loss of life expectancy expressed as relative survival and thyroid cancer-specific mortality. Comparison was based on P values of univariate Cox regression analyses as well as analysis of the proportion of variance explained (PVE). RESULTS Median available follow-up time was 7·2 years (range: 0-35·1 years). Three hundred and twenty-seven patients died, 149 of whom died of DTC. Version 7 of the TNM system was best for predicting DTC-related mortality (P = 7·1 × 10-52 ; PVE = 0·296), followed by TNM version 5 (P = 6·7 × 10-44 ; PVE = 0·255). For prediction of loss of life expectancy, version 7 of the TNM system was also best, closely followed by the Clinical Class system (P both < 2 × 10-16 ). CONCLUSIONS The UICC/AJCC TNM system version 7 outperforms other prognostic classification systems based on extent of disease at the start of treatment both for prediction of differentiated thyroid cancer-related death and for prediction of loss life expectancy.
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Affiliation(s)
- Karina Tanase
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
| | - Elena-Daphne Thies
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Uwe Mäder
- Comprehensive Cancer Center, University of Würzburg, Würzburg, Germany
| | - Christoph Reiners
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
| | - Frederik A Verburg
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
- Department of Nuclear Medicine, RWTH University Hospital Aachen, Aachen, Germany
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Lang BHH, Ng CPC, Au KB, Wong KP, Wong KKC, Wan KY. Does preoperative neutrophil lymphocyte ratio predict risk of recurrence and occult central nodal metastasis in papillary thyroid carcinoma? World J Surg 2015; 38:2605-12. [PMID: 24809487 DOI: 10.1007/s00268-014-2630-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Preoperative neutrophil to lymphocyte ratio (NLR) might be prognostic in papillary thyroid carcinoma (PTC). Given the controversy of prophylactic central neck dissection (pCND) in clinically nodal-negative (cN0) PTC, our study evaluated whether preoperative NLR predicted disease-free survival (DFS) and occult central nodal metastasis (CNM) in cN0 PTC. METHODS A total of 191 patients who underwent pCND were analyzed. Complete blood counts with differential counts were taken before operation. NLR was calculated by dividing preoperative neutrophil count with lymphocyte count. Patients were categorized into NLR tertiles: first (NLR < 1.93; n = 63), second (NLR = 1.93-2.79; n = 64), and third tertile (NLR > 2.79; n = 64). Four other patient types, namely, benign nodular goiter, clinically nodal-positive (cN1) PTC, poorly differentiated thyroid carcinoma, and anaplastic thyroid carcinoma (ATC), were used as references. RESULTS Age at operation (p < 0.001) and tumor size (p = 0.037) significantly increased with higher NLR. First tertile had significantly more TNM stage I tumors (p = 0.01) and lowest MACIS score (p = 0.002). Tumor size [hazard ratio (HR) 1.422, 95% confidence interval (CI) 1.119-1.809, p = 0.004] and multicentricity (HR = 2.545, 95% CI 1.073-6.024, p = 0.034) independently predicted DFS, whereas old age [odds ratio (OR) 1.026, 95% CI 1.006-1.046, p = 0.009), male (OR 2.882, 95% CI 1.348-6.172, p = 0.006), and large tumor (OR 1.567, 95% CI 1.209-2.032, p = 0.001) independently predicted occult CNM. NLR was not significantly associated with DFS or occult CNM. ATC had significantly higher NLR than cN1 PTC (7.28 vs. 2.74, p < 0.001). CONCLUSIONS Although a higher NLR may imply a poorer tumor profile, it was not significantly associated with a worse DFS or higher risk of occult CNM in cN0 PTC. Perhaps, future research should focus on the prognostic value in other thyroid cancer types with a poorer prognosis.
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Baek HJ, Kim DW, Ryu JH. Association between TNM staging system and histopathological features in patients with papillary thyroid carcinoma. Endocrine 2015; 48:589-94. [PMID: 25052062 DOI: 10.1007/s12020-014-0362-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/07/2014] [Indexed: 12/01/2022]
Abstract
We aimed to assess the validity of the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system in patients with papillary thyroid carcinoma (PTC) by evaluating the relationships between clinicopathologic factors and TNM stage using histopathological specimens and electronic medical records. We enrolled 733 consecutive patients who had undergone thyroid surgery for PTC between 2010 and 2013. Clinical data were obtained from electronic medical records. TNM stages, multifocality, and bilaterality were analyzed after review of histopathological specimens by applying the AJCC TNM staging system. Multiple statistical analyses were performed to evaluate the correlation between the AJCC TNM staging system and the clinicopathologic factors. Of the 733 patients, there were T stage including T1a (46.9 %, 344/733), T1b (12.6 %, 92/733), T2 (2.0 %, 15/733), T3 (38.1 %, 279/733), T4a (0.4 %, 3/733), and T4b (0 %, 0/733), N stage including N0 (58.9 %, 432/733), N1a (24.3 %, 178/733), and N1b (16.8 %, 123/733), and multiplicity including multifocality (31.1 %, 228/733) and bilaterality (23.7 %, 174/733). There was a significant association between the PTC primary tumor size and T stage, N stage, multifocality, and bilaterality (p < 0.0001). Multifocality, bilaterality, and the presence of nodal metastasis were most frequently seen in patients with T3 stage (p < 0.0001). In multivariate logistic regression analyses, T and N stages were independent predictors of multiple PTCs. The PTC primary tumor size had a significant association with the T and N stages of the AJCC TNM staging system, and these factors were independent predictors of multifocality and bilaterality.
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Affiliation(s)
- Hye Jin Baek
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, 612-896, South Korea,
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Lang BHH, Lo CY, Wong KP, Wan KY. Long-Term Outcomes for Older Patients with Papillary Thyroid Carcinoma: Should Another Age Cutoff Beyond 45 Years Be Added? Ann Surg Oncol 2014; 22:446-53. [DOI: 10.1245/s10434-014-4055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Indexed: 01/15/2023]
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Chan AC, Lang BHH, Wong KP. The pros and cons of routine central compartment neck dissection for clinically nodal negative (cN0) papillary thyroid cancer. Gland Surg 2014; 2:186-95. [PMID: 25083482 DOI: 10.3978/j.issn.2227-684x.2013.10.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 10/31/2013] [Indexed: 01/27/2023]
Abstract
Metastatic disease to regional lymph nodes (LNs) is common in papillary thyroid carcinoma (PTC). LN dissection is increasingly performed as part of the surgical management of PTC. The role of prophylactic central neck dissection (pCND) in PTC is unclear. There is limited evidence to support a routine pCND in clinical setting for nodal negative (cN0) PTC. The aim of this review was to examine the pros and cons of prophylactic neck dissection in cN0 PTC. In summary, the advantages of pCND are: removal of the central LNs that potentially harbor micro-metastases, more accurate staging of disease in order to plan more individualized management, reducing the need for re-operation to remove the metastatic LNs which have developed later and possible improvement in overall survival. The disadvantages are: an extensive surgery but lack of evidence of survival benefit, higher incidence of complications with little impact on local recurrence rate, possibility of over treating in cN0 patients and it does not sound like a cost effective approach in the management of small thyroid cancer. Considering low frequency of permanent morbidity, some authors believe that prophylactic neck dissection is safe in experienced hands even though its prognostic benefit has yet to be demonstrated.
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Affiliation(s)
- Ai Chen Chan
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Brian Hung Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai Pun Wong
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Lang BHH, Chan DTY, Wong KP, Wong KKC, Wan KY. Predictive Factors and Pattern of Locoregional Recurrence After Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma. Ann Surg Oncol 2014; 21:4181-7. [DOI: 10.1245/s10434-014-3872-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Indexed: 01/28/2023]
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Mankarios D, Baade P, Youl P, Mortimer RH, Onitilo AA, Russell A, Doi SAR. Validation of the QTNM staging system for cancer-specific survival in patients with differentiated thyroid cancer. Endocrine 2014; 46:300-8. [PMID: 24174176 DOI: 10.1007/s12020-013-0078-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
Abstract
An Australian state database was used to test the validity of the Quantitative tumor/node/metastasis (QTNM) staging system for assessing prognosis of differentiated thyroid cancer (DTC) on the basis of four variables quantified at diagnosis (histopathology, age, node involvement, and tumor size). Using the Queensland Cancer Registry (QCR), we identified 788 cases of DTC diagnosed from 1982 to 2006 with complete staging information. Causes of death were ascertained by linking the QCR database with the Australian National Death Index. Subjects were staged according to AJCC TNM 7th edition and QTNM, and cancer-specific survival (CSS) was calculated by the Kaplan-Meier method. Cancer-specific mortality was observed in 22 (2.8 %) patients, with 10-year CSS for the cohort of 97.0 % at a median follow-up of 262.8 months. QTNM stage specific cancer survival at 10 years was 99.6, 97.0, and 78.6 % for low-, intermediate-, and high-risk groups, respectively. This was comparable to the original US dataset in which the QTNM was initially studied, and it fared better at discriminating survival than the standard TNM system, where there was overlap in survival between stages. The current study validates the QTNM system in an Australian cohort and shows at least equivalent discriminatory capacity to the current TNM staging system. The QTNM utilized prognostic variables of significance to produce an optimal three-stage stratification scheme. Given, its advantage in clearly discriminating between prognostic groups, clinical relevance and simplicity of use, we recommend that TNM be replaced with QTNM for risk stratification for both recurrence and CSS.
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Affiliation(s)
- Daniel Mankarios
- School of Medicine, University of Queensland, Brisbane, Australia
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Vrachimis A, Gerss J, Stoyke M, Wittekind C, Maier T, Wenning C, Rahbar K, Schober O, Riemann B. No significant difference in the prognostic value of the 5th and 7th editions of AJCC staging for differentiated thyroid cancer. Clin Endocrinol (Oxf) 2014; 80:911-7. [PMID: 24417487 DOI: 10.1111/cen.12405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/07/2013] [Accepted: 01/04/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The seventh edition of the American Joint Committee on Cancer (AJCC) has more detailed staging categories for differentiated thyroid cancer (DTC) than the fifth edition. The aim was to compare potential alterations in the disease-specific (DSS), event-free (EFS) and overall survival (OS), after reclassification from the fifth to the seventh edition. METHODS Data of 2460 patients with DTC referred to our centre were reclassified from the fifth to the seventh edition of AJCC. DSS, EFS and OS were calculated using the Kaplan-Meier method and compared by the log-rank test. The relative abilities of each edition to predict survival were calculated by the proportion of variance explained (PVE). RESULTS After reclassification to the seventh edition, there was an increase in stage I and IV patients from 58·1% to 65·0% and from 6·2% to 10·1%, respectively, and a corresponding decrease in stage II and III patients from 22·4% to 12·5% and 13·3% to 12·4%, respectively. As to DSS, the seventh edition had only a marginally higher PVE value than the fifth edition. With respect to EFS, the predictability of the seventh edition was even inferior to that of the fifth edition. Similarly, with regard to OS, the PVE value was slightly better for the older edition. Furthermore, a comparison only for those patients affected by the reclassification revealed no differences for DSS, EFS or OS between classifications. CONCLUSION When comparing the stages of the seventh with the fifth edition of the AJCC for DTC, there was no significant difference in predicting DSS, EFS and OS.
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Affiliation(s)
- Alexis Vrachimis
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
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Lang BHH, Chai YJ, Cowling BJ, Min HS, Lee KE, Youn YK. Is BRAFV600E mutation a marker for central nodal metastasis in small papillary thyroid carcinoma? Endocr Relat Cancer 2014; 21:285-95. [PMID: 24402044 DOI: 10.1530/erc-13-0291] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Utilizing BRAF(V600E) mutation as a marker may reduce unnecessary prophylactic central neck dissection (pCND) in clinically nodal negative (cN0) neck for small (≤2 cm) classical papillary thyroid carcinoma (PTC). We aimed to assess whether BRAF is a significant independent predictor of occult central nodal metastasis (CNM) and its contribution to the overall prediction after adjusting for other significant preoperative clinical factors in small PTC. Primary tumor tissue (paraffin-embedded) from 845 patients with small classical cN0 PTC who underwent pCND was tested for BRAF mutation. Clinicopathologic factors were compared between those with and without BRAF. BRAF was evaluated to see if it was an independent factor for CNM. Prediction scores were generated using logistic regression models and their predictability was measured by the area under the ROC curve (AUC). The prevalence of BRAF was 628/845 (74.3%) while the rate of CNM was 285/845 (33.7%). Male sex (odds ratio (OR): 2.68, 95% CI: 1.71-4.20), large tumor size (OR: 2.68, 95% CI: 1.80-4.00), multifocality (OR: 1.49, 95% CI: 1.07-2.09), lymphovascular permeation (OR: 10.40, 95% CI: 5.18-20.88), and BRAF (OR: 1.65, 95% CI: 1.10-2.46) were significant independent predictors of CNM, while coexisting Hashimoto's thyroiditis (OR: 0.56, 95% CI: 0.40-0.80) was an independent protective factor. The AUC for prediction score based on tumor size and male sex was similar to that of prediction score based on tumor size, male sex, and BRAF status (0.68 vs 0.69, P=0.60). Although BRAF was an independent predictor of CNM, knowing its status did not substantially improve the overall prediction. A simpler prediction score based on male sex and tumor size might be sufficient.
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Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China Department of Surgery, Seoul National University College of Medicine and Hospital, Seoul, Korea School of Public Health, The University of Hong Kong, Hong Kong SAR, China Department of Pathology, Seoul National University College of Medicine and Hospital, Seoul, Korea Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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[Current TNM system of the UICC/AJCC : the prognostic significance for differentiated thyroid carcinoma]. Chirurg 2014; 83:646-51. [PMID: 22273853 DOI: 10.1007/s00104-011-2216-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of study was an evaluation of prognostic factors of the current TNM version (UICC/AJCC 2009, 7th revision) for differentiated thyroid carcinoma (DTC). PATIENTS AND METHODS A total of 368 patients with DTC (papillary thyroid carcinoma [PTC] n = 269, follicular thyroid carcinoma [FTC] n = 99) were included. Disease-specific survival (DSS) was calculated based on the different TNM stages (mean follow-up 60 ± 37.5 months). RESULTS When compared to patients with FTC, PTC patients had smaller tumors (diameter 19 mm versus 33 mm), more often lymph node metastases (40.9% versus 9.1%) but less frequent distant metastases (2.6 versus 13.1%) and poorly differentiated variants (PDTC 3.0% versus 8.1%). The 5-year and 10-year DSS for PTC versus FTC were 97.3% versus 91.5% and 96.2% versus 91.5% (p = 0.086), respectively. When comparing different TNM categories between well-differentiated PTC and FTC, no statistically significant differences were found but PDTCs, had a significantly worse DSS. CONCLUSIONS The current TNM system is a sufficient tool for predicting DSS in well-differentiated PTC. In FTC, the extent of capsular and vascular invasion should also be considered. The implementation of a specific TNM system for PDTC needs to be confirmed in further studies.
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Lang BHH, Ng SH, Lau LLH, Cowling BJ, Wong KP, Wan KY. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid 2013; 23:1087-98. [PMID: 23402640 DOI: 10.1089/thy.2012.0608] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone. METHODS A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing > 10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model. RESULTS Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]). CONCLUSIONS Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (< 5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.
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Lang BHH, Wong CKH. A cost-minimization analysis comparing total thyroidectomy alone and total thyroidectomy with prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma. Ann Surg Oncol 2013; 21:416-25. [PMID: 23982258 DOI: 10.1245/s10434-013-3234-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Total thyroidectomy (TT) with prophylactic central neck dissection (pCND) remains controversial for clinically nodal-negative (cN0) papillary thyroid carcinoma (PTC), and the issue of cost rarely has been examined. We evaluated whether pCND at the time of TT is more cost-saving than TT alone in the medium- to long-term. METHODS For a hypothetical group of 50-year-old females with a 1.5-cm cN0 PTC, a decision-tree model using TreeAge Software was developed to simulate outcomes and compare the 20-year accumulative direct cost between TT alone and TT+pCND strategies. Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. Cost estimate of surgical procedures, complications, and radioiodine (RAI) ablation was based on government gazette. RESULTS The cost accrued per patient for the primary operation under TT alone and TT+pCND strategies were USD 6,702.81 and USD 10,062.35, respectively, whereas the cost for the reoperative procedure were USD 12,981.40 and USD 12,509.09, respectively. The 20-year accumulative cost for TT alone and TT+pCND strategies were USD 19,888.36 and USD 22,760.86, respectively. The incremental cost per patient was USD 2,872.50. In the univariate and bivariate sensitivity analyses, no change in conclusion was seen by varying the rates of complications, annualized locoregional recurrences and RAI, or by extending the model to 50 years. CONCLUSIONS From a pure economic institution's perspective, TT+pCND is more expensive in the medium- and long-term and seems less justified compared with TT alone for cN0 PTC.
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Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China,
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Lee YM, Lee JB. Prognostic value of epidermal growth factor receptor, p53 and galectin-3 expression in papillary thyroid carcinoma. J Int Med Res 2013; 41:825-34. [PMID: 23569038 DOI: 10.1177/0300060513477312] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the protein expression and prognostic value of epidermal growth factor receptor (EGFR), p53 and galectin-3 in papillary thyroid carcinoma (PTC). METHODS A retrospective analysis was performed using tumour specimens from patients with PTC who underwent thyroidectomy between July 2007 and December 2008. The percentages of tumour cells staining positively for EGFR, galectin-3 and p53 were determined by immunohistochemistry. Associations between protein expression and age, sex, extrathyroidal extension and lymph node metastasis were assessed, together with the total Metastasis, Age, Completeness of resection, Invasion, Size (MACIS) score (a marker of prognosis). MACIS prognostic scores were categorized into four groups. RESULTS Data from 168 patients with PTC (mean follow-up, 35 months) were included. EGFR expression was significantly associated with male sex and lymph node metastasis; p53 expression was higher in males than in females; galectin-3 expression was not significantly associated with age, sex, extrathyroidal extension, lymph node metastasis or total MACIS score category, however. CONCLUSION Immunohistochemical evaluation of EGFR and p53 expression in patients with PTC may be useful for determining prognosis, in PTC patients.
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Affiliation(s)
- Yu Mi Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Lang BHH, Tang AH, Wong KP, Shek TW, Wan KY, Lo CY. Significance of size of lymph node metastasis on postsurgical stimulated thyroglobulin levels after prophylactic unilateral central neck dissection in papillary thyroid carcinoma. Ann Surg Oncol 2012; 19:3472-8. [PMID: 22565664 PMCID: PMC3442170 DOI: 10.1245/s10434-012-2385-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Indexed: 11/24/2022]
Abstract
Background The prognostic significance of size of central lymph node metastasis (CLNM) in papillary thyroid carcinoma (PTC) remains unknown. Because postsurgical detectable stimulated thyroglobulin (DsTg) after radioiodine ablation may imply persistent or recurrent disease, we evaluated the association between size of CLNM and rate of DsTg in patients with PTC who underwent unilateral prophylactic central neck dissection. Methods To be eligible for analysis, the prophylactic central neck dissection specimen with <3 central lymph nodes (CLNs) or size of CLNM ≥1 cm as measured under the microscope was excluded. Of 132 specimens, 89 (67.4 %) were eligible. Forty patients (44.9 %) had no metastasis or pN0, 20 (22.5 %) had micrometastasis (<2 mm) or pN1mic and 29 (32.6 %) had macrometastasis (≥2 mm) or pN1mac. Postablation sTg level was measured 9 months after surgery. A multivariable analysis was conducted to identify independent factors for postablation DsTg. Results Larger-sized CLNM correlated significantly with younger age (p = 0.028), greater number of CLN retrieved (p = 0.016), greater number of metastatic CLN excised (p < 0.001), higher metastatic CLN ratio (p = 0.006) and postablation sTg level (p = 0.012). In the multivariable analysis, after adjusting for tumor size and metastatic CLN ratio, size of CLNM was an independent predictor of postablation DsTg (odds ratio 1.56, 95 % confidence interval 1.09–2.24, p = 0.015). Relative to pN0, the odds ratios for postablation DsTg in pN1mic and pN1mac were 2.53 (95 % confidence interval 0.35–19.00, p = 0.351) and 5.81 (95 % confidence interval 1.22–27.70, p = 0.027), respectively. Conclusions Size of CLNM was an independent factor for DsTg 9 months after surgery. Patients with pN1mac were almost 6 times more likely to have postablation DsTg than those with pN0 or pN1mic.
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Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Hong Kong SAR, China.
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Smith VA, Sessions RB, Lentsch EJ. Cervical lymph node metastasis and papillary thyroid carcinoma: Does the compartment involved affect survival? Experience from the SEER database. J Surg Oncol 2012; 106:357-62. [DOI: 10.1002/jso.23090] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 02/13/2012] [Indexed: 11/11/2022]
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The role of prophylactic central neck dissection in differentiated thyroid carcinoma: issues and controversies. JOURNAL OF ONCOLOGY 2011; 2011:127929. [PMID: 21977029 PMCID: PMC3184411 DOI: 10.1155/2011/127929] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 07/18/2011] [Indexed: 11/17/2022]
Abstract
Prophylactic central neck dissection (pCND) in differentiated thyroid carcinoma (DTC) is one of the most controversial surgical subjects in recent times. To date, there is little evidence to support the practice of pCND in patients with DTC undergoing total thyroidectomy. Although the recently revised American Thyroid Association (ATA) guideline has clarified many inconsistencies regarding pCND and has recommended pCND in “high-risk” patients, many issues and controversies surrounding the subject of pCND in DTC remain. The recent literature has revealed an insignificant trend toward lower recurrence rate in patients with DTC who undergo total thyroidectomy and pCND than those who undergo total thyroidectomy alone. However, this was subjected to biases, and there are concerns whether pCND should be performed by all surgeons who manage DTC because of increased surgical morbodity. Performing a unilateral pCND may be better than a bilateral pCND given its lower surgical morbidity. Further studies in this controversial subject are much needed.
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Lang BHH, Wong KP, Wan KY, Lo CY. Impact of routine unilateral central neck dissection on preablative and postablative stimulated thyroglobulin levels after total thyroidectomy in papillary thyroid carcinoma. Ann Surg Oncol 2011; 19:60-7. [PMID: 21681379 PMCID: PMC3251780 DOI: 10.1245/s10434-011-1833-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Indexed: 12/19/2022]
Abstract
Background Prophylactic central neck dissection (CND) remains controversial in papillary thyroid carcinoma (PTC). Because postsurgical stimulated thyroglobulin (sTg) level is a good surrogate for recurrence, the study aimed to evaluate the impact of prophylactic CND on preablative and postablative sTg levels after total thyroidectomy. Methods Of the 185 patients retrospectively analyzed, 82 (44.3%) underwent a total thyroidectomy and prophylactic CND (CND-positive group) while 103 (55.7%) underwent total thyroidectomy only (CND-negative group). All patients had no preoperative or intraoperative evidence of lymph node metastases. Clinicopathological characteristics, postoperative outcomes, and preablative and postablative sTg levels were compared between the two groups. Preablative sTg level was taken at the time of radioiodine ablation, while postablative sTg level was taken 6 months after ablation. A multivariable analysis was conducted to identify factors for preablative athyroglobulinemia (sTg < 0.5 μg/L). Results Relative to the CND-negative group, the CND-positive group had larger tumors (15 mm vs. 10 mm, P < 0.005), more extrathyroidal extension (26.8% vs. 14.6%, P < 0.003), more tumor, node, metastasis system stage III disease (32.9% vs. 9.7%, P < 0.001), and more temporary hypoparathyroidism (18.3% vs. 8.7%, P = 0.017). Fourteen patients (17.1%) in the CND-positive group were upstaged from stages I/II to III as a result of prophylactic CND. The CND-positive group experienced lower median preablative sTg (<0.5 μg/L vs. 6.7 μg/L, P < 0.001) and a higher rate of preablative athyroglobulinemia (51.2% vs. 22.3%, P = 0.024), but these differences were not observed 6 months after ablation. Prophylactic CND was the only independent factor for preablative athyroglobulinemia. Conclusions Although performing prophylactic CND in total thyroidectomy may offer a more complete initial tumor resection than total thyroidectomy alone by minimizing any residual microscopic disease, such a difference becomes less noticeable 6 months after ablation.
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Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, The University of Hong Kong, Hong Kong, Hong Kong SAR, China.
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Law TT, Lang BHH. Incidental thyroid carcinoma by FDG-PET/CT: a study of clinicopathological characteristics. Ann Surg Oncol 2011; 18:472-8. [PMID: 20740320 PMCID: PMC3032177 DOI: 10.1245/s10434-010-1287-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND The rising incidence of incidental thyroid carcinoma (ITC) detected during fluoro-2-deoxy-D: -glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scanning poses a challenge to clinicians. The present study aims to critically evaluate the clinicopathological characteristics of ITC detected by FDG-PET/CT. METHODS Among the 557 patients managed at our institution, 40 (7.2%) patients were identified as having ITC. Of these, 22 patients had their tumor detected by FDG-PET/CT (PET group) and 11 by ultrasonography (USG group). Additional bedside ultrasonography ± fine-needle aspiration (FNA) was done in all patients at their clinic visit. The clinicopathological characteristics were compared between the PET and USG groups. RESULTS The PET group had significantly more patients with history of nonthyroidal malignancy (P < 0.001). Papillary carcinoma was the most common histological type in both groups. Despite having similar histological and prognostic features including tumor size, tumor multifocality, capsular invasion, extrathyroidal extension, and lymph node metastases, tumor bilaterality (or presence of contralateral tumor focus) was significantly more frequent in the PET than the USG group (P = 0.04). The tumors were also more advanced by the tumor-node-metastasis (TNM) staging system in the PET group (P = 0.021). None of the contralateral tumor foci were evident preoperatively. One patient in the USG group developed metastatic thyroid carcinoma in neck lymph nodes 28 months after thyroid resection. CONCLUSION ITC by FDG-PET/CT had higher incidence of tumor bilaterality than those detected by ultrasonography. Total thyroidectomy should be considered for ITC detected by FDG-PET/CT even for tumor size <10 mm.
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Affiliation(s)
- T. T. Law
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong, Hong Kong SAR, China
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong, Hong Kong SAR, China
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China
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Abstract
Patients with distant, or extracervical, metastases from differentiated thyroid cancer require multimodality diagnostic, therapeutic, and monitoring approaches. Whereas cure is the initial goal, especially in those with small, radioiodine-avid pulmonary metastases, improved survival and management of symptoms become the primary objective in many patients with persistent disease, especially those with bone metastases. Levothyroxine therapy with suppression of serum TSH is a primary therapy in all patients with advanced differentiated thyroid cancer, and this therapy has been shown to improve overall survival and slow disease progression. Radioiodine is also an important systemic therapy for those patients with radioiodine-avid disease who respond to this targeted therapy. In this review, we compare standard fixed-dose radioiodine therapy vs. the dosimetric approach. Directed therapy such as external beam radiotherapy, surgery, and embolization is generally considered for large or painful lesions. Careful collaborations with multiple specialties through tumor boards or other mechanisms help to optimize complex management decisions in these patients with advanced thyroid cancer. Multimodality monitoring focused on the organ of interest such as pulmonary [computed tomography (CT)], bone (magnetic resonance imaging, CT, bone scan), and brain (CT, magnetic resonance imaging) metastases as well as general metastatic surveillance (bone scan, (18)F-fluorodeoxyglucose-positron emission tomography) aid decision making about careful monitoring vs. directed or systemic therapy. (18)F-fluorodeoxyglucose-positron emission tomography imaging has an additional role in patient prognosis and guiding directed therapy for fluorodeoxyglucose-avid lesions. Patients with asymptomatic, stable, radioiodine-resistant metastases may be carefully monitored for disease progression. Patients with symptomatic disease should receive directed therapy with the goal of symptom relief. Patients with progressive metastatic disease should be considered for clinical trials or targeted systemic therapy (sorafenib or sunitinib), although these agents are not Food and Drug Administration (FDA) approved for patients with thyroid cancer. The goals of therapy for patients with extracervical metastases should be to improve survival, relieve symptoms, and decrease the morbidity of disease progression and limit the morbidity associated with therapy.
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Vorburger SA, Übersax L, Schmid SW, Balli M, Candinas D, Seiler CA. Long-Term Follow-Up After Complete Resection of Well-Differentiated Cancer Confined to the Thyroid Gland. Ann Surg Oncol 2009; 16:2862-74. [DOI: 10.1245/s10434-009-0592-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 06/04/2009] [Accepted: 06/04/2009] [Indexed: 01/08/2023]
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Hirsch D, Ginat M, Levy S, Benbassat C, Weinstein R, Tsvetov G, Singer J, Shraga-Slutzky I, Grozinski-Glasberg S, Mansiterski Y, Shimon I, Reicher-Atir R. Illness perception in patients with differentiated epithelial cell thyroid cancer. Thyroid 2009; 19:459-65. [PMID: 19415995 DOI: 10.1089/thy.2008.0360] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Patients with differentiated thyroid cancer (DTC) usually have a good prognosis but may experience a decline in quality of life (QOL). The way patients perceive their illness may have a major impact on their QOL. Our hypothesis was that patients with DTC frequently perceive their illness as much more severe than its objective clinical characteristics indicate. The aim of the study was to investigate how patients with DTC perceive their illness and to correlate these findings to various demographic parameters as well as objective indices of disease severity. METHODS The self-administered Illness Perception Questionnaire-Revised (IPQ-R) was completed by consecutive patients with DTC during routine follow-up at the endocrine clinic. The questionnaire consists of three parts that measure different aspects of illness perception. The patients' medical records were reviewed for data on demographic parameters (sex, age) and indices of disease severity (duration of DTC, disease stage at diagnosis, number of operations, number of radioactive iodine treatments, and evidence of disease persistence/recurrence). The patients were also asked for additional data on family status, level of education, and employment status. Pearson and Spearman correlations and analysis of variance were used for statistical analysis. RESULTS The study group included 110 patients (91 women) of mean age 53.5 years. Level of education was the only demographic factor found to affect the patients' perception of their illness. There was no correlation of patient illness perception and cancer stage. Among the disease-severity parameters, time since last treatment, evidence of disease persistence, and number of iodine treatments were significantly associated with a negative disease perception. Number of iodine treatments was the most broadly affecting factor. There was a high correlation of scores among the various illness perception subscales. CONCLUSIONS Patients with DTC perceive their illness on a subjective, emotional basis unrelated to its actual severity. To improve patients' illness representations and, consequently, their QOL, a trained psychologist should be included in the multidisciplinary team that manages patients with DTC. Attention should be particularly directed to less-educated patients and patients who require repeated iodine treatments.
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Affiliation(s)
- Dania Hirsch
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
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Ward LS, Valente FOF, de Araujo PPC, Tincani AJ, Assumpcao LVM. Commonly used prognostic scoring systems are not adequate to predict the outcome of papillary microcarcinomas of the thyroid. Pediatr Blood Cancer 2008; 50:1288-9; author reply 1289. [PMID: 18314903 DOI: 10.1002/pbc.21540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ruggeri RM, Campennì A, Baldari S, Trimarchi F, Trovato M. What is New on Thyroid Cancer Biomarkers. Biomark Insights 2008; 3:237-252. [PMID: 19578508 PMCID: PMC2688342 DOI: 10.4137/bmi.s669] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Thyroid cancer harbours in about 5% of thyroid nodules. The majority of them are well-differentiated cancers originating from the follicular epithelium, and are subdivided into papillary and follicular carcinomas. Undifferentiated carcinomas and medullary thyroid carcinomas arising from C cells are less common. Although most thyroid nodules are benign, distinguishing thyroid cancer from benign lesions is crucial for an appropriate treatment and follow-up. The fine needle aspiration cytology (FNAC) allows the diagnosis of nature of thyroid nodules in the majority of cases. However, FNAC has some limitations, particularly in the presence of follicular lesions which can appear dubious in rare instances even at histology. In an effort to improve diagnostic accuracy and offer new prognostic criteria, several immunohistochemical and molecular markers have been proposed. However, most of them have to be validated on large series before being used in routine practice.
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Affiliation(s)
- Rosaria M Ruggeri
- Sezione di Endocrinologia, Dipartimento Clinico-Sperimentale di Medicina e Farmacologia
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Current World Literature. Curr Opin Otolaryngol Head Neck Surg 2008; 16:175-82. [DOI: 10.1097/moo.0b013e3282fd9415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wada N, Masudo K, Nakayama H, Suganuma N, Matsuzu K, Hirakawa S, Rino Y, Masuda M, Imada T. Recommendation for Subclass Evaluation of TNM stage IVA Papillary Thyroid Carcinomas: T4aN1b Patients Are at Risk for Recurrence and Survival. Ann Surg Oncol 2008; 15:1511-7. [DOI: 10.1245/s10434-008-9837-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 01/21/2008] [Accepted: 01/21/2008] [Indexed: 11/18/2022]
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Lang BHH, Lo CY, Chan WF, Lam KY, Wan KY. Staging systems for papillary thyroid carcinoma: a review and comparison. Ann Surg 2007; 245:366-78. [PMID: 17435543 PMCID: PMC1877011 DOI: 10.1097/01.sla.0000250445.92336.2a] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To find out the most predictive staging system for papillary thyroid carcinoma (PTC) currently available in the literature. BACKGROUND Various staging systems or risk group stratifications have been used extensively in the clinical management of patients with PTC, but the most predictive system for cancer-specific survival (CSS) based on distinct histologic types remains unclear. METHODS Through a comprehensive MEDLINE search from 1965 to 2005, a total of 17 staging systems were found in the literature and 14 systems were applied to the 589 PTC patients managed at our institution from 1961 to 2001. CSS were calculated by Kaplan-Meier method and were compared by log-rank test. Using Cox proportional hazards analysis, the relative importance of each staging system in determining CSS was calculated by the proportion of variation (PVE). RESULTS All 14 staging systems significantly predicted CSS (P < 0.001). The 3 highest ranked staging systems by PVE were the Metastases, Age, Completeness of Resection, Invasion, Size (MACIS) (18.7) followed by the new AJCC/UICC 6th edition tumor, node, metastases (TNM) (17.9), and the European Organization for Research and Treatment of Cancer (EORTC) (16.6). CONCLUSIONS All of the currently available staging systems predicted CSS well in patients with PTC regardless of which histologic type from which they were derived. When predictability was measured by PVE, the MACIS system was the most predictive staging system and so should be the staging system of choice for PTC in the future.
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Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China
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