Prognostic impact of vascular invasion in differentiated thyroid carcinoma: a systematic review and meta-analysis

Histologic parameters driving completion thyroidectomy for papillary thyroid carcinoma in a high-volume institution: A retrospective observational study

BACKGROUND

When the histological examination indicates papillary thyroid carcinoma (PTC), there is no unanimity on the need to proceed with completion thyroidectomy (CT). This study aims to assess the histologic parameters that influenced the decision to perform CT.

MATERIALS AND METHODS

This study included PTC patients who underwent thyroid lobectomy between 2019 and 2022. Group A included patients who underwent thyroid lobectomy without further treatments, whereas Group B included those who underwent CT based on histological findings. Differences in terms of histologic parameters were analyzed.

RESULTS

Group A included 291 patients (68.3 ​%), whereas Group B 135 patients (31.7 ​%). Multivariate analysis identified associations between CT and tumor size (p ​< ​0.001), aggressive variant (p ​= ​0.009), and vascular invasion (p ​< ​0.001). ROC curve analysis established a tumor size cut-off of 21 ​mm for CT. At ROC curve analysis, the cut-off number of aggressive factors required for CT was 2.

CONCLUSION

A thorough comprehensive assessment encompassing all pathological characteristics might be necessary in case of PTC with aggressive histologic features after thyroid lobectomy.

Differentiated Thyroid Carcinoma Long-Term Prognostic Factors

Introduction

Thyroid cancer is the most common cancer in women in Ecuador.

Objective

The aim of this study was to determine the demographics and clinical and treatment variables of patients with papillary or follicular thyroid cancer, referred to as differentiated thyroid cancer (DTC), treated at a third-level hospital in Quito, Ecuador.

Methods

We reviewed retrospectively the medical records of patients with DTC, who underwent surgical treatment, from 1990 to 2019. Data included demographics, pathological information, clinical stage, type of surgery, and radioactive iodine (RAI) adjuvant therapy. Patients were monitored for up to 29 years (median follow-up time 6.9 years).

Results

The corrected overall 5-, 10-, 20-, and 30-year survival rates (Kaplan-Meier) were 93%, 85%, 70%, and 63%, respectively. On univariate analysis, age, histological type, tumor grade, histological variants, capsular invasion, vascular invasion, tumor size, clinical stage, distant metastases at diagnosis, surgical margins, extrathyroidal invasion, radioactive iodine adjuvant treatment, and locoregional recurrence were found to be significant prognostic factors. In a multivariate analysis, the following independent variables: age over 55 years, extrathyroidal spread, metastasis at diagnosis, and stage II to IV raised the risk of death (hazard risk) (HR).

Conclusions

Age over 55 years, extrathyroidal spread, metastasis at diagnosis, and advanced clinical stage were found to have a harmful prognosis and an increased risk of death in a series of Ecuadorian patients surgically treated for a DTC.

Correlation of pN Stage and Hypoechogenicity with Tumour Encapsulation and Vascular Invasion in Thyroid Cancer (TC): A Comprehensive Analysis and Clinical Outcomes

In this retrospective study, the relationship between the pN stage of TC and the ultrasound hypoechogenicity of tumour encapsulation and vascular invasion was investigated. The data of a total of 678 TC patients were analysed. The goal of this study was to assess the significance of the pTNM score and preoperative ultrasound features in predicting cancer prognosis and guiding therapeutic decisions in patients with TC. The main research methods included a retrospective analysis of patient data, mainly the pTNM score and presence of tumour encapsulation and vascular invasion obtained from histopathological results and preoperative ultrasound imaging. Patients with well-differentiated TCs (papillary and follicular) were extracted from TC patients to better unify the results because of similar clinical strategies for these TCs. Significant associations were observed between advanced pN stage and the presence of encapsulation and vessel invasion. The majority of pN1a patients exhibited encapsulation (77.71%; p < 0.0001) and vascular invasion (75.30%; p < 0.0001), as did the majority of pN1b patients (100%; p < 0.0001 and 100%; p < 0.0001, respectively). Less than half of the patients with hypoeghogenic patterns presented with encapsulation (43.30%; p < 0.0001) and vascular invasion (43.52%; p < 0.0001), while the vast majority of patients without hypoechogenicity did not present with encapsulation (90.97%; p < 0.0001) or vascular invasion (90.97%; p < 0.0001). Hypoechogenicity was found to be indicative of aggressive tumour behaviour. The results of this study underscore the importance of accurate N staging in TC and suggests the potential use of ultrasound features in predicting tumour behaviour. Further research is needed to confirm these findings and explore additional prognostic markers to streamline TC management strategies and improve patient outcomes.

Papillary thyroid carcinoma: the impact of histologic vascular invasion

BACKGROUND

The American Thyroid Association (ATA) recurrence risk prediction system considers vascular invasion (VI) as a relative indicator for adjuvant radioactive iodine (RAI) treatment, nevertheless VI final role in PTC management is yet to be defined. This study aims to assess the impact of histologic VI in papillary thyroid carcinoma (PTC).

METHODS

A retrospective study with PTC patients admitted in our Thyroid Cancer Unit, between January 1960 and December 2016 was performed. We reviewed 905 patient records with 275 having full information about VI on their pathological reports. Demographic and clinical variables were obtained, and univariate/multivariate analysis was performed in order to obtain potential predictive prognostic factors.

RESULTS

Fifty-one out 275 patients presented VI (18.5%; 95% CI 14.4-23.6%), these individuals had larger tumors (median 19 mm vs. 12 mm, P<0.001) with more frequent extraglandular invasion (54.0% vs. 17.1%, P<0.001), regional lymph nodes involvement (29.8% vs. 12.6%, P=0.003)and distant metastasis (10.9% vs. 1.9%, P=0.003) at diagnosis. VI was an independent predictor for regional lymph node and/or distant metastasis at diagnosis (OR 2.93 [IC 95% 1.16-7.41, P=0.008]). After a median follow-up time was 68.5 months patients with VI presented higher rates of local recurrence and lymph node metastasis recurrence.

CONCLUSIONS

In this study, the presence of VI in PTC is associated to higher rate of lymph node and distant metastasis at diagnosis. Its presence should be probably considered an adverse prognostic factor in PTC, perhaps justifying more aggressive therapeutic and follow-up approaches in such cases.

The American Thyroid Association risk classification of papillary thyroid cancer according to presurgery cytology

OBJECTIVE

To compare the American Thyroid Association (ATA) risk staging of histologically proven papillary thyroid cancer (PTC) in patients who received a presurgery cytologic result of either indeterminate thyroid nodules (ITNs, Bethesda III/IV) or suspicious for malignancy/malignant (TIR 4/5, Bethesda V/VI).

METHODS

Clinical, ultrasonographic, cytological data from patients with histologically diagnosed PTC were retrospectively collected.

RESULTS

Patients were stratified according to the preoperative fine-needle aspiration cytology into 2 groups: 51 ITNs (TIR3A/3B) and 118 suspicious/malignant (TIR 4/5). Male/female ratio, age, and presurgery TSH level were similar between the 2 groups. At ultrasound, TIR 4/5 nodules were significantly more frequently hypoechoic (P = .037), with irregular margins (P = .041), and with microcalcifications (P = .020) and were more frequently classified as high-risk according to the European Thyroid Imaging and Reporting Data System (EU-TIRADS; P = .021). At histology, the follicular PTC subtype was significantly more prevalent among ITNs while classical PTC subtype was more frequent in TIR 4/5 group (P = .002). In TIR 4/5 group, a higher rate of focal vascular invasion (P < .001) and neck lymph node metastasis (P = .028) was observed. Intermediate-risk category according to ATA was significantly more frequent in TIR 4/5 group while low-risk category was more frequently found among ITNs (P = .021), with a higher number of patients receiving radioiodine in TIR 4/5 group (P = .002). At multivariate logistic regression, having a TIR 4/5 cytology was associated with a significant risk of having a higher ATA risk classification as compared to ITN (OR 4.6 [95% CI 1.523-14.007], P = .007), independently from presurgery findings (nodule size at ultrasound, sex, age, and EU-TIRADS score).

CONCLUSIONS

Papillary thyroid cancers recorded among ITNs are likely less aggressive and are generally assessed as at lower risk according to ATA classification.

Impact of the number of intermediate risk factors on outcome of papillary thyroid cancer

PURPOSE

The 2015 American Thyroid Association risk stratification system (2015-RSS) is used to assess the tumor recurrence rate and guide the initial treatment. At the current moment, patients with one or multiple intermediate risk factors (IRF) have the same treatment. This study was conducted to evaluate the impact of the number of IRF characteristics on tumor persistence or recurrence rates.

METHODS

Patients with intermediate risk papillary thyroid cancer (PTC) were selected and analyzed, furthermore, they were divided into two subgroups, one with 1-2 IRF and another with ≥3 IRF. Those data were analyzed in relation to response to therapy at the end of the first year and in last appointment, time to reach non evidence of disease (NED) state and time in NED state.

RESULTS

A total of 257 patients were evaluated. Extrathyroidal invasion, vascular invasion, the total number of IRF and the subgroup of ≥3 IRF were associated with non-excellent response in last consultation; IRF lymph node metastasis was associated with non-excellent response in the first year and in last appointment and prolonged time in NED state; vascular invasion was associated with a shorter time in NED state; total number of IRF and aggressive histology were related to delay in the achievement of NED state.

CONCLUSIONS

Higher number of IRF was a predictive factor of non-excellent response in the last visit and was associated with longer time to reach the NED state. Those data suggest a benefit from closer follow-up and more intensive treatment in these patients.

Radio-iodine refractory thyroid cancer patients: a tailored follow-up based on clinicopathological features

OBJECTIVE

To report the experience of a single center for the selection of radioiodine-refractory (RAIR) thyroid cancer patients (RAIR-TC) who needed tyrosine kinase inhibitor (TKIs) treatment.

PATIENTS AND METHODS

We evaluated all features of 279 RAIR-TC patients both at the time of diagnosis and at the RAIR diagnosis.

RESULTS

Ninety-nine patients received indication to TKIs (Group A), while 180 remained under active surveillance (Group B). Group A had greater tumor size, more aggressive histotype, more frequent macroscopic extrathyroidal extension, distant metastases, advanced AJCC stage, and higher ATA risk of recurrence. After RAIR diagnosis, 93.9% of Group A had progression of disease (PD) after which TKIs' therapy was started. The remaining 6.1% of patients had a so severe disease at the time of RAIR diagnosis that TKIs' therapy was immediately started. Among Group B, 42.7% had up to 5 PD, but the majority underwent local treatments. The mean time from RAIR diagnosis to the first PD was shorter in Group A, and the evidence of PD within 25 months from RAIR diagnosis was associated with the decision to start TKIs.

CONCLUSIONS

According to our results, a more tailored follow-up should be applied to RAIR-TC patients. A too strict monitoring and too many imaging evaluations might be avoided in those with less-aggressive features and low rate of progression. Conversely, RAIR-TC with an advanced stage at diagnosis and a first PD occurring within 25 months from RAIR diagnosis would require a more stringent follow-up to avoid a late start of TKIs.

Immunohistochemistry in the pathologic diagnosis and management of thyroid neoplasms

The use of immunohistochemistry cannot be underestimated in the everyday practice of thyroid pathology. It has evolved over the years beyond the traditional confirmation of thyroid origin to molecular profiling and the prediction of clinical behavior. In addition, immunohistochemistry has served to implement changes in the current thyroid tumor classification scheme. It is prudent to perform a panel of immunostains, and the immunoprofile should be interpreted in light of the cytologic and architectural features. Immunohistochemistry can also be easily performed in the limited cellularity specimen preparation generated from thyroid fine-needle aspiration and core biopsy; however, it will require laboratory validation of immunostains specific to these preparations to avoid diagnostic pitfalls. This review discusses the application of immunohistochemistry in thyroid pathology with a focus on limited cellularity preparations.

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.

Deescalating Follow-up After Hemithyroidectomy for Patients With Low-risk Papillary Thyroid Microcarcinoma

Importance

Structural recurrent disease (RD) after surgical treatment of papillary thyroid microcarcinoma (mPTC) is rare. We hypothesized that the RD rate after hemithyroidectomy in low-risk patients with mPTC is low.

Objective

To assess the occurrence of RD in Dutch patients with mPTC who received surgical treatment according to the Dutch guidelines.

Design, Setting, and Participants

This nationwide retrospective cohort study included all patients who had undergone surgery with a diagnosis of cN0/cNx mPTC in the Netherlands between January 2000 and December 2020 were identified from the Netherlands Cancer Registry database. Patients with preoperative lymph node metastases were excluded. Two groups were defined: group 1 (incidental), mPTC in pathology report after thyroid surgery for another indication; and group 2 (nonincidental), patients with a preoperative highly suspect thyroid nodule (Bethesda 5) or proven mPTC (Bethesda 6). Dutch guidelines state that a hemithyroidectomy is sufficient in patients with unifocal, intrathyroidal mPTC.

Main Outcomes and Measures

The occurrence of RD in patients with low-risk mPTC after hemithyroidectomy.

Results

In total, 1636 patients with mPTC were included. Patients had a median (IQR) follow-up time of 71 (32-118) months. Median (IQR) age at time of diagnosis was 51 (41-61) years and 1292 (79.0%) were women. Overall, RD after initial treatment was seen in 25 patients (1.5%). The median (IQR) time to RD was 8.2 (3.6-16.5) months and 22 of the 25 (88%) patients developed RD within 2 years. Recurrent disease was not significantly different between both groups (group 1, n = 15 [1.3%]; group 2, n = 10 [2.1%]; difference, 0.8%; 95% CI, -0.5% to 2.5%). Of the 484 patients with nonincidental mPTC (group 2), 246 (50.8%) patients were treated with a hemithyroidectomy and follow-up in accordance with Dutch guidelines. Lymph node metastases were found in 1 of 246 (0.4%) patients after hemithyreoidectomy, and new mPTC in the contralateral thyroid was detected in 3 of 246 (1.2%) patients. Median (IQR) follow-up of this patient group was 37 (18-71) months. The 10-year probability of RD was 1.3% for patients without vascular invasion and 24.4% for patients with vascular invasion.

Conclusions and Relevance

This nationwide cohort study found that overall, RD after hemithyroidectomy for patients with low-risk mPTC was rare (<2%). Based on these results, it seems reasonable to deescalate follow-up of patients with low-risk mPTC without vascular invasion after hemithyroidectomy. From a health care perspective, deescalation of follow-up may contribute to increased sustainability and accessibility to health care, both large challenges for the future.

Molecular and clinical features of papillary thyroid cancer in adult patients with a non-classical phenotype

Purpose

Genotyping is fundamental in papillary thyroid cancer (PTC) and helps to enhance diagnosis and prognosis and determine appropriate treatments. The phenotype-genotype association in PTC was previously studied, with BRAF V600E characterizing classic PTC and tall-cell PTC and RAS mutations characterizing follicular-variant PTC. In clinic, some non-classical histological subtypes of PTC were also identified, however, their genotype remains unclear. In this study, we collected samples of these non-classical PTC after the exclusion of classic phenotypes and examined their phenotypes, genotype and the relationship between phenotype and genotype.

Methods

We screened out non-classical PTC by excluding classical PTC from 1,059 different thyroid samples, and a total of 24 cases was obtained and described from the morphological features, which is rare in differentiated PTC. DNA/RNA sequencing was performed using 18 available samples to describe the genetic features.

Results

PTC with the non-classical phenotype were characterized cuboidal to low columnar tumor cells with subtle nuclear features of PTC and without discernible nuclear elongation, concurrently with dense microfollicles, delicate papillae or solid nodules with delicate fibrovascular cores. They were associated with lymphatic vessel invasion (P<0.001) but not with a worse prognosis (P=0.791). Gene fusions were identified in 14 of 18 (77.8%) cases, including eight fusions of NTRK and six fusions of RET. The high percentage of fusions in this papillary thyroid cancer subgroup suggested a correlation of gene fusions with the phenotype that does not belong to the BRAF V600E-mutant or RAS-mutant group.

Conclusions

Our study retrospectively screened a large cohort of different thyroid tissue samples, and presented the histopathological and genetic features of a non-classical phenotype of PTC from 24 patients. It may contribute to diagnose in PTC, and patients of these non-classical phenotype may benefit from targeted therapy, compared to a natural patient cohort without selection.

Clinical significance of extrathyroidal extension to major vessels in papillary thyroid carcinoma

PURPOSE

Gross extrathyroidal extension (gETE) into major vessel is considered the most advanced stage of the locally advanced papillary thyroid cancer (PTC). Surgical intervention may not benefit some patients at this disease stage or even result in intraoperative death due to massive hemorrhage; however, it is still considered an effective strategy for most cases. The lack of description for this challenging invasion in PTC warrants detailed characterization of its pattern, risk factors, optimal surgical method, and prognostic value.

METHODS

In total, 3127 patients diagnosed as having PTC were enrolled and categorized into two the following groups, namely the major vessel invasion (MVI) group (n = 30) and the control group (n = 3097). Data regarding clinicopathological and demographic characteristics, vascular invasion sites, postoperative complications, locoregional recurrence, distant metastasis, and surgical strategies were collected. Predictive disease-free survival (DFS) was also compared between the two groups.

RESULTS

MVI was independently associated with invasion of the esophageal extension, age < 55 years, tumor size > 1 cm, lateral lymph node metastasis, and distant metastasis (P = 0.00; P = 0.01; 0.05; P = 0.00; P = 0.00, respectively). The difference in the predictive DFS between the two groups was significant (P = 0.00), and the difference remained significant even in patients with ETE when compared with patients without ETE (P = 0.00). Additionally, predictive DFS did not differ significantly between patients who received vessel repairment and those who received vessel resection (P = 0.28).

CONCLUSIONS

This study first characterized the gross MVI pattern exhibited by PTC and the risk factors for MVI. Additionally, it demonstrated the DFS of patients with PTC. Extensive gross MVI significantly worsened the biological characteristics of PTC. Regardless of the high risk and difficulty of the operation, patients still benefited from the surgical intervention, and vessel repairment may be the optimal surgical strategy.

Construction of a predictive model of abdominal lymph node metastasis in thoracic esophageal squamous cell carcinoma and preliminary analysis of its effect on target for postoperative radiotherapy

Purpose

To investigate the influencing factors of abdominal lymph node metastasis in thoracic esophageal squamous cell carcinoma (TESCC), and to construct its predictive model, in order to analyze the targets for postoperative radiotherapy.

Methods and materials

From January 2008 to December 2014, the clinicopathological data of 479 patients who underwent radical resection for esophageal cancer in the Fourth Hospital of Hebei Medical University were collected and retrospectively analyzed. The influencing factors of postoperative abdominal lymph node metastasis were analyzed, and a predictive model was constructed based on their independent influencing factors. Receiver operating characteristic (ROC) curve was utilized to analyze the predictive value of this model; in the meantime, the postoperative locoregional recurrence (LRR) of this group was analyzed.

Results

The postoperative pathology of all patients showed that the lymph node metastasis rate (LNR) was 39.7%, of which the abdominal lymph node metastasis rate was 22.0%. Logistic regression analysis revealed that the patient's lesion location, pN stage, vascular invasion, LND and mediastinal lymph node metastasis were independent risk factors for the positive rate of abdominal lymph nodes after surgery (P = 0.000, 0.000, 0.033, 0.000, 0.000). The probability of abdominal lymph node metastasis was Y = ex/(1 + ex), and X = -5.502 + 1.569 × lesion location + 4.269 × pN stage + 1.890 × vascular invasion + 1.950 × LND-4.248 × mediastinal lymph node metastasis. The area under the ROC curve (AUC) of this model in predicting abdominal lymph node metastasis was 0.962 (95% CI, 0.946-0.977). This mathematical model had a high predictive value for the occurrence of abdominal lymph node metastasis (P = 0.000), and the sensitivity and specificity of prediction were 94.6% and 88.3% respectively. The overall survival rate was significantly higher (X2 = 29.178, P = 0.000), while abdominal lymph node recurrence rate was lower in patients with negative abdominal lymph nodes than in those with negative lymph nodes (1.4%&7.7%, X2 = 12.254, P = 0.000).

Conclusion

The lesion location, pN stage, vascular invasion, LND and mediastinal lymph node metastasis are independent influencing factors of abdominal lymph node metastasis in patients with TESCC. The mathematical model constructed by these indicators can accurately predict abdominal lymph node metastasis, which can help clinicians to choose the targets for postoperative radiotherapy.

Completion thyroidectomy may not be required for papillary thyroid carcinoma with multifocality, lymphovascular invasion, extrathyroidal extension to the strap muscles, or five or more central lymph node micrometastasis

OBJECTIVE

This study aimed to determine whether completion thyroidectomy is necessary based on long-term follow-up oncological results according to various clinical and pathological characteristics of patients with papillary thyroid carcinoma (PTC) who underwent lobectomy.

MATERIALS AND METHODS

We enrolled 1815 patients with PTC who underwent thyroid lobectomy from January 2003 to December 2014. Various clinical and pathological characteristics were reviewed retrospectively, and clinicopathologic characteristics and recurrence rates were analyzed.

RESULTS

Eighty-two (4.5%) patients showed locoregional recurrence during the average 10.2-year follow-up period. There was no significant difference in tumor size, multifocality, lymphovascular invasion (LVI), microscopic or strap muscle-extrathyroidal extension, and central neck lymph node (LN) micrometastasis between the recurrence and non-recurrence groups. The gross strap muscle-extrathyroidal extension group was associated with older age (p < 0.001), larger tumor size (p < 0.001), more capsular invasion (p < 0.001), and more LVI (p < 0.001) than the negative extrathyroidal extension group; there was no significant difference in recurrence between the groups (p = 0.096). Patients with five or more central LN micrometastases were associated with younger age (p = 0.006), larger tumor size (p = 0.04), and presence of LVI (p = 0.033) than patients with less than five central LN metastases; there was no significant difference in recurrence between the groups (p = 0.867). All patients with recurrence were cured through reoperation after recurrence was confirmed.

CONCLUSION

After thyroid lobectomy, PTC patients with multifocality, LVI, extrathyroidal extension to the strap muscles, or five or more central LN micrometastases may not require immediate completion thyroidectomy.

Papillary Thyroid Cancer Prognosis: An Evolving Field

Simple Summary

Over the last couple of decades, the prognostic stratification systems of differentiated thyroid cancer (DTC) patients have been revised several times in an attempt to achieve a tailored clinical management reflecting the single patients’ needs. Such revisions are likely to continue in the near future, since the prognostic value of a number of promising clinicopathological features and new molecular biomarkers are being evaluated. Here, we will review the current staging systems of thyroid cancer patients and discuss the most relevant clinicopathological parameters and new molecular markers that are potentially capable of refining the prognosis.

Abstract

Over the last few years, a great advance has been made in the comprehension of the molecular pathogenesis underlying thyroid cancer progression, particularly for the papillary thyroid cancer (PTC), which represents the most common thyroid malignancy. Putative cancer driver mutations have been identified in more than 98% of PTC, and a new PTC classification into molecular subtypes has been proposed in order to resolve clinical uncertainties still present in the clinical management of patients. Additionally, the prognostic stratification systems have been profoundly modified over the last decade, with a view to refine patients’ staging and being able to choose a clinical approach tailored on single patient’s needs. Here, we will briefly discuss the recent changes in the clinical management of thyroid nodules, and review the current staging systems of thyroid cancer patients by analyzing promising clinicopathological features (i.e., gender, thyroid auto-immunity, multifocality, PTC histological variants, and vascular invasion) as well as new molecular markers (i.e., BRAF/TERT promoter mutations, miRNAs, and components of the plasminogen activating system) potentially capable of ameliorating the prognosis of PTC patients.

Challenges in the Correct Assessment of a Case of Aggressive Thyroid Carcinoma with Synchronous Breast Cancer: A Case Report and Review of the Literature of Essential Role of Radiopharmaceuticals

Thyroid carcinoma represents a complex pathology that can still be considered a medical challenge, despite having a better prognosis and life expectancy than most other neoplasms; also the scenario of multiple malignancies involving thyroid cancer is nowadays a common reality.

MATERIALS AND METHODS

We reviewed the literature regarding the aggressive presentation of synchronous thyroid and breast cancer. In the current paper, we report the case of a 59 years-old woman, diagnosed with invasive ductal breast carcinoma and papillary thyroid carcinoma, presenting a natural history of both aggressive synchronous tumors. At the moment of hospitalization, the diagnosis was breast carcinoma with multiple secondary lesions, suggestive of lung and bone metastases, and nodular goiter.

RESULTS

Searching the literature in PUBMED with the terms "thyroid carcinoma and synchronous breast carcinoma, we found 86 studies; introducing the term "aggressive," the result included 4 studies, among which, none showed to be relevant to the terms aggressive and synchronous. A similar search was done in SCOPUS finding 92 documents and after introducing the term aggressive, the number of papers was 8, none including the literature on synchronous aggressive metastatic thyroid and breast carcinoma. A majority of imaging diagnostic tools were used in this particular medical case in order to ensure the best potential outcome. The final diagnosis was papillary thyroid carcinoma with lung and unusual multiple bone metastases and synchronous invasive ductal breast carcinoma with subcutaneous metastases.

CONCLUSION

The case illustrates the challenges in the correct assessment of oncologic patients, despite the advances in medical imaging and technologies and underlines the essential role of nuclear medicine procedures in the diagnostic and therapy protocols.

Lymphovascular invasion of papillary thyroid carcinoma revisited in the era of active surveillance

INTRODUCTION

Lymphovascular invasion (LVI) is associated with disease recurrence and compromised survival in patients with thyroid cancer. Nonetheless, LVI is not identifiable on preoperative ultrasound or cytologic assessment. We aimed to explore the clinicopathological features associated with LVI.

PATIENTS AND METHODS

We conducted a retrospective review of our prospectively maintained database from 2009 to 2018. Multivariate analyses were performed to determine the associations between clinicopathological parameters and LVI. Generalized additive models were used to examine the nonlinear relationship between continuous variables and LVI.

RESULTS

A total of 795 patients were included in the analysis, and 174 (22%) had LVI. Patients' age (odds ratio [OR] = 0.982), tumor size (OR = 1.466), clinical lymphadenopathy (OR = 6.975), and advanced extrathyroidal extension (OR = 2.938) were independently associated with LVI. In the subset analysis of 198 patients with available genetic information, tumor size (OR = 1.599), clinical lymph node metastasis (OR = 3.657), and TERT promoter mutation (OR = 4.726) were predictive of LVI. Among 573 patients who had no clinical lymphadenopathy or advanced extrathyroidal extension, tumor size was the only predictor of LVI. Tumor size >1.5 cm had an increased risk of LVI based on the generalized additive model plot and receiver operating characteristic curve analysis.

CONCLUSION

Tumor size is positively associated with the risk of LVI in papillary thyroid cancer. To avoid delayed treatment in patients with LVI, a tumor size of 1.5 cm may be considered as the safe upper limit for active surveillance.

Papillary and Follicular Thyroid Cancer in children and adolescents: Current approach and future directions

An increasing number of children are diagnosed with differentiated thyroid cancer. With an excellent prognosis for the majority of pediatric patients, the goal of therapy is to optimize outcome while reducing complications. Increased knowledge of the somatic, oncogenic driver mutations provides opportunities to improve the accuracy of diagnosis, to stratify surgery, and to treat patients with morbidly invasive or refractory disease. Treatment complications can be reduced by referral to regional, high-volume pediatric thyroid centers.

Invasion in thyroid cancer: Controversies and best practices

Invasion is a key feature of malignancy and an important element in the classification, risk-stratification, and staging of thyroid cancers. However, the histopathologic criteria for tumor capsular invasion, angioinvasion, and extrathyroidal extension (ETE) have varied among pathologists, both in practice as well as in studies assessing the clinical significance of these findings. In this review, we provide historic context for the controversies surrounding the definition of invasion in thyroid neoplasms and highlight recent efforts to standardize how pathologists report capsular invasion, angioinvasion, and ETE. We offer practical suggestions for distinguishing invasion from its mimics and provide an algorithmic approach for classifying thyroid tumors based on integration of tumor invasiveness, nuclear atypia, and architectural pattern.

The surgical management of locally advanced well-differentiated thyroid carcinoma: changes over the years according to the AJCC 8th edition Cancer Staging Manual

Background

Well-differentiated thyroid carcinoma is defined as locally advanced in the presence of an extra thyroid extension, e.g., when the surrounding structures such as the trachea, larynx, esophagus and main blood vessels are invaded by cancer. The 8th edition AJCC Cancer Staging Manual states that this is the main characteristic to evaluate for the staging and consequently for the prognosis in patients over 55 years old.

Main body

Distinguishing different forms of locally advanced thyroid cancer is essential, and the various anatomical structures and the clinical and therapeutic consequences must be taken into account. An accurate diagnosis of the organs invaded by thyroid cancer is necessary for the planning of surgical treatment, and both aspects are crucial to improving the patients’ survival. Patients affected by thyroid cancer with extra thyroid extension have a poor prognosis and the removal of the entire neoplasm represents a key factor for better disease-free survival.

Conclusions

We discuss the changes introduced by the 8th edition AJCC Cancer Staging Manual, in terms of the diagnostic and surgical management of extra thyroid extension, in patients affected by papillary and follicular thyroid cancer.

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.