Age, thyroglobulin levels and ATA risk stratification predict 10-year survival rate of differentiated thyroid cancer patients

[Endocrine oncology : An update on surgical treatments]

BACKGROUND

In the management of solid tumours, routine concepts are increasingly being transformed into individualized patient treatment. Endocrine surgery is traditionally characterized by resection strategies that are adapted to phenotype and genotype of the underlying disease. As complication rates in surgery correlate with the extent of resection, continuous efforts are made to identify selection criteria in order to limit the extent of surgery without compromising the oncological outcome. The aim is to design risk-stratified precision endocrine surgery.

MATERIALS AND METHODS

A search was carried out in PubMed for new and modern strategies and approaches for oncological endocrine surgery.

RESULTS

Several developments in surgical technique and technology, molecular pathology, medical therapy, and study data identify the potential to adapt the surgical strategy in all areas of endocrine surgery.

CONCLUSION

According to prevalent data, limited extent of resection in thyroid cancer surgery shows a reduction in complication rates while preserving oncological outcome when adequate selection criteria are implemented. New insights and innovative technologies also influence additional areas in oncological endocrine surgery for parathyroid, adrenal, and neuroendocrine neoplasia. However, the broad practice of these new concepts needs to be evaluated with regard to long-term oncological outcome.

Machine learning for risk stratification of thyroid cancer patients: a 15-year cohort study

PURPOSE

The objective of this study was to train machine learning models for predicting the likelihood of recurrence in patients diagnosed with well-differentiated thyroid cancer. While thyroid cancer mortality remains low, the risk of recurrence is a significant concern. Identifying individual patient recurrence risk is crucial for guiding subsequent management and follow-ups.

METHODS

In this prospective study, a cohort of 383 patients was observed for a minimum duration of 10 years within a 15-year timeframe. Thirteen clinicopathologic features were assessed to predict recurrence potential. Classic (K-nearest neighbors, support vector machines (SVM), tree-based models) and artificial neural networks (ANN) were trained on three distinct combinations of features: a data set with all features excluding American Thyroid Association (ATA) risk score (12 features), another with ATA risk alone, and a third with all features combined (13 features). 283 patients were allocated for the training process, and 100 patients were reserved for the validation of stage.

RESULTS

The patients' mean age was 40.87 ± 15.13 years, with a majority being female (81%). When using the full data set for training, the models showed the following sensitivity, specificity and AUC, respectively: SVM (99.33%, 97.14%, 99.71), K-nearest neighbors (83%, 97.14%, 98.44), Decision Tree (87%, 100%, 99.35), Random Forest (99.66%, 94.28%, 99.38), ANN (96.6%, 95.71%, 99.64). Eliminating ATA risk data increased models specificity but decreased sensitivity. Conversely, training exclusively on ATA risk data had the opposite effect.

CONCLUSIONS

Machine learning models, including classical and neural networks, efficiently stratify the risk of recurrence in patients with well-differentiated thyroid cancer. This can aid in tailoring treatment intensity and determining appropriate follow-up intervals.

Basal or stimulated thyroglobulin in evaluating response to treatment in papillary thyroid carcinoma? A retrospective cohort study

OBJECTIVE

It is not clear whether response to initial treatment in papillary thyroid carcinoma (PTC) patients is best evaluated by measuring thyroglobulin (Tg) in the presence of levothyroxine (BTg) or when stimulated by elevated TSH (STg). The aim of this study was to evaluate whether response to therapy 1 year after initial treatment changes with the use of STg in relation to BTg in PTC patients treated with total thyroidectomy (TT) and radioiodine (131I), and, if observed, to assess which response is better associated with clinical course.

SUBJECTS AND METHODS

This is a retrospective study of 148 PTC patients submitted to TT and 131I. We analyzed the response to therapy (excellent, biochemical incomplete, or indeterminate) at 1 year after initial treatment, using BTg or STg, and compared which method was better associated with "excellent response at final evaluation."

RESULTS

Twenty-eight patients (20.4%) presented change in response to therapy, with 17 of these (60.7%) presenting a worse response. Response using STg was 1.6 times better associated with proposed outcome [odds ratio (OR) = 4.61; confidence interval 95% (IC95%): 2.13-9.98] than with BTg (OR = 2.84; IC95%: 1.33-6.06).

CONCLUSION

Response to therapy at 1 year using STg was altered in approximately 20% of cases and therefore proved to be a better predictor of excellent response in the last evaluation.

Surgical and Biochemical Outcomes in Nerve Monitored Reoperation Surgery for Recurrent Papillary Thyroid Carcinoma

OBJECTIVE

To study the surgical and biochemical outcomes in nerve-monitored reoperation or revision surgery for recurrent thyroid cancers.

STUDY DESIGN

A single-center retrospective study.

SETTING

Tertiary center.

METHODS

We identified patients with recurrent papillary thyroid carcinoma (PTC) who underwent reoperation/revision surgery. Study outcomes were surgical complications frequency, recurrence, distant metastasis, and biological complete response (BCR) by comparing preoperative and postoperative thyroglobulin (Tg) levels.

RESULTS

Out of 227 patients, 33.9% presented for ≥2 reoperation surgeries. Nineteen (8.4%) had permanent preoperative hypoparathyroidism while 22 patients (9.7%) had preoperative vocal cord paralysis (VCP). Following reoperation surgery, there were 12 cases (5.3%) of permanent hypocalcemia and no cases of unexpected postoperative VCP. BCR was achieved in 31 patients (35.2%) with complete Tg data. Mean preoperative Tg was 47.7 ng/mL and was 19.7 ng/mL postoperatively (p = .003). The cervical nodal recurrence rate after final surgery was 7.0% (n = 16).

CONCLUSION

Reoperation surgery for recurrent PTC may help achieve biochemical remission regardless of age or the number of prior surgeries.

Radioiodine (131I) treatment decision-making for low- and intermediate-risk differentiated thyroid cancer

Objective

The purpose of this study was to investigate the effect and influencing factors of postsurgical radioactive iodine (RAI) therapy for patients with low- and intermediate-risk differentiated thyroid cancer (DTC).

Subjects and methods

A retrospective analysis of 423 low- and intermediaterisk DTC patients admitted to the Department of Nuclear Medicine, Sichuan Provincial People's Hospital from January 2005 to December 2020 was performed. All patients were treated with surgery, had a postoperative pathological diagnosis, and were treated with RAI, including 89 males and 334 females. Recurrence risk stratification: 143 cases were low-risk, and 280 cases were intermediaterisk.

Results

The excellent response (ER) rate for low- and intermediate-risk were 93.7% and 78.2%, respectively (P < 0.05). There were significant differences in age, cumulative dose of [131I], and pretreatment stimulated-Tg (pre-Tg) levels between the low- and intermediate-risk groups (P < 0.05). There were significant differences in the cumulative dose of 131I and pre-Tg levels between ER and the non-ER group (P < 0.05). The area under the curve (AUC) values were 0.799 in the low-risk group, and 0.747 in the intermediate-risk group for the ROC curve by ER status of pre-Tg. The ER rate with RAI treatment decreased with an increase in pre-Tg levels.

Conclusion

Pre-Tg was an important factor for RAI treatment decision-making and prognostic evaluation and differed between low-risk and intermediate-risk DTC. Aggressive RAI therapy was recommended for low-risk DTC with pre-Tg ≥ 20.0 ng/mL and in intermediate-risk group with pre-Tg ≥ 10.0 ng/mL.

Prognostic Utility of Tumor Stage versus American Thyroid Association Risk Class in Thyroid Cancer

OBJECTIVE

To evaluate the prognostic strengths of American Joint Committee on Cancer (AJCC) staging and American Thyroid Association (ATA) risk classification in well-differentiated thyroid cancer (DTC), and their implications in guiding medical decision-making and epidemiological study designs.

METHODS

The 2004-2017 National Cancer Database was queried for DTC patients. Cox proportional hazards (CPH) and Kaplan-Meier analyses modeled patient mortality and overall survival, respectively. Each CPH model was evaluated by its concordance index, measure of explained randomness (MER), Akaike information criterion (AIC), and area under receiver operating characteristic curve (AUC).

RESULTS

Overall, 134,226 patients were analyzed, with an average age of 48.1 ± 15.1 years (76.9% female). Univariate CPH models using AJCC staging demonstrated higher concordance indices, MERs, and AUCs than those using ATA risk classification (all p < 0.001). Multivariable CPH models using AJCC staging demonstrated higher concordance indices (p = 0.049), MERs (p = 0.046), and AUCs (p = 0.002) than those using ATA risk classification. The AICs of multivariable AJCC staging and ATA risk models were 7.564 × 104 and 7.603 × 104 , respectively. AJCC stage I tumors were associated with greater overall survival than those classified as ATA low risk, whereas AJCC stages II-III and stage IV tumors demonstrated worse survival than ATA intermediate- and high-risk tumors, respectively (all p < 0.001).

CONCLUSION

AJCC staging may be a more predictive system for patient survival than ATA risk. The prognostic utility of these two systems converges when additional demographic and clinical factors are considered. AJCC staging was found to classify patients across a wider range of survival patterns than the ATA risk stratification system.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:205-211, 2023.

Evaluating Disease Specific Survival Prediction of Risk Stratification and TNM Systems in Differentiated Thyroid Cancer

BACKGROUND

Many countries have national guidelines for the management of differentiated thyroid cancer (DTC), including a risk stratification system to predict recurrence of disease. Studies whether these guidelines could also have relevance, beyond their original design, in predicting survival are lacking. Additionally, no studies evaluated these international guidelines in the same population, nor compared them to the TNM system. Therefore, we investigated the prognostic value of six stratification systems employed by ten International guidelines, and the TNM system with respect to predicting disease specific survival (DSS).

METHODS

We retrospectively studied adult patients with DTC from a Dutch university hospital. Patients were classified using the risk classification described in the British, Dutch, French, Italian, Polish, Spanish, European Society of Medical Oncology, European Thyroid Association, and 2009 and 2015 American Thyroid Association (ATA) guidelines, and the latest TNM system. DSS was analyzed using the Kaplan-Meier method, and the statistical model performance using the C-index, AIC, BIC and PVE.

RESULTS

We included 857 patients with DTC (79% PTC, 21% FTC). Median follow-up was 9 years, and 67 (7.8%) died due to DTC. The Dutch guideline had the worst statistical model performance, while the 2009 ATA/2014 British guideline had the best. However, the (adapted) TNM system outperformed all stratification systems.

CONCLUSIONS

In a European population of patients with DTC, out of ten International guidelines employing six risk of recurrence stratification systems and one mortality based stratification system, our optimized age-adjusted TNM system (8th edition) outperformed all other systems.

Is conservative management of the indeterminate thyroid nodule [Thy3f or Bethesda category IV] safe?

PURPOSE

The histological diagnosis after diagnostic thyroidectomy for indeterminate thyroid nodules is often non-malignant and some cancers detected are considered 'indolent'. The safety and effectiveness of conservative management in these patients are unclear. The aim of this study was to determine the safety of conservative management of indeterminate thyroid nodules and to explore association between clinical features and pathology in patients undergoing surgery.

METHODS

This is a retrospective cohort study of patients presenting to a single centre over a 4-year period (2013-2016) with thyroid nodules that were considered indeterminate (thy3f in the UK RCPath classification) on cytology. Demographic data, ultrasound features, follow-up details (in those undergoing conservative management) and histology details (in those undergoing surgery) were collected.

RESULTS

Of 164 patients that had Thy3f cytology, 34 were initially managed conservatively; however, 4 of these eventually had surgery (due to patient preference). No patient on conservative management had significant disease progression on ultrasound at a median (interquartile range) of 27 (16-40) months. Of the 134 patients that underwent surgery, 26 had thyroid malignancy. The BTA 'U' classification, gender and age (> 55) were not associated with malignancy in these nodules, but larger nodules (> 40 mm) were more likely to be malignant (p = 0.042).

CONCLUSIONS

Conservative management of indeterminate (Thy3f or Bethesda stage IV) thyroid nodules is safe in the short term and may be indicated in selected cases after appropriate discussion of risks and benefits of surgery.

Incomplete response to therapy in intermediate- and high-risk thyroid cancer

CONTEXT

The American Thyroid Association (ATA) risk stratification system predicts risk of recurrence of differentiated thyroid cancer (DTC). Although the majority of patients achieve an excellent response, patients with intermediate- or high-risk DTC are at a significant risk of developing incomplete responses. We undertook this work to understand the factors associated with development of biochemically or structurally incomplete response in these two risk subgroups of DTC.

PATIENTS AND METHODS

We retrospectively reviewed 287 consecutive patients with intermediate- (213 patients) or high-risk (74 patients) DTC. All patients underwent total thyroidectomy with (223 patients) or without (64 patients) lymph node dissection and 94% of them received at least one dose of I-131ablation/therapy. Univariate and multivariate analysis and Kaplan Meier analysis were used to compare patients who achieved an excellent response with those who continued to have biochemically or structurally incomplete responses.

RESULTS

In univariate and multivariate analyses, age (P 0.002, Odds ratio 4.8, 95% CI: 1.8-12.9), tumor size (P 0.027, Odds ratio 1.30, 95% CI: 1.03-1.64) and distant metastases (P &lt; 0.0001, Odds ratio 44.6, 95% CI: 10.7-184.5) were significantly associated with the risk of developing biochemically or structurally incomplete statuses. Patients ≥ 55 years, tumors &gt; 2.5 cm and presence of distant metastasis were associated with higher risk of incomplete response and death from DTC. However, when this analysis was performed on intermediate and high-risk groups separately, only age was consistently associated with risk of biochemically or structurally incomplete response in either and both groups.

CONCLUSION

Age is a strong predictor of biochemically and structurally incomplete responses in patients with intermediate and high-risk DTC.

Value of stimulated pre-ablation thyroglobulin as a prognostic marker in patients with differentiated thyroid carcinoma treated with radioiodine

OBJECTIVE

To determine which Thyroglobulin (Tg) level after levothyroxine (LT₄) withdrawal (stimulated thyroglobulin - sTg) measured before radioiodine therapy (RAIT) is able to predict incomplete response to treatment of differentiated thyroid carcinoma (DTC) with greater sensitivity and specificity one year after initial treatment with I¹³¹.

METHODS

A chart review was performed in which 375 patients with DTC treated with RAIT were included. The sTg was measured in all patients prior to treatment with I¹³¹. Follow up were then performed one year later. Initial sTg levels were associated to DTC outcomes. A receiver operating characteristic (ROC) curve was performed to achieve a sTg level able to predict which patients would have a greater chance of having an incomplete response to RAIT.

RESULTS

Incomplete response to treatment was found in 122 patients (32.5%), this group had a mean sTg of 23.2 ng/mL. ROC curve showed that the optimal cut-off sTg level was 4.4 ng/mL. (sensitivity: 72.1%; specificity: 72.3%; accuracy: 72.2%; positive predictive value of 55.7%; and negative predictive value: 84.3%).

CONCLUSION

sTg pre-ablation is a valuable predictor of DTC incomplete response to treatment one year after RAIT. Levels of 4.4 ng/ml or more showed higher accuracy to predict this outcome.

Is there a relationship between preoperative cytological diagnosis and evolution in patients with differentiated thyroid carcinoma? A retrospective study

Objective

Cytological analysis and Bethesda classification of thyroid nodules is the standard method of diagnosing differentiated thyroid carcinoma (DTC). However, even for nodules with a non-malignant cytological diagnosis, there is a not insignificant risk of cancer. There are doubts whether this lack of certainty would influence patient prognosis. Our aim was to compare patients with DTC, classified according to the preoperative cytological diagnosis, regarding their evolution.

Methods

A retrospective study was carried out with 108 DTC patients submitted to total thyroidectomy (TT) between 2009 and 2015, divided into three groups according to preoperative cytological diagnosis (Bethesda classification): classes I/II, III/IV, and V/VI. Groups were compared for evolution considering response to treatment at last evaluation as well as time disease free. Statistical analysis used ANOVA, chi squared, and Kaplan-Meier curves with p<0.05 considered significant.

Results

Groups differed for time between nodule puncture and TT [in months; V/VI (2.35 ± 2.48) < III/IV (7.32 ± 6.34) < I/II (13.36 ± 8.9); p < 0.0001]. There was no significant difference between groups for evolution at final evaluation (disease free status; classes I/II: 71.4%; classes III/IV: 60%; classes V/VI: 66.6%; p = 0.7433), as well as time disease free (in months; classes I/II: 34.57 ± 25.82; classes III/IV: 38.04 ± 26.66; classes V/VI: 30.84 ± 26.34; p = 0.3841).

Conclusion

DTC patients classified according to preoperative cytological diagnosis did not differ for evolution. Although patients with non-malignant cytological diagnoses were submitted to TT later, this did not affect the evolution of the cases.

BAX gene (-248 G > A) polymorphism in a sample of patients diagnosed with thyroid cancer in the Federal District, Brazil

INTRODUCTION

Papillary thyroid cancer corresponds to approximately 1% of all carcinomas; nevertheless, it is the most prevalent endocrine neoplasm in the world. Studies reveal that the BAX (-248 G > A) polymorphism may be associated with negative regulation of BAX gene transcription activity, causing a decrease in its protein expression.

OBJECTIVE

The present study aimed to describe the genotype and allele frequencies of BAX single nucleotide polymorphisms (-248 G > A) (rs4645878) in the research patients, and to associate its presence with susceptibility to papillary thyroid cancer.

METHODS

This case-control study was conducted with 30 patients with papillary thyroid cancer. For the evaluation of genetic polymorphisms, the polymerase chain reaction-restriction fragment length polymorphism technique was employed. Allele and genotype frequencies were estimated using the SPSS program, and significant associations were considered when p < 0.05.

RESULTS

There was a significant genotypic difference between papillary thyroid cancer and the control group (p = 0.042). The GG genotype provided a protective factor for papillary thyroid cancer (p = 0.012, odds ratio (OR) = 0.313; confidence interval (CI) = 0.123-0.794). Likewise the G allele was a protective factor for papillary thyroid cancer (p = 0.009; OR = 0.360; CI = 0.163-0.793). The BAX gene polymorphism (-248 G > A) was associated with papillary thyroid cancer.

CONCLUSION

BAX (-248 G > A) GG genotype carriers, or at least one mutated allele, was associated with papillary thyroid cancer in the Brazilian population studied, and the G allele presence is considered a protective factor against papillary thyroid cancer occurrence.

Course and Predictive Factors of Incomplete Response to Therapy in Low- and Intermediate-Risk Thyroid Cancer

Context

Controversy surrounds the extent and intensity of the management of American Thyroid Association (ATA) intermediate- and low-risk patients with differentiated thyroid cancer (DTC). Understanding the natural history and factors that predict outcome is important for properly tailoring the management of these patients.

Objective

This work aims to study the natural course and predictive factors of incomplete response to therapy in low- and intermediate-risk DTC.

Patients and Methods

We studied a cohort of 506 consecutive patients [418 women (82.6%) and 88 men (17.4%)] with low and intermediate risk with a median age of 35 years (interquartile range [IQR], 27-46 years). We analyzed the natural course and the predictive factors of biochemically or structurally incomplete response.

Results

Of 506 patients studied, 297 (58.7%) patients were in the low-risk group and 209 (41.3%) were in the intermediate-risk group. Over a median follow-up of 102 months (IQR, 66-130 months), 458 (90.5%) patients achieved an excellent response, 17 (3.4%) had a biochemically incomplete status, and 31 (6.1%) had a structurally incomplete status. In univariable and multivariable analyses, age (≥ 33 years) (P < .0001, odds ratio 1.06 [1.04-1.08]) and lateral lymph node metastasis (LNM; P < .0001, odds ratio 3.2 [1.7-5.9]) were strong predictive factors for biochemically and structurally incomplete response to therapy. Sex, tumor size, multifocality, extrathyroidal extension, and lymphovascular invasion did not predict incomplete response to therapy.

Conclusions

Patients with low- and intermediate-risk DTC have favorable outcomes. Age and lateral LNM are strong predictors of an incomplete response to therapy. This suggests that older patients and those with LNM should be managed and followed up more actively than younger patients and those without LNM.

Surgical Complications and Referral Patterns in 567 Patients with Differentiated Thyroid Cancer in the Northern Region of the Netherlands: A Population-Based Study Towards Clinical Management Implementation

BACKGROUND

In the Netherlands, differentiated thyroid cancer (DTC) is treated surgically in three different hospital types, including university, teaching, and non- teaching peripheral hospitals. This study evaluates postoperative complications and referral patterns in patients with DTC in the northern region of the Netherlands to gain an understanding on how to improve management implementation.

METHODS

Data from 567 patients diagnosed between 1989 and 2009 were obtained from the Netherlands Cancer Registry and were supplemented with information from hospital digital information systems and patient records from 15 hospitals: 1 university, 3 teaching, and 11 peripheral hospitals. Surgically treated patients with a histologically proven DTC derived from the original pathology reports were included.

RESULTS

Surgical treatment could be performed in a single procedure in 234 patients (41.3%), but several surgeries were needed in the remaining 333 patients (58.7%). Recurrent laryngeal nerve (RLN) palsy occurred after all types of thyroid surgical procedures, but mostly after initial (hemi)thyroidectomy and reoperations. RLN was temporary in 3.2% of the nerves at risk and persistent in 1.8%. Temporary hypocalcemia developed in 13.7% of patients, and persistent hypocalcemia occurred in 4.8%. Patients were mainly referred to the university hospital from a non-teaching (40.7%, 48/118) or teaching hospital (11.1%, 16/144); however, 80% of patients were not referred.

CONCLUSIONS

The complication rate and number of multiple surgeries support the efforts in optimizing clinical management in thyroid cancer. Careful considerations prior to initial surgical treatment by early discussion in telemedicine-based regional tumor boards could possibly prevent reoperations and potentially diminish complications.

Management of Patients with Renal Failure Undergoing Dialysis During 131I Therapy for Thyroid Cancer

Radioactive iodine (¹³¹I) therapy may be used to treat thyroid cancer in end-stage renal disease patients who undergo hemodialysis. Because iodine uses predominantly renal clearance, treatment management in hemodialysis patients may be problematic, and no formal recommendations on hemodialysis currently exist. This work details our experience with treating thyroid cancer with iodine in chronic renal failure patients who require hemodialysis and details the dosimetry results obtained during treatment to ensure that the dose to the bone marrow (BM) was acceptable. Methods: We treated 6 patients in the metabolic radiotherapy unit after thyroid stimulation. Two hemodialysis sessions in the metabolic radiotherapy unit were performed at 42 and 90 h after radiopharmaceutical administration. BM toxicity was estimated with activity measurements from blood samples and with whole-body measurements that were regularly repeated during hospitalization and measured with a γ-counter. The patients underwent thyroid and hematologic monitoring to assess treatment efficacy and therapeutic toxicity in the short, medium, and long term. Results: Whole-body activity was reduced on average by 66.7% (range, 60.1%-71.5%) after the first dialysis session and by 53.3% (range, 30.4%-67.8%) after the second. The mean estimated total absorbed dose to the BM was 0.992 Gy for all patients (range, 0.431-2.323 Gy). We did not observe any significant hematologic toxicity, and the clinical, biologic, and ultrasound test results confirmed the success of ablative treatment for most patients. Conclusion: In hemodialysis patients with thyroid cancer, an ¹³¹I activity approximately 30% lower than the nominal dose appears to strike an appropriate balance between absence of BM toxicity and therapeutic efficacy. To avoid overirradiation, we recommend pretherapeutic dosimetry studies for metastatic patients to calculate the amount of activity to be administered. We also recommend dosimetry monitoring during the hemodialysis sessions performed after therapeutic dose administration and under the same conditions.