Appropriateness of the revised Japanese guidelines' risk classification for the prognosis of papillary thyroid carcinoma: a retrospective analysis of 5,845 papillary thyroid carcinoma patients

Central node dissection from the perspective of lateral neck node metastasis in papillary thyroid carcinoma

OBJECTIVES

Controversy exists on how to handle central lymph nodes in papillary thyroid carcinoma, particularly regarding indications for prophylactic central neck dissection (CND). Central node metastases are more difficult to diagnose preoperatively than lateral node metastases.

METHODS

We enrolled 493 patients with papillary thyroid carcinoma treated at our department in the past 22 years. Metastatic lymph nodes were diagnosed preoperatively mainly by ultrasonography. In principle, CND was performed for all cases; ipsilateral CND was performed for hemithyroidectomy, and bilateral CND was performed for total thyroidectomy. Lateral neck dissection (levels II to V; LND) was performed for metastases to lateral neck lymph nodes (clinical node (cN) 1b).

RESULTS

The cN stage was cN0 in 365 patients, cN1a in 10, and cN1b in 118. Of the 357 patients with stage cN0 who underwent CND, 42.9 % had pathologically positive nodes (pN+) in level VI, and of the 118 with stage cN1b who underwent CND, 78.0 % had pN+ in level VI. Cases with advanced T stage were significantly more common with pN+ in level VI. Level VI metastases were significantly associated with pN+ in level IV. As the total number of pN+ at each level of the lateral neck increased, the rate of patients with pN+ in level VI increased, and in patients with 3 or more pN+, about 85 % had level VI metastases.

CONCLUSION

Because about half of the patients with cN0 patients had pN+ in level VI, and the rate of pN+ in level VI in each clinical T stage was 46 to 65 %, prophylactic CND should be performed, considering the various clinical benefits. Central nodes will have metastases in about 80 % of cases with lateral node metastases, requiring more accurate dissection. In lateral node metastases, there is a significant association between metastases in levels IV and VI.

Outcomes of Patients with an Intermediate-Risk Group According to the Japanese Risk Classification of Papillary Thyroid Carcinoma

BACKGROUND

The management of intermediate-risk group of papillary thyroid cancer (PTC) is still vague, particularly regarding whether or not total thyroidectomy, postoperative radioactive iodine ablation (RAI-a), and postoperative TSH suppression are mandatory.

METHODS

This retrospective study evaluated 680 PTC patients from 2010 to 2017, who were classified into the three risk groups as low, intermediate, and high-risk groups according to the criteria of the Japanese Association of Endocrine Surgeons (JAES) 2010 and underwent surgery according to the JAES guidelines. We retrospectively collected patient data for analyses of disease-free survivals in the intermediate-risk group patients.

RESULTS

We performed surgery on 680 PTC patients from 2010 to 2017. Of them, 297 were classified as the intermediate-risk group. DFS was not statistically significantly different in patients with/without total thyroidectomy and postoperative TSH suppression therapy. For RAI-a, DFS (95% confidence interval) at 3, 5, and 8 years were 93.2% (84.6 ~ 97.2), 81.6% (68,3 ~ 90.2), and 70.7% (51.4 ~ 84.6) in patients with postoperative RAI-a and 100%, 100%, and 100% in patients without postoperative RAI-a after total thyroidectomy, respectively. DFS of patients without RAI-a was superior to those with RAI-a (P < 0.0004). Multivariable analysis by stepwise selection method revealed that postoperative RAI-a was a risk factor with a hazard ratio of 5.69. (95% CI 1.998-16.21) (P = 0.001131).

CONCLUSIONS

Our study did not show the efficacy of RAI-a in patients with intermediate-risk PTC. This study implies that judging the efficacy of adjuvant therapy such as RAI or TSh suppression in intermediate-risk patients is difficult.

Migration of Risk Classification Between the JAES Versus ATA guidelines for Papillary Thyroid Carcinoma

BACKGROUND

This study aimed to investigate outcomes in the same cohort of patients with papillary thyroid carcinoma (PTC) risk-stratified according to the Japan Association of Endocrine Surgery (JAES) and American Thyroid Association (ATA) guidelines.

METHODS

A total of 1044 patients with PTC who underwent initial thyroidectomy at Yokohama City University Medical Center between January 2000 and June 2022 were included.

RESULTS

According to the JAES guidelines, 480 (46%), 386 (37%), and 178 (17%) patients were classified as low, intermediate, or high risk, respectively. Furthermore, according to the ATA guidelines, 590 (57%), 261 (25%), and 193 (18%) patients were reclassified as low, intermediate, or high risk, respectively. Among 1044 patients with PTC, the 10-year cause-specific survival (CSS) rates of patients with JAES low and intermediate risk were 99.7 and 98.6%, respectively, and there was no statistically difference (p = 0.096). However, the 10-year CSS rates of patients with ATA low and intermediate risk were 100 and 99.5%, respectively (p = 0.007). Among 1001 patients with M0 PTC, the 10-year distant metastasis-free survival (DMFS) rates of patients with JAES intermediate and high risk were 94.2, and 76.7%, respectively (p < 0.001). However, the 10-year DMFS rates of patients with ATA intermediate and high risk were 88.1 and 86.6%, respectively (p = 0.233), and there was no statistically difference.

CONCLUSIONS

Both JAES and ATA risk classifications properly stratified the PTC patients. Furthermore, the ATA risk classification more precisely extracted patients with better and worse prognoses.

PSG7 indicates that age at diagnosis is associated with papillary thyroid carcinoma: A study based on the cancer genome atlas data

The age of the patients at diagnosis (age at diagnosis) is a self-contained element of danger for the prognosis of patients with papillary thyroid carcinoma (PTC), which has been well recognized and continuously adopted by the international cancer staging system. However, few studies have investigated its intrinsic mechanisms. In this study, we aim to comprehensively reveal the age-related pathogenesis of PTC and identify potential prognostic biomarkers. We divided the samples into two groups, young and elderly, to filter differentially expressed genes in The Cancer Genome Atlas (TCGA), with an age of 55 years serving as a cutoff. Moreover, we combined univariate, LASSO, and multivariate Cox regression analyses to construct age-related signatures for predicting progression-free survival. Additionally, functional enrichment analysis, immune infiltration analysis, differential expression analysis, clinicopathological correlation analysis, and drug sensitivity analysis were performed in different risk subgroups and expression subgroups. We screened 88 upregulated genes and 58 downregulated genes. Both the LASSO regression model that is validated in TCGA and the model of six age-related prognostic genes (IGF2BP1, GPRC6A, IL37, CRCT1, SEMG1, and PSG7) can be used to evaluate the progression-free survival of PTC patients. The GO, KEGG, and GSEA analyses revealed that each key gene was closely associated with PTC development. Furthermore, CD8⁺ T cells decreased significantly, while regulatory T cells increased dramatically in the high-risk and PSG7 high expression groups. PSG7 was remarkably correlated with clinicopathological parameters (pathologic stage, T stage, and N stage) of PTC patients, and PSG7 expression was elevated in tumor samples from both TCGA and the Gene Expression Omnibus and was strongly associated with progressive stage and poor prognosis. Our results provide an innovative understanding of the age-related molecular mechanisms of PTC development. PSG7 was identified to exert a critical role in PTC progression and may serve as a promising strategy for predicting the prognosis of PTC.

Development and validation of a nomogram to predict cancer-specific survival in elderly patients with papillary thyroid carcinoma: a population-based study

Objective

Thyroid carcinoma (TC) is the most common endocrine tumor in the human body. Papillary thyroid carcinoma (PTC) accounts for more than 80% of thyroid cancers. Accurate prediction of elderly PTC can help reduce the mortality of patients. We aimed to construct a nomogram predicting cancer-specific survival (CSS) in elderly patients with PTC.

Methods

Patient information was downloaded from the Surveillance, Epidemiology, and End Results (SEER) program. Univariate and multivariate Cox regression models were used to screen the independent risk factors for patients with PTC. The nomogram of elderly patients with PTC was constructed based on the multivariate Cox regression model. We used the concordance index (C-index), the area under the receiver operating characteristic curve (AUC) and the calibration curve to test the accuracy and discrimination of the prediction model. Decision curve analysis (DCA) was used to test the clinical value of the model.

Results

A total of 14,138 elderly patients with PTC were included in this study. Patients from 2004 to 2015 were randomly divided into a training set (N = 7379) and a validation set (N = 3141), and data from 2016 to 2018 were divided into an external validation set (N = 3618). Proportional sub-distribution hazard model showed that age, sex, tumor size, histological grade, TNM stage, surgery and chemotherapy were independent risk factors for prognosis. In the training set, validation set and external validation set, the C-index was 0.87(95%CI: 0.852–0.888), 0.891(95%CI: 0.866–0.916) and 0.931(95%CI:0.894–0.968), respectively, indicating that the nomogram had good discrimination. Calibration curves and AUC suggest that the prediction model has good discrimination and accuracy.

Conclusions

We constructed a new nomogram to predict CSS in elderly patients with PTC. Internal cross-validation and external validation indicate that the model has good discrimination and accuracy. The predictive model can help doctors and patients make clinical decisions.

Clinical advantages and neuroprotective effects of monitor guided fang's capillary fascia preservation right RLN dissection technique

OBJECTIVE

To investigate the feasibility and advantages of Fang's capillary fascia preservation right recurrent laryngeal nerve (RLN) dissection technique (F-R-RLN dissection) with preservation of the capillary network and fascia between the RLN and common carotid artery for greater neuroprotective efficiency compared with traditional techniques.

METHODS

We retrospectively analyzed 102 patients with papillary thyroid carcinoma undergoing right level VI lymph node dissection in our department from March 2021 to January 2022. Sixty patients underwent F-R-RLN dissection (the experimental group) and 42 patients underwent standard dissection (the control group). The intraoperative electrical signal amplitude ratios of the RLN, the number of dissected lymph nodes, and the preservation rates of the parathyroid glands were recorded and compared between the two groups.

RESULTS

The electrical signal amplitude ratio of the lower neck part point of the RLN to the upper laryngeal inlet point in the experimental group was significantly lower than the ratio in the control group (p = 0.006, Z-score = -2.726). One patient suffered transient RLN paralysis in both groups, but this resolved within 1 month after operation. There were no significant differences between the two groups in terms of the number of level VIa or level VIb lymph nodes dissected, nor in the rate of preservation of the parathyroid glands.

CONCLUSIONS

F-R-RLN dissection is a thorough dissection technique that is effective at preventing an electrical signal amplitude decrease in the RLN, and at preventing RLN paralysis by preserving its blood supply.

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

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

How to identify indolent thyroid tumors unlikely to recur and cause cancer death immediately after surgery-Risk stratification of papillary thyroid carcinoma in young patients

Current histopathological diagnosis methods cannot distinguish the two types of thyroid carcinoma: clinically significant carcinomas with a potential risk of recurrence, metastasis, and cancer death, and clinically insignificant carcinomas with a slow growth rate. Both thyroid tumors are diagnosed as "carcinoma" in current pathology practice. The clinician usually recommends surgery to the patient and the patient often accepts it because of cancer terminology. The treatment for these clinically insignificant carcinomas does not benefit the patient and negatively impacts society. The author proposed risk stratification of thyroid tumors using the growth rate (Ki-67 labeling index), which accurately differentiates four prognostically relevant risk groups based on the Ki-67 labeling index, ≥30%, ≥10 and <30%, >5 and <10%, and ≤5%. Indolent thyroid tumors with an excellent prognosis have the following four features: young age, early-stage (T1-2 M0), curatively treated, and low proliferation index (Ki-67 labeling index of ≤5%), and are unlikely to recur, metastasize, or cause cancer death. Accurate identification of these indolent tumors helps clinicians select more conservative treatments to avoid unnecessary aggressive (total thyroidectomy followed by radio-active iodine) treatments. Clinicians can alleviate the fears of patients by confirming these four features, including the low proliferation rate, in a pathology report immediately after surgery when patients are most concerned.

Oncological outcomes in differentiated thyroid cancer in South East Scotland

BACKGROUND

Differentiated thyroid cancer (DTC) is increasing in incidence but little is known about oncological outcomes for patients treated in the UK. Internationally there is a move toward conservative treatment of DTC. However, this is based on evidence from outside the UK. The aim of this study was to analyse oncological outcomes for a contemporary cohort of patients treated in a UK centre.

METHODS

Review of 470 consecutive prospectively recorded cases of DTC from the South East of Scotland endocrine MDT 2009-2018. Data on patient, tumour and treatment details as well as recurrence and survival details were extracted from the electronic patient record.

RESULTS

Of 470 patients female:male ratio was 3.4:1, median age at presentation was 48 years (range 16-86 years). Overall 193 (41%), 134 (29%), 119 (25%) and 22 (5%) patients were p T1, T2, T3, and p T4 respectively. 385 patients (82%) were pN0, 31 patients (7%) were pN1a and 53 patients (11%) were pN1b. 19 patients (4%) were M1. Of 470 patients 350 (74%) had papillary thyroid carcinoma, 120 patients (26%) had follicular carcinoma. Surgical management was lobectomy, isthumusectomy, total thyroidectomy and lobectomy then completion thyroidectomy in 14%,1%, 41% and 43% cases respectively. 64% patients received radioactive Iodine (RAI) therapy. With a median follow-up of 70 months (range 4-124 months), 5 years overall survival and disease specific survival were 96.7% and 98.5% respectively. The 5 year local recurrence free survival (LRFS), regional recurrence free survival (RRFS), locoregional recurrence free survival (LRRFS), distant recurrence free survival (DRFS) and any recurrence free survivals were 100%, 95.8%, 95.8%, 98.3% and 95% respectively.

CONCLUSION

Oncological outcomes for patients treated with DTC were excellent, in keeping with experience from international groups, suggesting that a move towards conservative treatment in the UK seems reasonable.

Contemporary considerations in adjuvant radioiodine treatment of adults with differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy with a growing incidence worldwide. The initial conventional management is surgery, followed by consideration of ¹³¹ I treatment that includes three options. These are termed remnant ablation (targeting benign thyroid remnant), adjuvant (targeting presumed microscopic DTC) and known disease (targeting macroscopic DTC) treatments. Some experts mostly rely on clinicopathologic assessment for recurrence risk to select patients for the ¹³¹ I treatment. Others, in addition, apply radioiodine imaging to guide their treatment planning, termed theranostics (aka theragnostics or radiotheragnostics). In patients with low-risk DTC, remnant ablation rather than adjuvant treatment is generally recommended and, in this setting, the ATA recommends a low ¹³¹ I activity. ¹³¹ I adjuvant treatment is universally recommended in patients with high-risk DTC (a primary tumor of any size with gross extrathyroidal extension) and is generally recommended in intermediate-risk DTC (primary tumor >4 cm in diameter, locoregional metastases, microscopic extrathyroidal extension, aggressive histology or vascular invasion). The optimal amount of ¹³¹ I activity for adjuvant treatment is controversial, but experts reached a consensus that the ¹³¹ I activity should be greater than that for remnant ablation. The main obstacles to establishing timely evidence through randomized clinical trials for ¹³¹ I therapy include years-to-decades delay in recurrence and low disease-specific mortality. This mini-review is intended to update oncologists on the most recent clinical, pathologic, laboratory and imaging variables, as well as on the current ¹³¹ I therapy-related definitions and management paradigms, which should optimally equip them for individualized patient guidance and treatment.

Subset analysis of the Japanese risk classification guidelines for papillary thyroid carcinoma

Guidelines published by the Japan Association of Endocrine Surgeons (JAES)/Japanese Society of Thyroid Surgery (JSTS) for patients with papillary thyroid carcinoma describe four risk classes (very low-, low-, intermediate- and high-risk) for deciding on therapeutic strategies. Here, we investigate cause-specific survival (CSS) of high- and intermediate-risk patients, taking their age into consideration. CSS of intermediate-risk patients ≥55 years was poorer than that of those <55 years (p < 0.0001) (20-year CSS rates, 96.9% vs. 98.7%). CSS of intermediate-risk patients <55 years was excellent but still poorer (p = 0.0152) than that of low- or very low-risk patients (20-year CSS rates, 100%). CSS of high-risk patients <55 years (20-year CSS rates, 96.0%) was similar (p = 0.7412) to that of intermediate-risk patients ≥55 years, while high-risk patients ≥55 years (20-year CSS rates, 80.6%) showed much poorer prognosis (p < 0.0001) than the others. In high-risk patients <55 years, distant metastasis (M1), extrathyroid extension (Ex), node metastasis ≥3 cm, and extranodal tumor extension, and in those ≥55 years, M1, Ex, and tumor size >4 cm were regarded as prognostic factors on multivariate analysis. We therefore conclude that 1) prognosis of high-risk patients ≥55 years should be carefully treated because of significantly poor prognosis, 2) prognostic factors of high-risk patients vary according to patient age, and 3) overtreatment of intermediate-risk patients and young high-risk patients should be avoided; however, appropriate treatment strategies need to be established, considering that their prognoses are excellent, but still poorer than low- or very low-risk patients.

Herbal Active Ingredients: An Emerging Potential for the Prevention and Treatment of Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) is the most common subtype of differentiated thyroid cancers in Asian coastal cities, where the patients have increased risk of potentially high or excessive iodine intake. Given the high metastasis and recurrence of patients with BRAF^V600E mutation, the mortality rate of thyroid cancer has recently shown an upward trend. A variety of therapies, including surgery, radiotherapy, and chemotherapy, have been used to treat thyroid cancer, but these therapies still have limitations, including postoperative complications, drug resistance, poor efficacy, or serious side effects. Recent studies have shown the potential of active ingredients derived from herbal medicine in inhibiting PTC via various cell signaling pathways. Some plant-derived compounds, such as apigenin, genistein, and curcumin, are also known to prevent and treat PTC. This article summarizes the recent advances in the structure-functional impact of anti-PTC active ingredients and their effects on PTC cells and tumor microenvironments with an emphasis on their challenges from basic research to clinical practice.

Older Age Significantly Affects Mortality of Patients with Papillary Thyroid Carcinoma Only When They Have High-Risk Features

Background

Old age is a known prognostic factor for mortality in patients with papillary thyroid carcinoma (PTC). This study aimed to investigate the relationship between cause-specific survival (CSS) following PTC and the extent of old age.

Methods

We enrolled 4692 patients aged ≥ 55 years with PTC who underwent surgery between 1989 and 2009 at Kuma Hospital (median follow-up period 140 months). The presence of at least one of the following was used to classify the patients as high risk: (1) tumor sizes > 4 cm, (2) node metastasis ≥ 3 cm, (3) significant extrathyroid extension corresponding to T4a, (4) extranodal tumor extension, and (5) distant metastasis. T1N0M0 PTC was classified as low risk, and all other patients were classified as intermediate risk. We divided all patients into three categories based on age: 55–64, 65–74, and ≥ 75 years.

Results

One low-risk patient (0.04%), 18 intermediate-risk patients (1.5%), and 105 high-risk patients (9.4%) died of PTC, and CSS of high-risk patients was poorer than that of others (p < 0.0001). The CSS of low and intermediate-risk patients did not differ with age. However, CSS of high-risk patients became significantly poorer with advancing age (p = 0.0017 for 55–64 years vs. 65–74 years, and p = 0.0109 for 65–74 years vs. ≥ 75 years).

Conclusions

Advanced age has a significant prognostic impact on CSS only for high-risk patients with PTC.