Prognosis and prognostic factors of patients with papillary carcinoma showing distant metastasis at surgery (M1 patients) in Japan

Cervical exenteration and its variants for locally advanced thyroid cancer: when, why, and how?

PURPOSE OF REVIEW

To describe the modern surgical approach for management of advanced thyroid cancers infiltrating the cervicovisceral axis with special attention to well differentiated tumors not amenable to organ-sparing techniques. In particular, cervical exenteration, herein defined as the sum of total thyroidectomy, central compartment and lateral neck dissections, variously associated with total laryngectomy and possible partial or total pharyngoesophagectomy, represents an extreme surgical procedure that, in properly selected cases, allows for reasonable palliation of central compartment life-threatening signs/symptoms if not cure for an advanced oncologic condition.

RECENT FINDINGS

Cervical exenteration is not contraindicated by the presence of limited distant metastases at presentation. Even though it requires that the patient is in general good health as it can be associated with a number of complications and long in-hospital stay, when appropriately planned and performed according to the most recent reconstructive nuances, it allows good oncologic outcomes that are not inferior to those described for similarly advanced primaries of the upper aerodigestive tract. In addition, quality of life and functional results are not significantly different from those described after total laryngectomy for primary laryngeal squamous cell carcinomas.

SUMMARY

Cervical exenteration requires a tertiary, expert, multidisciplinary effort in terms of diagnosis, surgical performance, and postoperative care. A patient-centered decision process is strongly warranted taking into consideration alternative therapeutic and symptom-based palliative strategies.

Levothyroxine suppressive therapy in differentiated thyroid cancer treatment

Levothyroxine therapy in management of diferentiated thyroid carcinoma (DTC) has been common practice for decades. Levothyroxine is being administered to patiens with DTC after total thyreoidectomy (with or without postopreative radioiodine treatment) not only to restore euthyroidism but to suppress the production of thyroid-stimulating hormone (TSH) as well because TSH is considered as a growth factor for thyroid follicular cells. However there has been a downside to this threatment recently. The main concerns are the known risks related to iatrogenic subclinical or even mild but clinicaly overt iatrogenic hyperthyroidism. Therefore individualized treatment approach aiming to balance between the risk of tumor recurence and the risks related to hypertyhroidism in view of pateints age, risk factors and comorbidities is essential. Close folow-up is therefore necessary with frequent dose adjustments according to target TSH values published in American Thyroid Association guidelines.

Multikinase Inhibitor Treatment Patterns for Advanced Thyroid Cancer in Japan: An Administrative Claims Database Study

BACKGROUND

The multikinase inhibitors (MKIs) sorafenib, lenvatinib, and vandetanib are approved for advanced thyroid cancer (TC) in Japan. How sequential treatment with MKIs is conducted in Japanese clinical practice is unknown.

METHODS

This retrospective observational cohort study used a Japanese administrative claims database (April 2008-September 2021). Patients with a confirmed TC subtype diagnosis of papillary (PTC), follicular (FTC), medullary (MTC), or anaplastic (ATC), who received MKI treatment after TC diagnosis within the index period (June 2014-August 2021), were included. Overall MKI treatment duration was estimated by Kaplan-Meier analysis.

RESULTS

The analysis population included 795 patients (PTC, N = 447; FTC, N = 86; MTC, N = 32; ATC, N = 230). Median age was ≥ 64 years; most patients (> 60%) were female except for the MTC subgroup (43.8%). First-line (1L) MKI treatment was mainly lenvatinib for PTC (81.7%), FTC (83.7%), and ATC (97.8%), and vandetanib for MTC (62.5%). Among patients discontinuing 1L MKI treatment and evaluable for subsequent therapy [PTC: 57.9% (259/447); FTC: 48.8% (42/86); MTC: 62.5% (20/32); ATC: 70.4% (162/230)], 26.3% (68/259), 21.4% (9/42), 50.0% (10/20), and 4.9% (8/162) of PTC, FTC, MTC, and ATC patients, respectively, received second-line (2L) treatment. Median (95% CI) overall MKI treatment duration was 21.2 (17.9-27.5), 43.9 (30.9-not assessable), 39.0 (17.7-not assessable), and 4.0 (3.0-4.8) months for PTC, FTC, MTC, and ATC, respectively.

CONCLUSION

Advanced TC treatment options are limited. In this study, most patients received only 1L MKI treatment; of those who discontinued 1L, ≤ 50% progressed to 2L.

Clinical outcomes of a cohort of 271 patients with lung metastases from differentiated thyroid carcinoma

CONTEXT

Lung is the most common site of distant metastases from differentiated thyroid carcinoma (DTC).

OBJECTIVE

To investigate the outcomes of a cohort of patients with DTC and lung metastases (LM).

METHODS

A retrospective analysis of a cohort of 271 patients with LM was performed.

RESULTS

The female-to-male ratio was 1:1 and the median follow-up time was 5.9 (1.1-38.4) years. Papillary thyroid carcinoma (PTC) was the most frequent type (83.4%), mainly the classic variant, followed by follicular thyroid carcinoma (FTC, 10.3%) and Hürthle cell carcinoma (HTC, 6.3%). The prevalence of PTC, FTC and HCC was different between the micronodular and macronodular LM groups [87.4%, 6.3% and 6.3% vs. 74.6%, 19.0% and 6.3%, respectively (p = .013)]. Only 5.0% of the patients had LM diagnosed after a period of remission. LM were submitted to radioactive iodine treatment (RAIT) in 84.5% (52.8% showed ¹³¹ iodine avid metastases). Complete remission was only achieved in 12.2%. Micronodular disease and age <55 years at LM diagnosis were associated with a better prognosis (p < .05). We found no difference in survival between patients with LM treated or not with RAIT. However, in patients submitted to RAIT, there was a tendency for longer survival in the group of patients with ¹³¹ I avid lesions.

CONCLUSION

The classic variant of PTC was the most frequent histology found in LM of DTC. LM are rarely diagnosed in the follow-up when complete remission is achieved after surgery and ¹³¹ I. Younger age at LM diagnosis and a micronodular pattern are associated with a better prognosis.

Seeking optimization of LT4 treatment in patients with differentiated thyroid cancer

Levothyroxine sodium (LT4) is the mainstay treatment to replace thyroid hormonal production in thyroidectomized patients, but, depending on the aggressiveness of the cancer and on the risk of recurrence, patients with differentiated thyroid cancer may also be treated in a TSH-suppressive or semi-suppressive mode. The pathophysiological rationale for this LT4 treatment stems from the role of TSH, considered to be a growth factor for follicular cells, potentially inducing initiation or progression of follicular cell-derived thyroid cancer. Therefore, accurate tailoring of treatment, taking into account both patient characteristics (age and comorbidities) and risk of persistent/recurrent disease, is highly recommended. Furthermore, adjustments to traditional LT4 treatment should be made in thyroidectomized patients due to the lack of thyroidal contribution to whole body triiodothyronine (T₃) concentration. Since LT4 exhibits a narrow therapeutic index and the side effects of over- and under-treatment could be deleterious, particularly in this category of patients, caution is required in dose individualization, in the mode of ingestion, and in potential pharmacological and other types of interference as well. Our aim was to analyze the current knowledge concerning LT4 dose requirements in patients with thyroid cancer according to different therapeutic approaches, taking into account a number of factors causing interference with LT4 efficacy. Specific mention is also made about the use of the novel LT4 formulations.

A Predictive Model for the 10-year Overall Survival Status of Patients With Distant Metastases From Differentiated Thyroid Cancer Using XGBoost Algorithm-A Population-Based Analysis

Purpose: To explore clinical and non-clinical characteristics affecting the prognosis of patients with differentiated thyroid cancer with distant metastasis (DTCDM) and establish an accurate overall survival (OS) prognostic model.

Patients and methods: Study subjects and related information were obtained from the National Cancer Institute’s surveillance, epidemiology, and results database (SEER). Kaplan‐Meier analysis, log-rank test, and univariate and multivariate Cox analysis were used to screen for factors influencing the OS of patients with DTCDM. Nine variables were introduced to build a machine learning (ML) model, receiver operating characteristic (ROC) was used to evaluate the recognition ability of the model, calibration plots were used to obtain prediction accuracy, and decision curve analysis (DCA) was used to estimate clinical benefit.

Results: After applying the inclusion and exclusion criteria, a total of 3,060 patients with DTCDM were included in the survival analysis from 2004 to 2017. A machine learning prediction model was developed with nine variables: age at diagnosis, gender, race, tumor size, histology, regional lymph node metastasis, primary site surgery, radiotherapy, and chemotherapy. After excluding patients who survived <120 months, variables were sub-coded and machine learning was used to model OS prognosis in patients with DTCDM. Patients 6–50 years of age had the highest scores in the model. Other variables with high scores included small tumor size, male sex, and age 51–76. The AUC and calibration curves confirm that the XGBoost model has good performance. DCA shows that our model can be used to support clinical decision-making in a 10-years overall survival model.

Conclusion: An artificial intelligence model was constructed using the XGBoost algorithms to predict the 10-years overall survival rate of patients with DTCDM. After model validation and evaluation, the model had good discriminative ability and high clinical value. This model could serve as a clinical tool to help inform treatment decisions for patients with DTCDM.

OUP accepted manuscript

Papillary thyroid carcinoma (PTC) is the most common malignancy originating from the thyroid, with a good overall prognosis. However, distant metastasis of such lesions is very rare, with the brain being an incredibly uncommon site for secondary spread. The authors report a case of PTC brain metastasis 17-years after successful treatment of the primary malignancy, with no local or locoregional recurrence. Initial diagnostic uncertainty necessitated the involvement of a multidisciplinary team, and eventually the patient underwent image-guided gross surgical resection with intraoperative neuromonitoring (IOMN).

Application and prospect of trabecular bone score in differentiated thyroid cancer patients receiving thyrotropin suppression therapy

Thyroid-stimulating hormone (TSH) suppression therapy is one of the common treatments for most patients with differentiated thyroid cancer (DTC). Unfortunately, its detrimental effects on bone health are receiving increasing attention. It may increase the risk of osteoporosis and osteoporotic fractures. The trabecular bone score (TBS) is a relatively new gray-scale texture measurement parameter that reflects bone microarchitecture and bone strength and has been shown to independently predict fracture risk. We reviewed for the first time the scientific literature on the use of TBS in DTC patients on TSH suppression therapy and aim to analyze and compare the utility of TBS with bone mass strength (BMD) in the management of skeletal health and prediction of fracture risk. We screened a total of seven relevant publications, four of which were for postmenopausal female patients and three for all female patients. Overall, postmenopausal female patients with DTC had lower TBS and a significant reduction in TBS after receiving TSH suppression therapy, but their BMD did not appear to change significantly. In addition, TBS was also found to be an independent predictor of osteoporotic fracture risk in postmenopausal women with DTC receiving TSH suppression therapy. However, due to limitations in the number of studies and study populations, this evidence is not sufficient to fully demonstrate the adverse effects of TSH suppression therapy on patients' TBS or BMD and the efficacy of TBS, and subsequent larger and more case-cohort studies are needed to further investigate the relationship and application of TBS to TSH suppression therapy in terms of skeletal health impairment and fracture risk in DTC patients.

Successful Treatment by Surgery and Lenvatinib of a Patient with Adrenal Metastasis of Papillary Thyroid Cancer

Papillary thyroid cancer (PTC) is considered an indolent cancer, but some PTC patients do present with distant metastases and treatment strategies for such patients are not well established. Recently, lenvatinib, an inhibitor of multiple tyrosine kinases, has been introduced to treat patients with advanced PTC but carries a risk of serious adverse events such as hemorrhage. Here, we report a PTC patient with a left adrenal metastasis and lenvatinib-induced hemorrhage who underwent successful surgical resection and was subsequently treated with a lower dose of lenvatinib. The patient has now been in a stable state with no adverse events for nearly two years. This case highlights the importance of surgical resection of metastatic PTC and subsequent lenvatinib therapy, even when the tumor is at an advanced stage.

Routine Chest Computed Tomography at Presentation Does Not Identify Distant Metastasis in cT1aN0 Papillary Thyroid Carcinoma

Background: Active surveillance is accepted as a first-line management for patients with low-risk papillary thyroid microcarcinoma (PTMC) without metastasis or extrathyroid extension. While the lung is the most frequent site of distant metastasis of papillary thyroid carcinomas (PTCs), it is unclear if chest computed tomography (CT) is necessary at the initiation of active surveillance. In our institution, we usually did not perform chest CT for candidates identified for active surveillance. However, routine preoperative chest CT for patients with thyroid cancers, including PTMCs, was standard practice. The present study aimed to evaluate the clinical value of chest CT for patients with PTMCs. Methods: We retrospectively reviewed preoperative chest CT images from 1000 consecutive patients (88.5% women; median age, 55 years) with cT1aN0 PTC who underwent surgery between January 2006 and May 2012 in our hospital. The median maximum size of PTMCs was 8 mm. Results: Abnormal findings were detected in 326 (32.6%) of the 1000 patients. Of these, 290 patients had presumed benign or inflammatory lesions of no clinical importance. In total, 36 patients (3.6%) were referred to specialized departments for further evaluation of the lesions, and 9 patients (0.9%) received invasive tests and/or treatments. Five patients (0.5%) benefited from the chest CT (lung cancer was detected in four, and a cardiac lesion was detected and treated in one), while the lesions in the other four patients were benign, not necessarily requiring treatment. The remaining 27 patents were followed for presumed benign or inflammatory lesions. Thus, none of the present 1000 patients was found with distant metastasis of thyroid cancer. Conclusions: Routine chest CT did not detect thyroid cancer lung metastasis in patients with PTMC. Thus, routine chest CT at the time of presentation is not required for patients with cT1aN0 PTCs.

Oncologic and functional outcomes following laryngectomy for locally advanced thyroid cancer

BACKGROUND AND OBJECTIVES

Total laryngectomy in thyroid cancer is controversial. Functional and oncologic outcomes are needed to inform surgical indications in this population.

METHODS

A retrospective cohort study was performed at a tertiary referral center from 1997 to 2018 to identify patients with a diagnosis of thyroid carcinoma who underwent total laryngectomy. Complications, survival outcomes, and functional outcomes were analyzed.

RESULTS

Thirty patients met the inclusion criteria. The mean age was 62 years (range, 30-88 years) and the male-to-female ratio was 1:2.75. The most common diagnosis was well-differentiated thyroid cancer (53.3%), followed by poorly differentiated (30%) and anaplastic (16.7%). Total laryngectomy was performed with a 10% rate of Clavien-Dindo Grade III-V complications. The median overall survival was 40 months (range, 1-237). Five-year overall survival was 39.5% and disease-specific survival was 51.1%. Locoregional control was achieved in 80.0% of patients. Twelve months postoperatively, 100% of surviving patients were taking oral intake and 86.4% had a self-reported functional voice.

CONCLUSION

Total laryngectomy for locally advanced thyroid cancer is safe and provides acceptable rates of locoregional control. While the risk of distant metastases remains high, advances in systemic therapy may justify aggressive local control strategies to improve the quality of life.

Clinical outcomes and risk stratification for papillary thyroid carcinoma presenting with distant metastasis before the era of tyrosine kinase inhibitors

Radioactive iodine (RAI) therapy has been the mainstay of treatment for papillary thyroid carcinoma (PTC) patients with distant metastasis (DM). Although tyrosine kinase inhibitors (TKIs) were introduced for the treatment of RAI refractory metastatic thyroid carcinoma several years ago, clinical outcomes for PTC patients with DM treated using RAI therapy remain unclear. We retrospectively examined 64 PTC patients (9 men, 55 women) with DM at diagnosis treated using RAI therapy without administration of any kind of chemotherapy or TKIs. Median age of patients was 58 years. Site of DM was the lungs (n = 59), bone (n = 3), and pleural dissemination (n = 2). No patients showed multiple-organ metastases at diagnosis. By the end of the study period, 21 patients had died of PTC. Cause-specific survival rates at 10, 15, and 20 years after initial surgery were 68.2%, 63.6% and 61.1%, respectively. Uni- and multivariate analyses identified age ≥55 years (HR 3.1, p = 0.023), site of DM other than the lungs (HR 13.4, p < 0.0001), and DM with no RAI avidity (HR 5.1, p = 0.0098) as factors independently associated with disease-related death. When analyses were restricted to patients with lung metastasis (n = 59), surgical non-curability was another independent risk factor (HR 5.2, p = 0.0047) in addition to age and RAI avidity. According to risk stratification analysis based on these risk factors, patients with site of DM other than the lungs or with lung metastasis showing ≥2 risk factors among age ≥55 years, DM with no RAI avidity, and surgical non-curability are expected to show higher mortality rates.

Papillary thyroid carcinoma with hyperthyroidism and multiple metastases: A case report

RATIONALE

Papillary thyroid carcinoma (PTC) is the most common type of primary thyroid cancer with a low incidence of distant metastases. PTC represents more than 70% to -90% of thyroid malignancies. Distant metastases have only been observed in only 1% to 15% of patients with PTC. In this article, we reported the case of a patient with PTC and hyperthyroidism as well as simultaneous multiple metastases.

PATIENT CONCERNS

A 47-year-old man was admitted to our hospital on February 22, 2019, with several neck masses that had been present for 12 months, low back pain for 9 months, and lower limb paraplegia for 3 months.

DIAGNOSES

According to the patient physical examination, adjuvant examination (e.g., ultrasound, computed tomography, magnetic resonance imaging, blood test, and biopsy) and medical history, the clinical diagnosis was as follows: thyroid papillary carcinoma; cervical lymph node metastasis; multisite bone metastasis (6th and 7th cervical vertebrae, left clavicle proximal, right scapula bone, thoracic vertebrae, lumbar vertebrae, sacral vertebrae, bilateral ilium, and left pubic bone); muscular metastasis (the right medial femoral muscle, the vastus lateralis muscle, left thigh muscle, and the flexor superficialis of the left forearm); possible mediastinal lymph node metastasis; and paraplegia due to the soft-tissue metastasis around the 9th thoracic vertebral spine; and hyperthyroidism (free thyroxine: 36.59 pmol/L, free triiodothyronine: 9.58 pmol/L, thyroid-stimulating hormone: 0.005 μIU/mL, thyroid autoantibody: 2.53 IU/L).

INTERVENTIONS AND OUTCOMES

The patient refused to undergo further intervention or follow-up.

LESSONS

In summary, this is the 1st case of in which a patient with PTC and hyperthyroidism, as well as simultaneous multiple skeletal muscles and bone metastases, lymph node metastasis, and paraplegia was observed. In practice, in cases where patients have PTC and hyperthyroidism, practitioners should perform further examinations to rule out the presence of distant metastases. We believe that the use of ultrasound has a unique advantage in the diagnosis of PTC and skeletal muscle metastasis.

Thyroid hormone therapy in differentiated thyroid cancer

Surgery-with or without postoperative radioiodine-is the standard of care for most patients with differentiated thyroid carcinoma (DTC). Thyroid hormone replacement therapy is the mainstay of long-term medical management. Patients treated with total thyroidectomy and some who undergo lobectomy alone require thyroid hormone therapy to restore euthyroidism with normal serum thyroid-stimulating hormone (TSH) levels. Because TSH acts as a growth factor for thyroid follicular cells (including those that are neoplastic), it can potentially affect the onset and/or progression of follicular-cell derived thyroid cancer. For this reason, some patients are placed on thyroid hormone therapy at doses that suppress secretion of TSH (suppression therapy). This mini-review looks at the potential benefits and risks of this practice in patients diagnosed with DTC. Aggressive TSH-suppressive therapy is of little or no benefit to the vast majority of patients with DTC. Practice guidelines, therefore, recommend a graded algorithm in which the potential benefits of suppression are weighed against the associated cardiovascular and skeletal risks. Large randomized controlled studies are needed to confirm the presumed oncological benefits of TSH-suppression and its causal role in adverse cardiac, skeletal, and quality of life effects and to assess the efficacy of TSH normalization in reversing or reducing these effects.

Thyroid Hormone Suppression Therapy

Thyroid hormone suppression therapy is designed to lower serum thyrotropin (TSH) levels using doses of thyroid hormone in excess of what would normally be required to maintain a euthyroid state. The basis of this therapy is the knowledge that TSH is a growth factor for thyroid cancer, so that lower serum TSH levels might be associated with decreased disease activity. However, clinical studies have not documented improved outcomes with TSH suppression, except in patients with the most advanced disease. Furthermore, there are a number of negative outcomes related to aggressive thyroid hormone therapy, including osteoporosis, fracture, and cardiovascular disease. Therefore, a graded approach to TSH suppression is recommended by the American Thyroid Association, based on initial risk and ongoing risk assessment.

The efficacy of radioactive iodine for the treatment of well-differentiated thyroid cancer with distant metastasis

Objective

Radioactive iodine (¹³¹I) has been used as a treatment for high-risk well-differentiated thyroid cancer after thyroidectomy. The aim of this study was to evaluate the long-term follow-up results after using high accumulated doses of ¹³¹I (>600 mCi) for the treatment of well-differentiated thyroid cancer.

Patients and methods

In this study, we retrospectively evaluated prospectively enrolled patients with well-differentiated thyroid cancer who were treated and followed up in Chang Gung Memorial Hospital in Linkou and Keelung, Taiwan. All the patients underwent thyroidectomy between 1979 and 2016.

Results

For our study, 228 patients with papillary and follicular thyroid carcinoma with distant metastases were enrolled. Of the 228 patients, 71 (31.1%) received ¹³¹I therapy with an accumulated dose of at least 600 mCi. Forty-four died because of disease-specific mortality (DSM) after a mean follow-up of 10.6±6.3 years. Compared with the patients in the DSM group, which included 27 survival cases, patients who were younger, and those with a multifocal tumor, more extensive thyroidectomy, and papillary thyroid carcinoma showed better prognosis. The DSM group included a higher percentage of patients who developed a secondary primary cancer after receiving a diagnosis of thyroid cancer than the survival group (18.2 vs. 3.7%). However, the difference did not reach statistical significance (P=0.075).

Conclusion

¹³¹I provided an effective therapeutic modality for well-differentiated thyroid cancer patients with distant metastasis. After a mean of follow-up 10 years, more than 60% of cases resulted in DSM when high accumulated ¹³¹I doses were administered.

Circulating Epithelial Cell Characterization and Correlation with Remission and Survival in Patients with Thyroid Cancer

BACKGROUND

Thyroid cancer is the most common endocrine tumor and generally has relatively good clinical outcomes. However, 15-20% of patients ultimately develop recurrence or disease-related death. The appropriate prognostic factors for thyroid cancer are still elusive. This study evaluated whether the number of circulating tumor cells/circulating epithelial cells (CECs) expressing either epithelial cell adhesion molecule (EpCAM), podoplanin (PDPN), or thyrotropin receptor (TSHR) is related to remission and disease-specific mortality (DSM) of patients with thyroid cancer.

METHODS

Blood samples were collected from patients (n = 128) after thyroidectomy or radioactive iodide therapy. CECs were enriched by lysis of red blood cells and depletion of leukocytes. Subtyping and quantification of the enriched cells were performed with immunofluorescence staining using antibodies against EpCAM, TSHR, and PDPN, respectively. Whether the number of a specific subtype of CECs is related to remission and DSM of patients was determined by univariate and multivariate analyses.

RESULTS

The EpCAM⁺-CECs, TSHR⁺-CECs, and PDPN⁺-CECs counts for patients in the non-remission group (n = 43) were significantly higher when compared to the remission group (n = 85; p < 0.001). Receiver operating characteristic analysis showed that the number of EpCAM⁺-CECs, TSHR⁺-CECs, and PDPN⁺-CECs was able to distinguish the status of remission from non-remission. The cutoff point for EpCAM⁺-CECs, TSHR⁺-CECs, and PDPN⁺-CECs was 40, 47, and 14 (cells/mL), with the accuracy of the assay equivalent to 80.4%, 76.6%, and 77.3%, respectively. On the other hand, the number of EpCAM⁺-CECs (p < 0.001), PDPN⁺-CECs (p = 0.013), and TSHR⁺-CECs (p < 0.001) for patients in the DSM group (n = 17) was significantly higher when compared to the patients who survived (n = 111). Receiver operating characteristic analysis showed that EpCAM⁺-CECs, TSHR⁺-CECs, and PDPN⁺-CECs counts were able to distinguish mortality from survival status. The cutoff point for EpCAM⁺-CECs, TSHR⁺-CECs, and PDPN⁺-CECs was 27, 25, and 9 (cells/mL), with the accuracy of the assay equivalent to 69.5%, 67.2%, and 68.5%, respectively.

CONCLUSIONS

CEC testing is a useful tool for analysis of overall survival and remission status of patients with thyroid cancer. Implementation of CEC testing into routine clinical test may be worthy to consider for patient clinical care.

Overall Survival of Papillary Thyroid Carcinoma Patients: A Single-Institution Long-Term Follow-Up of 5897 Patients

Introduction

Papillary thyroid carcinoma (PTC) generally shows an excellent prognosis except in cases with aggressive backgrounds or clinicopathological features. Although the cause-specific survival (CSS) of PTC patients has been extensively investigated, the overall survival (OS) of these patients is unclear. We herein investigated both the OS and CSS of a large PTC patient series.

Materials and methods

We enrolled 5897 PTC patients who underwent initial surgery between 1987 and 2005 (658 males and 5339 females; median age 51 years). Their median postoperative follow-up period was 177 months. Univariate and multivariate analyses for OS and CSS assessed the effects of gender, older age (≥55 years), distant metastasis at diagnosis (M1), significant extrathyroid extension, tumor size (cutoffs 2 and 4 cm), large node metastasis (N ≥ 3 cm), and extranodal tumor extension.

Results

To date, 387 patients (7%) in this series have died from various causes, including 117 (2%) due to PTC. The 10-, 15-, and 20-year OS rates are 97, 95, and 90%, respectively. Older age and M1 were important prognostic factors for OS and CSS. Older age was a more significant factor than M1 for OS and vice versa for CSS. In the older patients, M1 was a prominent prognostic factor for both OS and CSS. In the young patients, M1 had less prognostic impact than in the older patients, and the prognostic values of M1 and N ≥ 3 cm for OS and CSS were identical and similar, respectively.

Conclusions

The most important prognostic value for OS was patient age, indicating that PTC is generally indolent. However, the control of distant metastasis in older patients remains a future challenge in order to further improve their OS and CSS. PTC of ≥3 cm in young patients should be carefully followed, even in the absence of metastases, and these patients should undergo aggressive therapies for recurrent lesions and metastases.

Clinicopathological Risk Factors for Distant Metastasis in Differentiated Thyroid Carcinoma: A Meta-analysis

INTRODUCTION

Distant metastasis (DM) is not a frequent event in differentiated thyroid carcinoma (DTC) but has an adverse impact on mortality of patients with DTC. In the current study, we aimed to conduct a comprehensive systematic review and meta-analysis to investigate the risk factors for DM in DTCs and for each histological subtype.

METHODS

Five electronic databases were searched from inception to December 2016 for relevant articles. Pooled odd ratios and 95% confidence interval were calculated using random-effect model.

RESULTS

Thirty-four articles with 73,219 patients were included for meta-analyses. In DTCs, male gender, age ≥45 years, tumor size ≥4 cm, multifocality, vascular invasion (VI), extrathyroidal extension (ETE), lymph node metastasis (LNM), and lateral LNM were demonstrated to be associated with significant risks for DM. In addition, several clinicopathological factors such as age ≥45 years, VI, ETE, and LNM were shown to be significant risk factors for DM in both PTC and FTC subgroups.

CONCLUSION

Our study demonstrated the promising value of several clinicopathological factors such as male gender, older age, VI, ETE, and LNM in predicting DM in PTCs and FTCs. Our study affirms the value of the selected clinicopathological factors for tumor risk stratification and assessment of patients' prognosis.

Skeletal muscle metastases from papillary and follicular thyroid carcinomas: An extensive review of the literature

Skeletal muscle metastasis of papillary or follicular thyroid cancer (PTC/FTC) is a rare finding; only 11 cases of skeletal muscle PTC or FTC metastasis have been included in medical literature reviews. The aim of this study was to identify all published cases of PTC and FTC muscle metastases and derive the true incidence of this malignancy. The probability of detecting the skeletal muscle metastasis of PTC and FTC was calculated based on epidemiological data. Databases of scientific literature on the Internet were searched for articles using relevant key words. The analysis of epidemiological data calculated the probability of detecting skeletal muscle lesions of this type as approximately zero. The literature search revealed 44 published international papers, reporting 58 cases of PTC or FTC skeletal muscle metastasis in 45 patients over 110 years, from 1907 to 2017. The most frequent PTC/FTC metastatic muscle was the gluteus. The majority of cases of muscle metastasis were caused by PTC, and metastatic tumors in the skeletal muscle negatively impacted the survival of patients with PTC or FTC.

Prognostic indicators of outcomes in patients with lung metastases from differentiated thyroid carcinoma during long-term follow-up

BACKGROUND

Distant metastases, although uncommon, represent maximum disease-related mortality in differentiated thyroid carcinoma (DTC). Lungs are the most frequent sites of metastases. We aimed to evaluate long-term outcomes and identify prognostic factors in metastatic DTC limited to the lungs.

METHODS

This retrospective study included 89 patients with DTC and metastases limited to the lungs, who were treated between 1996 and 2012 at Samsung Medical Center. Progression-free survival (PFS) and cancer-specific survival (CSS) rates were evaluated according to clinicopathologic factors. Cox regression analysis was used to identify independent factors associated with structural progressive disease (PD) and cancer-specific death.

RESULTS

With a median follow-up of 84 months, the 5- and 10-year CSS rates were 78% and 73%, respectively. Older age at diagnosis (≥55 years), radioactive iodine (RAI) nonavidity, preoperative or late diagnosis of metastasis and macro-nodular metastasis (≥1 cm) were predictive of decreased PFS and CSS. Multivariate analysis identified older age (P = .002), RAI nonavidity (P = .045) and preoperative (P = .030) or late diagnosis (P = .026) as independent predictors of structural PD. RAI avidity was also independent predictor of cancer-specific death (P = .025).

CONCLUSION

Patients with DTC and metastatic disease limited to the lungs had favourable long-term outcomes. Age, RAI avidity and timing of metastasis were found to be major factors for predicting prognosis.

Efficacy of Superselective Neck Dissection in Detecting Metastasis in Patients with cN0 Papillary Thyroid Carcinoma at High Risk of Lateral Neck Metastasis

Background

This study aimed to evaluate superselective neck dissection (SSND) in patients with cN0 papillary thyroid carcinoma (PTC) at high risk of lateral cervical lymph node (LN) metastasis.

Material/Methods

This study enrolled 138 patients with PTC who underwent SSND. These patients were at high risk for LN metastasis and the rate of cervical LN metastasis was recorded.

Results

In all, 146 lateral neck dissections were performed in 138 patients. Intraoperative pathological data revealed LN metastasis from 55 cases, for which Level II and V dissection were performed. Ninety SSNDs were performed in the other 83 patients without metastasis identified in frozen sections. Occult lymph node metastasis (OLNM) rates were 56.8% and 43.5% in the central compartment and lateral neck, respectively. OLNM rates of Level II–VI were 17.8%, 31.5%, 36.3%, 1.4%, and 56.8%, respectively. Level VI metastasis (p<0.001), extra thyroidal extension (p=0.003), and tumor size (p=0.011) were significant factors for lateral neck LN metastasis.

Conclusions

SSND might be effective for early diagnosis of lateral neck metastases of PTC. Patients with OLNM should receive level II, III, and IV dissection, but level V dissection could be omitted.

Primary Thyroid Carcinoma with Low-Risk Histology and Distant Metastases: Clinicopathologic and Molecular Characteristics

BACKGROUND

Distant metastases (DM) are a rare occurrence in well-differentiated thyroid carcinoma. The aim of this study was to analyze the clinical, pathologic, and molecular features of primary thyroid carcinoma with low-risk histology that develop DM.

METHODS

A detailed clinicopathologic review and targeted next-generation sequencing were performed on a cohort of well-differentiated thyroid carcinoma lacking gross extrathyroidal extension, extensive vascular invasion, or significant lymph node metastases but exhibiting DM.

RESULTS

Primary well-differentiated thyroid carcinoma with low-risk histologic features and DM was a rare occurrence, accounting for only 3% of metastatic non-anaplastic thyroid carcinoma. All 15 cases meeting the inclusion criteria harbored DM at presentation. The majority (11/15) of these tumors were follicular variant of papillary thyroid carcinoma (PTC), especially the encapsulated form (n = 8). The remaining patients harbored encapsulated Hürthle cell carcinoma (n = 2), encapsulated follicular carcinoma (n = 1), and an encapsulated papillary carcinoma classical variant (n = 1). Of the 12 encapsulated carcinomas, 10 had capsular invasion only and no vascular invasion. Ninety-two percent of the tumors exhibited extensive intra-tumoral fibrosis. Among the eight tumors that were subjected to next-generation sequencing analysis, a RAS mutation was the main driver (5/8), and TERT promoter mutation was highly prevalent (6/8). In four cases, TERT promoter mutations were associated with RAS or BRAF mutations. BRAF-mutated classical variant of papillary carcinoma also presented with DM but was less common (1/8). In 11/15 cases, the clinician was able to diagnose distant disease based on the clinical presentation. In 3/4 incidental cases that were genotyped, TERT promoter mutations were found.

CONCLUSIONS

When DM occur in primary thyroid carcinoma with low-risk histology, they are almost always found at presentation. The majority are encapsulated follicular variant of PTC with capsular invasion only. TERT promoter mutations occur at a higher rate than that seen in PTC in general and may help explain the aggressive behavior of these histologically deceptive primary carcinomas.

Prognostic implications of radioiodine avidity and serum thyroglobulin in differentiated thyroid carcinoma with distant metastasis

BACKGROUND

Although differentiated thyroid carcinoma (DTC) rarely develops distant metastases, the present study was performed to evaluate factors that affect the survival of patients with DTC who present with distant metastasis.

METHODS

Among 4,989 patients who underwent thyroid surgery for DTC, 82 presenting with distant metastasis were analyzed. Based on radioiodine ((131)I) avidity and the thyroid-stimulating hormone-stimulated serum thyroglobulin (sTg) level at the time of metastasis, patients were divided into three groups: group 1 ((131)I uptake + sTg ≤ 215 ng/mL, n = 46), group 2 ((131)I uptake + sTg > 215 ng/mL, n = 24), group 3 (no (131)I uptake, n = 12). Disease-specific survival (DSS) was estimated using the Kaplan-Meier method. Factors predicting the outcome were evaluated using Cox proportional hazard regression analysis.

RESULTS

The age of patients (p = 0.04), frequency of follicular thyroid carcinoma (p = 0.002), tumor size (p < 0.001), and number of multiple metastatic sites (p = 0.004) differed significantly among the groups. With a median follow-up after surgery of 72 months, the 5- and 10-year DSSs for all patients were 84 and 69 %, respectively. The predictors of survival were age (p = 0.004), symptoms at the time of presentation (p = 0.045), histology (p = 0.01), sites of metastasis (p = 0.03), and (131)I avidity and sTg level at the time of metastasis (p = 0.002). In the multivariate analysis, age, histology, and (131)I avidity and sTg level at the time of metastasis remained significant factors for survival.

CONCLUSIONS

Certain DTC patients with distant metastasis demonstrate favorable outcomes dependent on age, histology, and (131)I avidity and sTg level at the time of metastasis.

The impact of locoregional recurrences and distant metastases on the survival of patients with papillary thyroid carcinoma

OBJECTIVE

Some patients with papillary thyroid carcinoma (PTC) would suffer from locoregional recurrences or distant metastases. This study was aimed to elucidate the impacts of locoregional recurrences and distant metastases on these patients' survival.

DESIGN

Retrospective hospital-based cohort study.

POPULATION

Data were collected from 1636 subjects with PTC at National Taiwan University Hospital between 1985 and 2007.

MEASUREMENTS

Overall and disease-specific survival curves were estimated by the Kaplan-Meier method. Time-independent and time-dependent prognostic factors were included simultaneously in multivariate analyses using Cox models.

RESULTS

Overall survival (OS) rates at 10- and 20-years were 90% and 76%, respectively. The 10- and 20-year disease-specific survival (DSS) rates were 95% and 90%, respectively. Our multivariate analyses identified that older age, distant metastases (hazard ratio, HR: 6·69, 95% CI: 4·40-10·18), locoregional recurrences (HR: 1·88, 95% CI: 1·22-2·89), lymph node metastases, massive extrathyroid extension, male gender and larger tumour size (>4 cm) were significantly associated with poorer OS. Older age, distant metastases (HR: 15·03, 95% CI: 8·31-27·21), locoregional recurrences (HR: 3·63, 95% CI: 2·03-6·51), massive extrathyroid extension, male gender and larger tumour size (>4 cm) were independently related to worse DSS. The performance of high-dose (131) I ablation had a protective effect on OS and DSS.

CONCLUSION

The locoregional recurrences had a moderately harmful impact on OS and DSS, but age and distant metastases were the major decisive factors for OS and DSS. High-dose (131) I ablation had a protective role. However, lymph node dissection did not alter the prognosis whenever lymph node metastases only influenced OS.

Thyrotropin in the development and management of differentiated thyroid cancer

Thyrotropin (TSH) is the major regulator and growth factor of the thyroid. TSH may be important in the development of human thyroid cancer, with both suggestive animal models and clinical evidence, although definitive proof is still required. Applications for TSH in thyroid cancer management include TSH stimulation of radioiodine uptake, enhancement of biochemical monitoring through thyroglobulin measurement, and long-term suppression of TSH with supraphysiologic levothyroxine. This review synthesizes current knowledge of TSH in both the development and management of differentiated thyroid cancer.

Static and dynamic prognostic factors of papillary thyroid carcinoma

The two types of prognostic factors of papillary thyroid carcinoma (PTC) are static and dynamic. The following static prognostic factors have been conventionally adopted: age, tumor size, extrathyroid extension, lymph node metastasis, and distant metastasis based on pre-, intra- and post-operative findings. These factors are useful to decide therapeutic strategies for PTC patients, including the extent of surgery and radioactive iodine (RAI) ablation. However, even the combination of these factors evaluated pathologically postoperatively is not good enough at predicting recurrence in clinical settings. The dynamic prognostic factors of changes in serum thyroglobulin (Tg) and thyroglobulin antibody (TgAb) values in patients who have undergone a total thyroidectomy are important to evaluate the progression of carcinoma recurrence and to predict patients' cause-specific survival, regardless of their backgrounds and the clinicopathological features of their PTC. Dynamic prognostic factors are superior to static prognostic factors in terms of expressing the condition of recurrence on a real-time basis.

Controversies in primary treatment of low-risk papillary thyroid cancer

In many parts of the world, incidence of papillary thyroid cancer is increasing faster than any other malignancy. Most papillary thyroid cancers that are diagnosed are small and are generally regarded as being low risk, with little or no effect on mortality. Papillary thyroid cancer is a clinical challenge because it is difficult to prove benefit from the traditional therapeutic triad for this disorder (ie, total thyroidectomy with or without prophylactic central neck dissection, radioiodine remnant ablation, and suppression of serum thyroid-stimulating hormone with levothyroxine). However, risk of disease recurrence might be reduced by these therapies in a subset of patients with more aggressive disease. In the past decade, professional societies and other groups have established evidence-based clinical practice guidelines for management of papillary thyroid cancer, but these efforts have been made difficult by a paucity of randomised controlled trials. In this review, we summarise epidemiological data for disease incidence, discuss some controversies in disease management, and outline a therapeutic framework founded in the best available medical evidence and existing recommendations from clinical practice guidelines.

Neoadjuvant chemotherapy in 16 patients with locally advanced papillary thyroid carcinoma

BACKGROUND

It is believed that chemotherapy (ChT) is ineffective in papillary thyroid carcinoma (PTC). The aim of our retrospective chart review was to find out if neoadjuvant ChT before thyroid surgery had any effect on the size of primary tumors in patients with PTC.

METHODS

The study included 16 patients (13 women, 3 men; median age 63.5 years) with PTC, who were treated with neoadjuvant ChT from 1988 to 2005. Poorly differentiated PTC, classical PTC, a follicular variant of PTC, and a Hürthle cell variant of PTC were diagnosed in 5, 5, 3, and 3 cases, respectively. The mean tumor diameter was 9.67 cm. Seven patients had a pT4 tumor. Regional and distant metastases were detected in 10 and 7 patients, respectively. ChT consisted of vinblastine in 11 cases, vinblastine with adriamycin in 2 cases, and other schedules in 3 cases. Four patients were also treated with preoperative external irradiation.

RESULTS

Altogether, 40 cycles of ChT were given. After ChT, the tumor size decreased in all 16 patients: by >50% in 7 (44%) patients and by <50% in 9 patients. R0, R1, and R2 resection was performed in 2, 10, and 4 cases, respectively. The median survival time of our patients was 88 months. Six patients are still alive; two died of causes not related to carcinoma, while eight patients died of PTC.

CONCLUSIONS

Neoadjuvant ChT before thyroid surgery may be effective in patients with locally advanced PTC. After neoadjuvant ChT, in 44% of patients, the tumor size decreased by >50%.

Impact of moderate vs stringent TSH suppression on survival in advanced differentiated thyroid carcinoma

OBJECTIVES

To assess (i) the influence of Thyrotropin (TSH) suppression at a level of <0·1 mU/l and (ii) whether FT3 and FT4 levels have a prognostic significance independently of TSH values with regard to survival in patients with differentiated thyroid carcinoma (DTC) and distant metastases.

PATIENTS AND METHODS

In a retrospective patient chart study, we reviewed survival in 157 DTC patients with distant metastases treated between September 1985 and 1 July 2010. Patients with at least three available FT3 and FT4 values during TSH suppression were eligible.

RESULTS

Fifty-three of 157 patients died from DTC. DTC-specific survival was significantly better in patients with a median TSH level ≤0·1 mU/l (median survival 15·8 years) than those with a non-suppressed TSH level (median survival 7·1 years; P < 0·001). However, there was no further improvement in survival caused by TSH suppression to a level ≤ 0·03 mU/l (P = 0·24). FT3 and FT4 levels were also significantly associated with poorer survival; of these, only the prognostic value of FT3 was independent from that of TSH levels.

CONCLUSION

The care of patients with DTC and distant metastases is like walking an endocrinological tightrope: non-suppressed TSH levels, that is, >0·1 mU/l, are associated with an impaired prognosis. There is, however, no prognostic benefit from suppressing TSH to levels lower than 0·1 mU/l. On the contrary, an improvement in prognosis might be achieved by keeping FT3 levels as low as possible.

Prognostic factors of papillary and follicular carcinomas in Japan based on data of kuma hospital

There are some important prognostic factors for papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). In this paper, clinicopathological features significantly affecting patient prognosis are described based on our data as well as others. Distant metastasis at diagnosis is the most important prognostic factor for both PTC and FTC. Other than that, preoperative and intraoperative findings are important to evaluate the biological behavior of PTC. Extrathyroid extension, large lymph-node metastasis, and extranodal tumor extension that can be evaluated preoperatively or intraoperatively are significant prognostic factors for PTC patients. In contrast, pathological findings are important not only for diagnosis of FTC, but also for the evaluation of its biological character. Grade of invasiveness (minimally or widely invasive) and degree of differentiation (well differentiated or including a poorly differentiated component) greatly affect the prognosis of FTC patients.

Histological subtype is the most important determinant of survival in metastatic papillary thyroid cancer

BACKGROUND

Papillary thyroid cancer (PTC) comprises the commonest type of thyroid cancer and carries the highest rate of survival. However, when metastatic disease occurs, survival is significantly affected.

METHODS

We aimed to identify prognostic histopathological and clinical factors that modify survival in metastatic PTC. All cases of metastatic PTC treated at our department in the last 20 years were reviewed and analyzed.

RESULTS

Histological subtype was the most important determinant of survival, as classic PTC demonstrated clearly improved survival compared to follicular subtype of PTC and other less frequently seen histological subtypes. The instant risk of death for the other histological subtypes was 4.56 times higher than the risk for the classic papillary type. Overall, a 10-year survival of 76.6% in our patients was seen.

CONCLUSIONS

Patients with aggressive variants of PTC are more at risk for the development of metastatic disease. In these patients, established treatment modalities (surgery, radioiodine therapy) should be offered promptly, as well as close follow-up.

Clinical outcomes of patients with papillary thyroid carcinoma after the detection of distant recurrence

PURPOSE

Papillary thyroid carcinoma generally has an excellent prognosis but can have recurrence to the distant organs that is often life-threatening. To date, prognosis and prognostic factors of papillary carcinoma have been intensively investigated, but our knowledge regarding prognosis after the detection of distant recurrence remains inadequate.

METHODS

We investigated the prognosis and prognostic factors of papillary carcinoma after distant recurrence was detected during follow-up in a series of 105 patients who underwent locally curative surgery between 1987 and 2004.

RESULTS

To date, 30 patients (29%) have died of carcinoma, and the 5-year and 10-year cause-specific survival (CSS) rates after the detection of distant recurrence were 71 and 50%, respectively. Patients aged 55 years or older at recurrence or with massive extrathyroid extension of primary lesions demonstrated a significantly worse CSS. On multivariate analysis, these two parameters were recognized as independent prognostic factors. Gender, tumor size, and lymph node metastasis did not affect patient prognosis. Uptake of radioactive iodine (RAI) to distant metastasis was not significantly linked to CSS, but none of the patients younger than aged 55 years showing RAI uptake died of carcinoma. Appearance of distant recurrence to organs other than lung also predicted a dire prognosis.

CONCLUSIONS

Age at recurrence and extrathyroid extension of primary lesions were significantly related to patient prognosis after the detection of distant recurrence. RAI therapy is effective, especially for younger patients, if metastatic lesions show RAI uptake.

Evaluation of NDRG2 gene expression in primary papillary thyroid carcinoma and in metastases of this neoplasm to regional lymph nodes

Background

At present, researchers' attention has been concentrating on NDRG2 (N-Myc downstream-regulated gene 2) as a new gene candidate in the development and progression of papillary thyroid carcinoma (PTC). NDRG2, together with NDRG1, NDRG3 and NDRG4 are members of the NDRG family, a new class of genes, inhibited by N-Myc oncogene.

Aim

The aim of our study was to evaluate NDRG2 mRNA expression in the primary PTC and its metastases to regional lymph nodes.

Materials and methods

Postoperative tissue and macroscopically changed lymph nodes of sixteen (16) patients with PTC constituted the studied material. In this group, metastases of the cancer to regional lymph nodes were confirmed histopathologically in 8 cases. Quantitative evaluation of NDRG2 mRNA expression was performed by the real-time polymerase chain reaction (real-time PCR) method.

Results

The mean values of NDRG2 mRNA expression in the primary tumour tissues were statistically significantly lower vs. the levels of NDRG2 mRNA expression in macroscopically unchanged thyroid tissue (p < 0.0001). A comparison of the mean NDRG2 mRNA expression of primary tumours and that of their metastases to regional lymph nodes did not demonstrate any statistical differences (p > 0.05). A positive correlation was observed between NDRG2 mRNA expression in primary tumour cells and in the cancer metastases to lymph nodes (Rs = 0.7857; p < 0.05). Factors, such as age, sex, tumour stage in TNM system, were of no significance for NDRG2 mRNA expression level (p > 0.1).

Conclusion

The results of our study demonstrated decreased NDRG2 mRNA expression levels in PTC, when compared to macroscopically unchanged thyroid tissue, which may point to the potential role of NDRG2 in the development and progression of cancer in question.