Prognostic influence of clinical and pathological factors in medullary thyroid carcinoma: a study of 53 cases

Male gender as a poor prognostic factor in medullary thyroid carcinoma: behavior or biological difference?

BACKGROUND

Due to the low incidence and heterogeneous behavior of medullary thyroid carcinoma (MTC), its prognostic factors are still not well stablished. While several large studies have investigated the impact of gender in differentiated thyroid cancer (DTC), its role in MTC outcomes remains controversial. We aim to identify MTC prognostic features, specially focusing on the role of gender.

METHODS

The present study is a retrospective analysis of 76 patients diagnosed with MTC between 1984 and 2018 at a Portuguese Comprehensive Cancer Center.

RESULTS

Patients presented a median age at diagnosis of 49 years and multiple endocrine neoplasia type 2 (MEN2) was identified in 27.6% of them, with those individuals being significantly younger (P<0.001). Most cases were diagnosed as stage IV disease (46.9%), except for the subgroup detected through presymptomatic genetic screening (55.6% at stage I). The 5- and 10-year survival rates were 87.6% and 75.6%, respectively. Univariate analysis identified male gender (P=0.010), age ≥45 years (P=0.007), presence of distant metastasis at diagnosis (P<0.01), capsule invasion (P=0.004), extrathyroidal invasion (P=0.003) and absence of biochemical cure after surgery (P=0.042) as having a negative impact on prognosis. On multivariate analysis, male gender (P=0.046) remained an independent predictor of mortality, as well as an older age (P<0.001) and the presence of distant metastases (P=0.012).

CONCLUSIONS

Male gender independently predicted worse survival in MTC patients even after adjusting for age and disease stage. The few older studies on the topic pointed to a behavioral explanation regarding medical care seeking patterns by men, but our study and newer genetic and basic-science oriented publications raise the possibility of a true biological difference between genders in the tumorigenesis of MTC that should me further investigated.

Grading of medullary thyroid carcinoma on the basis of tumor necrosis and high mitotic rate is an independent predictor of poor outcome

Medullary thyroid carcinoma (MTC) is a rare nonfollicular cell-derived tumor. A robust grading system may help better stratify patients at risk for recurrence and death from disease. In total, 144 MTC between 1988 and 2018 were subjected to a detailed histopathologic evaluation. Clinical and pathologic data were correlated with disease specific survival (DSS), local recurrence free survival (LRFS)  and distant metastasis free survival (DMFS). Median age was 53 years (range: 3-88). Median tumor size was 1.8 cm (range: 0.2-11). Lymph node metastases were present in 84 (58%) cases while distant metastases at presentation were found in 9 (6%) patients. Seven (5%) had ≥5 mitoses/10 HPFs. Tumor necrosis was present in 30 cases (20%) while lymphovascular invasion occurred in 41 (28%) of tumors. Extra-thyroidal extension was found in 44 (31%) and positive margins were seen in 19 (14%). There was a strong correlation between increasing tumor size and tumor necrosis (p < 0.001). Median follow up was 39 months. In univariate analysis, male gender, higher American Joint Committee on Cancer (AJCC) stage group, larger tumor size, tumor necrosis, high mitotic index (≥5/10 HPF), nodal status, size of largest nodal metastasis, and elevated postoperative serum calcitonin predicted worse DSS, LRFS, and DMFS (p < 0.05). Extra-thyroidal extension correlated with DSS and DMFS while positive margins and distant metastasis at presentation imparted worse DSS (p < 0.05). In multivariate analysis, tumor necrosis and mitotic activity (5 mitosis/10 HPFs as the cutoff) were the only independent predictors for DSS (p = 0.008 and 0.026, respectively). Tumor necrosis was the sole independent prognostic factor for LRFS and DMFS (p = 0.001 and 0.003, respectively). The presence of tumor necrosis and high mitotic rate are powerful independent prognostic factors in MTC and outperform serum calcitonin and stage. We propose a grading system based on tumor necrosis and mitotic activity to better stratify MTC patients for counseling, post-resection surveillance, and therapy.

Long-Term Outcomes and Aggressiveness of Hereditary Medullary Thyroid Carcinoma: 40 Years of Experience at One Center

CONTEXT

Recent data on long-term outcomes and aggressiveness of medullary thyroid carcinoma (MTC) are lacking for patients with multiple endocrine neoplasia type 2 (MEN2).

OBJECTIVES

To analyze the long-term outcomes in MEN2 and compare MTC aggressiveness in three defined RET mutation-risk categories: moderate risk (MOD), high risk (H), and highest risk (HST).

DESIGN, SETTING

Retrospective study of 263 operated patients with MEN2 from one German tertiary referral center from 1979 to 2017 comparing demographic, biochemical, genetic, and outcome parameters.

INTERVENTION

None (observational study).

MAIN OUTCOME MEASURE

Long-term survival and outcomes in three risk groups.

RESULTS

Surgery was performed at a mean age of 35.3 ± 18.8 (MOD, n = 122), 23.0 ± 15.7 years (H, n = 120), and 14.9 ± 9.3 (HST, n = 21) years (P < 0.05). The mean follow-up was 12.9 ± 9.8 years. Age and tumor stage at diagnosis differed among the three risk groups (P < 0.0001). Multivariate analysis of disease-specific survival (DSS) showed that increasing age [hazard ratio (HR), 1.06; 95% CI, 1.02 to 1.09], stage III/IV at diagnosis (HR, 7.39; 95% CI, 2.39 to 22.8), and HST group (HR, 14.4; 95% CI, 3.32 to 62.6) were significantly associated with worse DSS; the H group was not (P = 0.175). The DSS rates and outcomes were not different between the MOD and H groups (P = 0.179 and P = 0.893, respectively) but were significantly inferior in the HST group (P < 0.0008 and P < 0.0001, respectively).

CONCLUSION

MTC in patients with MEN2 showed a clearly different age of onset in the different risk groups. DSS and outcomes after MTC diagnosis were similar in the MOD and H groups, suggesting similar tumor behavior. The HST group had inferior outcomes and survival vs the MOD and or H groups.

Survival and Long-Term Biochemical Cure in Medullary Thyroid Carcinoma in Denmark 1997-2014: A Nationwide Study

BACKGROUND

Survival of medullary thyroid carcinoma (MTC) subgroups in relation to the general population is poorly described. Data on the factors predicting long-term biochemical cure in MTC patients are nonexistent at a population level. A nationwide retrospective cohort study of MTC in Denmark from 1997 to 2014 was conducted, aiming to detect subgroups with survival similar to that of the general population and to identify prognostic factors for disease-specific survival and long-term biochemical cure.

METHODS

The study included 220 patients identified from the nationwide Danish MTC cohort between 1997 and 2014. As a representative sample of the general population, a reference population matched 50:1 to the MTC cohort was used.

RESULTS

Patients diagnosed with hereditary MTC by screening (hazard ratio [HR] = 1.5 [confidence interval (CI) 0.5-4.3]), patients without regional metastases (HR = 1.4 [CI 0.9-2.3]), and patients with stage I (HR = 1.3 [CI 0.6-3.1]), stage II (HR = 1.1 [CI 0.6-2.3]), and III (HR = 1.3 [CI 0.4-4.2]) disease had an overall survival similar to the reference population. On multivariate analysis, the presence of distant metastases (HR = 12.3 [CI 6.0-25.0]) predicted worse disease-specific survival, while the absence of regional lymph node metastases (odds ratio = 40.1 [CI 12.0-133.7]) was the only independent prognostic factor for long-term biochemical cure.

CONCLUSIONS

Patients with hereditary MTC diagnosed by screening, patients without regional metastases, and patients with stages I, II, and III disease may have similar survival as the general population. The presence of distant metastases predicted worse disease-specific survival, while the absence of regional metastases predicted long-term biochemical cure.

Treatment of medullary thyroid carcinoma with apatinib: A case report and literature review

RATIONALE

Medullary thyroid carcinoma (MTC) is a rare type thyroid carcinoma originating from the thyroid parafollicular cells (C cells). Chemotherapy has a limited efficacy for treating persistent or recurrent MTC.

PATIENT CONCERNS

A 46-year-old woman who underwent thyroidectomy for MTC in December 2007. She began experience recurring diarrhea in January 2015 and started to cough and feel shortness of breath in March 2016.

DIAGNOSES

A chestcomputed tomography (CT) scan showed metastases in the bilateral lungs, pulmonary hilum, and mediastinal lymph nodes. Percutaneous biopsy of the pulmonary occupying lesions performed on March 21, 2016 indicated medullary carcinoma metastases at the right pulmonary hilum.

INTERVENTIONS

This patient was treated with oral apatinib (500 mg daily).

OUTCOMES

The patient's symptoms of diarrhea, coughing, and shortness of breath disappeared. CT reexaminations for efficacy assessment at 1, 2, and 3 months after the treatment indicated partial remission. Systemic migrating bone and joint pains occurred during the treatment, which were considered to be adverse events of apatinib.

LESSONS

Treatment of MTC with apatinib has been shown to be effective in our case. Tyrosine kinase inhibitors (TKIs) that suppress rearranged during transfection (RET) and vascular endothelial growth factor receptor (VEGFR) should be considered as a effective therapeutic approaches.

Treating medullary thyroid carcinoma in a tertiary center. Current trends and review of the literature

OBJECTIVES

We present the clinical outcome and long-term survival in patients with medullary thyroid carcinoma treated in a tertiary center. A thorough review of published series and current therapeutic approaches is also addressed.

STUDY DESIGN

A retrospective review.

SETTING

An Academic Tertiary center.

SUBJECTS/METHODS

An analysis of oncologic outcomes from 25 patients treated in our department for medullary thyroid carcinoma is performed, together with a comparison of relevant studies over the literature.

RESULTS

The incidence of patients alive free of disease and the 5-year survival rate has been noticed to be slightly higher than the rate reported in most series.

CONCLUSIONS

Total thyroidectomy and neck dissection remains the gold standard in the treatment of medullary thyroid carcinoma. Early diagnosis and aggressive surgical treatment lead to lower rates of recurrence and invasiveness. Tyrosine-kinase inhibitor, especially vantetanib, appears to be a promising target for treatment.