Deaths related to differentiated thyroid cancer: a rare but real event

Profile of MicroRNAs Associated with Death Due to Disease Progression in Metastatic Papillary Thyroid Carcinoma Patients

Papillary thyroid carcinoma (PTC) is the most common neoplasm of the endocrine system and has an excellent long-term prognosis, with low rates of distant metastatic disease. Although infrequent, there are cases of deaths directly related to PTC, especially in patients with metastatic disease, and the factors that could be associated with this unfavorable outcome remain a major challenge in clinical practice. Recently, research into genetic factors associated with PTC has gained ground, especially mutations in the TERT promoter and BRAF gene. However, the role of microRNAs remains poorly studied, especially in those patients who have an unfavorable outcome at follow-up. This paper aims to evaluate molecular markers related to the different pathological processes of PTC, as well as the histological characteristics of the neoplasm, and to compare this profile with prognosis and death from the disease using an analysis of patients treated for metastatic disease in a single tertiary cancer center. Evaluation of microRNA expression in paraffin-embedded tumor specimens was carried out by quantitative PCR using the TaqMan^® Low Density Array (TLDA) system. Metastatic patients who died from progression of PTC had higher expressions of miR-101-3p, miR-17-5p, and miR-191-5p when compared to patients with stable metastatic disease. These findings are of great importance but should be considered as preliminary because of the small sample.

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.

Using 18F-FDG-PET/CT Metrics to Predict Survival in Ra-Dio-Iodine Refractory Thyroid Cancers

Radio-iodine refractory (RAI-R) differentiated thyroid cancer (DTC) is a rare disease with a poor prognosis and limited therapeutic resources. Therefore, identifying prognostic factors is essential in order to select patients who could benefit from an early start of treatment. The aim of this study is to identify positron emission tomography with 18F-fluorodeoxyglucose with integrated computed tomography (18F-FDG-PET/CT) parameters to predict overall survival (OS) in patients with RAI-R DTC. In this single-center retrospective study, we analyze the 18F-FDG-PET/CT parameters of 34 patients with RAI-R DTC between April 2007 and December 2019. The parameters collected are MTV, SUVmax and progression for each site of metastasis (neck, mediastinum, lungs, liver, bone) and total sites. ROC curves, Kaplan–Meier survival analysis curves, univariate and multivariate Cox analyses determine prognostic factors for 1-year and 5-year OS. The parameters for mediastinum, liver and total sites are significantly associated with worse 1-year and 5-year OS by both ROC curve analysis and Kaplan–Meier survival analysis. Univariate Cox analysis confirms significance of mediastinum SUVmax (HR 1.08; 95% CI [1.02–1.15]; p = 0.014) and total SUVmax (HR 1.06; 95% CI [1–1.12]; p = 0.042) for worse 1-year OS; of mediastinum SUVmax (HR 1.06; 95% CI [1.02–1.10]; p = 0.003), liver SUVmax (HR 1.04; 95% CI [1.01–1.08]; p = 0.02), liver MTV (HR 2.56; 95% CI [1.13–5.82]; p = 0.025), overall SUVmax (HR 1.05; 95% CI [1.02–1.08]; p = 0.001) and total MTV (HR 1.41; 95% CI [1.07–1.86]; p = 0.016) for worse 5-year OS. Multivariate Cox analysis confirms a significant association between liver MTV (HR 1.02; 95% CI [1–1.04]; p = 0.042) and decrease 1-year OS. In this study, we demonstrate that in RAI-R DTC, 18F-FDG-PET/CT parameters of the mediastinum, liver and overall tumor burden were prognostic factors of poor 1-year and 5-year OS. Identifying these criteria could allow early therapeutic intervention in order to improve patients’ survival.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Wnt3a but not CDX-2 expression is associated with differentiated thyroid cancer

OBJECTIVE

Thyroid neoplasm incidence has increased worldwide, mostly due to the advancements in medical imaging and screening rates. The aberrant Wnt/β-catenin pathway has been identified as a key mechanism, and it has also been related to the metastatic activity of differentiated thyroid cancer. We aimed to verify the difference in the expression of Wnt3a, a canonical activator of the β-catenin signaling, and CDX-2, a transcription factor upregulated by Wnt/β-catenin pathway, in multinodular goiter and differentiated thyroid cancer and to determine their prognostic value.

METHODS

We included 194 thyroid tissue surgical specimen and their clinicopathological data: study group (differentiated thyroid cancer, n=154) and control group (multinodular goiter, n=40). Immunohistochemistry (IHC) was performed on formalin-fixed, paraffin-embedded tissue by the primary antibodies Wnt3a and CDX-2.

RESULTS

High Wnt3a expression was significantly associated with differentiated thyroid cancer (p=0.031). CDX-2 was negative in all differentiated thyroid cancer cases (100%) and also in multinodular goiter. Wnt3a expression was significantly associated with tumors ≤20 mm (p=0.044) and with the absence of capsule invasion (p=0.031). The multivariate analyses suggested that older age (≥55), independent of capsular invasion and tumor size, was an independent prognostic factor for Wnt3a expression (p=0.058).

CONCLUSIONS

Wnt3a expression but not CDX-2 is correlated with differentiated thyroid cancer samples in comparison to multinodular goiter. Although its prognostic value was limited to tumor size and capsule invasion, a combined model in a panel of immune markers can add accuracy in the classification of challenging thyroid follicular-derived lesions.

Identification of Prognostic Biomarkers in Papillary Thyroid Cancer and Developing Non-Invasive Diagnostic Models Through Integrated Bioinformatics Analysis

BACKGROUND

Papillary thyroid cancer (PTC) is the most frequent subtype of thyroid carcinoma, mainly detected in patients with benign thyroid nodules (BTN). Due to the invasiveness of accurate diagnostic tests, there is a need to discover applicable biomarkers for PTC. So, in this study, we aimed to identify the genes associated with prognosis in PTC. Besides, we performed a machine learning tool to develop a non-invasive diagnostic approach for PTC.

METHODS

For the study purposes, the miRNA dataset GSE130512 was downloaded from the GEO database and then analyzed to identify the common differentially expressed miRNAs in patients with non-metastatic PTC (nm-PTC)/metastatic PTC (m-PTC) compared with BTNs. The SVM was also applied to differentiate patients with PTC from those patients with BTN using the common DEMs. A protein-protein interaction network was also constructed based on the targets of the common DEMs. Next, functional analysis was performed, the hub genes were determined, and survival analysis was then executed.

RESULTS

A total of three common miRNAs were found to be differentially expressed among patients with nm-PTC/m-PTC compared with BTNs. In addition, it was established that the autophagosome maturation, ciliary basal body-plasma membrane docking, antigen processing as ubiquitination & proteasome degradation, and class I MHC mediated antigen processing & presentation are associated with the pathogenesis of PTC. Furthermore, it was illustrated that RPS6KB1, CCNT1, SP1, and CHD4 might serve as new potential biomarkers for PTC prognosis.

CONCLUSION

RPS6KB1, CCNT1, SP1, and CHD4 may be considered new potential biomarkers used for prognostic aims in PTC. However, performing validation tests is inevitable in the future.

Percutaneous thermal ablation of lung metastases from thyroid carcinomas. A retrospective multicenter study of 107 nodules. On behalf of the TUTHYREF network

PURPOSE

To determine efficacy and safety of thermal ablation (TA) for the local treatment of lung metastases of thyroid cancer.

METHODS

We retrospectively studied 47 patients from 10 centers treated by TA (radiofrequency, microwaves, and cryoablation) over 10 years. The endpoints were overall survival (OS), local efficacy, complications (CTCAE classification), and factors associated with survival. OS curves after first TA were built using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

A total of 107 lung metastases during 75 sessions were treated by radiofrequency (n = 56), microwaves (n = 9), and cryoablation (n = 10). Median follow-up time after TA was 5.2 years (0.2-13.3). OS was 93% at 2 years (95% confidence interval (CI): 86-94) and 79% at 3 years (95% CI: 66-91). On univariate and multivariate analysis with a Cox model, histology was the only significant factor for OS. OS at 3 years was 94% for follicular, oncocytic, or papillary follicular variant carcinomas, compared to 59% for papillary, medullary, insular or anaplastic carcinomas (P = 0.0001). The local control rate was 98.1% at 1 year and 94.8% at 2, 3, 4, and 5 years. Morbidity was low with no major complications (grade 4 and 5 CTCAE) and no complications in 29 of 75 sessions (38.7%).

CONCLUSIONS

TA is a useful, safe and effective option for local treatment of lung metastases from thyroid carcinoma. Prolonged OS was obtained, especially for lung metastases from follicular, oncocytic, or papillary follicular variant carcinomas. Achieving disease control with TA delays the need for systemic treatment.

Thyroid cancer overdiagnosis and overtreatment: a cross- sectional study at a thyroid cancer referral center in Ecuador

Background

In contrast to the rapid increase in thyroid cancer incidence, the mortality has remained low and stable over the last decades. In Ecuador, however, thyroid cancer mortality has increased. The objective of this study is to determine possible drivers of high rates of thyroid cancer mortality, through a cross-sectional analysis of all patients attending a thyroid cancer referral center in Ecuador.

Methods

From June 2014 to December 2017, a cross-sectional study was conducted at the Hospital de Especialidades Eugenio Espejo, a regional reference public hospital for endocrine neoplasia in adults in Quito, Ecuador. We identified the mechanism of detection, histopathology and treatment modalities from a patient interview and review of clinical records.

Results

Among 452 patients, 74.8% were young adults and 94.2% (426) were female. 13.7% had a family history of thyroid cancer, and patients’ median tumor size was 2 cm. The incidental finding was 54.2% whereas 45.8% was non-incidental. Thyroid cancer histology reported that 93.3% had papillary thyroid cancer (PTC), 2.7% follicular, 1.5% Hurtle cells, 1.6% medullary, 0.7% poor differentiated, and 0.2% anaplastic carcinoma. The mean MACIS (metastasis, age, completeness, invasion, and size) score was 4.95 (CI 4.15–5.95) with 76.2% of the thyroid cancer patients having MACIS score less than or equal to 6. The very low and low risk of recurrence was 18.1% (79) and 62% (271) respectively. An analysis of 319 patients with non-metastatic thyroid cancer showed that 10.7% (34) of patients had surgical complications. Moreover, around 62.5% (80 from 128 patients with thyroglobulin laboratory results) of TC patients had a stimulated-thyroglobulin value equal or higher than 2 ng/ml. Overall, a poor surgical outcome was present in 35.1% (112) patients. Out of 436 patients with differentiated thyroid carcinoma, 86% (375) received radioactive iodine.

Conclusion

Thyroid cancer histological characteristics and method of diagnosis are like those described in other reports without any evidence of the high frequency of aggressive thyroid cancer histology. However, we observed evidence of overtreatment and poor surgical outcomes that demand additional studies to understand their association with thyroid cancer mortality in Ecuador.

Upregulation of miR-421 predicts poor prognosis and promotes proliferation, migration, and invasion of papillary thyroid cancer cells

BACKGROUND

Papillary thyroid carcinoma (PTC) represents the most frequent subtype of thyroid cancer (TC) with poor prognosis mainly due to the severe invasion and metastasis. As an oncogene, microRNA-421 (miR-421) is involved in the development of various cancers. This study was to investigate the clinical significance of miR-421 in PTC and its effects on the biological function of PTC cells.

METHODS

The expression level of miR-421 in all tissues and PTC cell lines was measured by quantitative real-time polymerase chain reaction (qRT-PCR). Subsequently, the relationship between miR-421 expression and the clinicopathological feature was detected by chi-square analysis in 106 patients with PTC. In addition, Kaplan-Meier and multivariate Cox regression analysis were used to detect the survival time and the prognostic value of miR-421. Finally, the regulatory effect of miR-421 on the proliferation, migration, and invasion ability of PTC cells was detected by Cell Counting Kit (CCK-8) and Transwell assay.

RESULTS

Compared with all control groups, the expression of miR-421 was significantly increased in 106 patients tissues and PTC cell lines (p < 0.001). In addition, patients with miR-421 upregulated in PTC showed more positive lymph node metastasis (p = 0.011), positive tumor infiltration (p = 0.031), and TNM stage III/IV (p = 0.019), and when miR-421 expression level was elevated, the survival rate of PTC patients was poor (log-rank test, p = 0.023). Furthermore, miR-421 might be an independent prognostic biomarker for PTC (hazard ratio [HR] = 3.172, 95% CI = 1.071-9.393, p = 0.037). Finally, increased levels of miR-421 can significantly promote cell proliferation, migration, and invasion (p < 0.01).

CONCLUSION

miR-421 is a novel oncogene of PTC and is a valuable prognostic biomarker. Moreover, the upregulation of miR-421 enhances the proliferation, migration, and invasion of PTC cells.

Prognostic Factors in Patients with Differentiated Thyroid Cancers Metastatic to the Cervical Spine

OBJECTIVES

The spine is the most common site of bone metastases in differentiated thyroid cancer (DTC). The role of surgery in the management of cervical spine (C-spine) metastases (CSpM) has not been adequately explored.

METHODS

This is a retrospective cohort study at a tertiary referral center from 2002 to 2018. Inclusion criteria were pathologic diagnosis of DTC and imaging/pathologic diagnosis of CSpM. Statistical analysis utilized t tests for continuous variables and χ² tests for categorical variables. Survival analysis was conducted using Kaplan-Meier curves with univariate and multivariate Cox regressions.

RESULTS

Fifty patients with DTC and CSpM were identified. Of those, 16 underwent surgical resection of the C-spine, whereas 34 did not. The most common presenting symptom was neck pain (N = 37, 74%). Patients in the surgery group were more likely to report a subjective improvement of symptoms (P < .01) and to have local (P < .01) and systemic (P = .04) disease control. Five-year overall survival was 44.7% for the surgery group (95% confidence interval [CI]: 17.1-69.3) and 11.1% (95% CI: 2.1-28.8) for the nonsurgery group (P = .01). The strongest risk factor for improved overall survival after C-spine metastasis was local disease control at the C-spine (multivariate hazard ratio [HR] = 0.32, 95% CI: 0.12-0.85, P = .02). Surgical intervention was significantly associated with improved survival on both univariate (HR = 0. 35, 95% CI: 0.15-0.82, P = .02) and multivariate (HR = 0.37, 95% CI: 0.14-0.98, P = .04) analysis.

CONCLUSION

Surgical management of CSpM in differentiated thyroid cancers is associated with significantly improved local disease control and overall survival. Referral to spine surgeons should be considered after diagnosis.

LEVEL OF EVIDENCE

IV. Laryngoscope, 131:E1741-E1747, 2021.

Unusual metastases from differentiated thyroid carcinoma: analysis of 36 cases

PURPOSE

Metastases of differentiated thyroid cancer (DTC) in sites different from lungs and bone are unusual (UM); their impact in management and prognosis remains unknown. Our aim was to evaluate the prevalence of UM, to describe their characteristics and to analyze their impact in disease outcome and mortality.

METHODS

We retrospectively reviewed the file records from 8 different centers. Those patients with DTC and UM were included. UM were diagnosed by: (i) biopsy/cytology and/or (ii) radioiodine (RAI) uptake associated to elevated thyroglobulin (Tg) levels and/or c) presence of one or more structural lesion/s with 18-FDG uptake in the PET/CT scan and elevated Tg levels.

RESULTS

Thirty-six (0.9%) out of a total of 3982 DTC patients were diagnosed with UM; 75% had papillary histology. The most frequent localization was central nervous system (CNS, 31%). UM were metachronous in 75%, symptomatic in 55.6% and fulfilled RAI-refractoriness criteria in 77.8% of cases. Metastatic lesions in lung/bone and/or locoregional disease were present in 34 cases (94.4%). Diagnosis of UM changed the therapeutic approach in 72.2% of patients. After a median follow up of 13 months, 21 (58.3%) patients died from DTC related causes. In 8 of them CNS progression was the immediate cause of death.

CONCLUSIONS

Prevalence of UM was low; they were frequently metachronic and RAI-refractory. Although UM were found in patients with widespread disease, their diagnosis usually led to changes in therapy. UM were associated with poor prognosis and high frequency of disease-specific mortality.

Association of the Cumulative Dose of Radioactive Iodine Therapy With Overall Survival in Patients With Differentiated Thyroid Cancer and Pulmonary Metastases

Purpose: The optimal cumulative dose of radioactive iodine therapy (RAIT) for patients with differentiated thyroid cancer (DTC) and pulmonary metastases (PM) is not known, therefore we evaluated the association between the cumulative dose of RAIT and overall survival (OS). Methods: A total of 202 patients with DTC and PM who underwent thyroidectomy and RAIT were analyzed in this study. The median cumulative dose of RAIT was 530 mCi. OS was compared with an age- and sex-matched general population from China to assess relative survival. Multivariable proportional hazards model smoothing by penalized spline was applied to identify independent predictors and examine the adjusted non-linear association of cumulative dose of RAIT and patient age with mortality. Results: The observed survival and relative survival at 10 years was 54.96 and 60.81%, respectively, with the standardized mortality ratio being 5.34. The cumulative dose of RAIT was associated with mortality in a dose-dependent fashion without an apparent cutoff point after adjustment of other variables. A linear but moderate association was found in the dose of 300 to 1,000 mCi. Cumulative dose of RAIT, patient age, diameter of pulmonary metastases, and extrapulmonary metastases were identified as independent predictors for OS. The increasing patient age was associated with mortality in a non-linear pattern, with the optimal threshold being 40 years. With advancing age, the risk of death increases rapidly in patients aged 40 years and younger, but slowly in patients over 40 years. Conclusions: RAIT should be assigned to RAI-avid patients until disease has been controlled or RAIT becomes refractory after consideration of the potential long-term side-effects. Patient age was associated with OS in a non-linear pattern, with a threshold at 40 years. Consideration of age as a binary variable could elucidate a more accurate prognosis in such patients.

Effects of different extracts of curcumin on TPC1 papillary thyroid cancer cell line

BACKGROUND

The thyroid gland is one of the largest endocrine glands in the body. The vast majority of TCs (> 90%) originate from follicular cells and are defined as differentiated thyroid cancers (DTC) and the two histological subtypes are the papillary TC with its variants and the follicular TC. Curcumin possesses a wide variety of biological functions, and thanks to its properties, it has gained considerable attention due to its profound medicinal values (Prasad, Gupta, Tyagi, and Aggarwal, Biotechnol Adv 32:1053-1064, 2014). We have undertaken the present work in order to define the possible role of curcumin in modulating the genetic expression of cell markers and to understand the effectiveness of this nutraceutical in modulating the regression of cancer phenotype.

METHODS

As a template we used the TPC-1 cells treated with the different extracts of turmeric, and examined the levels of expression of different markers (proliferative, inflammatory, antioxidant, apoptotic).

RESULTS

Treatment with the three different curcumin extracts displays anti-inflammatory, antioxidant properties and it is able to influence cell cycle with slightly different effects upon the extracts. Furthermore curcumin is able to influence cell metabolic activity vitality.

CONCLUSIONS

In conclusion curcumin has the potential to be developed as a safe therapeutic but further studies are needed to verify its antitumor ability in vivo.