Prognostic variables of papillary and follicular thyroid carcinoma patients with lymph node metastases and without distant metastases

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.

Risk factors for death of follicular thyroid carcinoma: a systematic review and meta-analysis

BACKGROUND

There are conflicting reports on the factors that increase the likelihood of patients dying from follicular thyroid carcinoma (FTC). Therefore, it is critical to identify risk factors of patients with FTC. This study aimed to identify the factors that increase the risk of death of patients with FTC and help clinicians make better treatment and follow-up decisions.

METHODS

A systematic literature review was conducted in PubMed and Web of Science databases for relevant studies published before January 31, 2023. Their reference lists were also analyzed. Two reviewers extracted data and evaluated the quality of eligible studies independently. Studies on patients who had open thyroidectomy procedures with or without neck dissection were included in this review. The RevMan 5.3 software was used to analyze the data.

RESULTS

This meta-analysis included thirteen studies with a total of 2075 patients. The following variables were associated with an increased risk of death in FTC patients: age > 45 years, male, tumor diameter > 4 cm, multifocality, extrathyroidal extension (ETE), widely invasive (WI), cervical lymph node metastasis (CLNM), distant metastases (DM) and non-radical resection tumor. Lobectomy and no radioactive iodine (RAI) treatment was not associated with the death of FTC patients.

CONCLUSION

Clinicians should pay closer attention to the following significant risk factors associated with the death of FTC patients: age (> 45), male, multifocality, tumor diameter > 4 cm, ETE, WI, non-radical resection tumor, CLNM, and DM. Individualized initial treatment and close follow-up are needed FTC patients who have these risk factors.

Synchronous lateral lymph node metastases from papillary and follicular thyroid carcinoma: case report and review of the literature

Background

Follicular thyroid carcinomas (FTCs) rarely metastasize to regional lymph nodes, and descriptions of synchronous lateral lymph node metastases of FTC and papillary thyroid carcinoma (PTC) are lacking.

Case Presentation

We describe a 43-year-old female with a preoperative cytology indicating a right-sided PTC with lateral lymph node metastases. She underwent a total thyroidectomy and central and lateral lymph node dissection, and histopathology confirmed a multifocal tall cell variant PTC together with a 12 mm minimally invasive FTC in the ipsilateral lobe. While the central compartment demonstrated metastatic PTC, the lateral compartment contained PTC metastases alongside a 15 mm large follicular-patterned mass in a separate lymph node. As the cells lacked PTC associated nuclear changes, the possibility of a lateral lymph node metastasis of FTC was considered, with the possibility of ectopic thyroid tissue as a differential diagnosis. By utilizing next-generation sequencing, a Q61R NRAS mutation was pinpointed, thus proving the tissue as tumorous. The patient underwent radioiodine treatment and is currently monitored following a negative whole-body scan.

Conclusions

This is probably the first case report of a patient with co-existing lateral lymph node PTC and FTC metastases. Consulting previous publications, there is currently a gap of knowledge in terms of how patients with regional FTC metastases should be followed-up and treated, especially when co-occurring with spread high-risk PTC subtypes. Moreover, what guides a seemingly indolent FTC to spread via the lymphatic system remains to be defined from a molecular standpoint.

Metastasis to ipsilateral medial retropharyngeal and deep cervical lymph nodes in 22 dogs with thyroid carcinoma

OBJECTIVE

To determine the rate of nodal metastasis to the medial retropharyngeal (MRP) and deep cervical lymph nodes in dogs surgically treated for thyroid carcinoma.

STUDY DESIGN

Retrospective study.

ANIMALS

Twenty-two client-owned dogs.

METHODS

Medical records between July 2015 and October 2019 at the Universities of Missouri and Florida were reviewed. Dogs that underwent thyroidectomy with concurrent elective MRP lymphadenectomy ± deep cervical lymphadenectomy were included. Tumor site, preoperative staging, and histopathological findings were recorded.

RESULTS

Twenty-two dogs with 26 total thyroid carcinomas were included. Primary tumors were lateralized in 19 dogs, bilateral in two dogs, and bilateral and midline ectopic in one dog. All dogs underwent ipsilateral MRP resection, including bilateral resection in dogs with bilateral tumors. Three contralateral MRP lymph nodes were excised from dogs with unilateral carcinomas. Four deep cervical lymph nodes and one superficial cervical lymph node were excised. Metastases were identified in 14 lymph nodes in 10 of 22 (45%) dogs. All four excised deep cervical lymph nodes and one contralateral MRP lymph node were identified as metastatic. Size of deposit could be classified in 13 of 14 metastatic lymph nodes. Macrometastasis was detected in seven lymph nodes, micrometastasis was detected in one node, and isolated tumor cells were detected in five lymph nodes.

CONCLUSION

Regional metastasis was common within the lymph nodes sampled in this population of dogs with thyroid carcinoma.

CLINICAL SIGNIFICANCE

These results provide evidence to justify further exploration of a larger population to verify the rate of regional metastasis and determine the prognostic impact of nodal metastasis.

Metastatic propagation of thyroid cancer; organ tropism and major modulators

Thyroid cancer, as the most prevalent endocrine malignancy, comprises nearly 1% of all cancers in the world. The metastatic propagation of thyroid cancer is under the control of a number of modulating processes and factors such as signaling pathways and their components, cell division regulators, metabolic reprogramming factors, extracellular matrix remodelers, epithelial to mesenchymal transition modulators, epigenetic mechanisms, hypoxia and cytokines. Identifying the exact molecular mechanisms of these dysregulated processes could help to discover the key targets for therapeutic purposes and utilizing them as diagnostic, prognostic and predictors of the clinical course of patients. In this review article, we describe different aspects of thyroid cancer metastasis by focusing on defective genes and pathways involved in its metastatic spread.

Prognostic factors in thyroid carcinomas: a 17-year outcome study

Objectives The aim of our study was to evaluate the survival rate of all thyroid carcinomas (TCs) diagnosed in the 1999-2015 period in the Republic of North Macedonia and to analyze the prognostic influence of several characteristics on development of distant metastases, as well as to analyze the prognostic effect of seven clinical and constitutional features on mortality. Material and methods A retrospective analysis of medical data from all TCs diagnosed in 1999-2015 was performed. The survival rate of all types of TCs was estimated using the Kaplan Meier method. Univariate and multivariate logistic regression analysis was applied for evaluation of the predictive role of seven clinical and constitutional characteristics for development of distant metastases, and the univariate Cox-proportional model was applied for evaluation of the predictors for mortality. Results A total of 422 TC cases were diagnosed in the 17-year period, with an average survival time of 212.99 months. Results of the univariate regression analysis showed that dimension at initial ultrasound and histopathological type of tumor were significantly predictive variables for distant metastases. Multifocal tumors vs. unifocal tumors < 15 mm significantly increased the probability of distant metastases by 7.401 (p = 0.005, 95% CI = 1.817-30.190) times. Age, initial lymph node involvement, number of radioiodine therapies, and histopathology of the tumor were selected as independent significant predictors for mortality. Conclusion Our results showed an excellent overall prognosis of thyroid tumors in the Macedonian population. The dimension of the tumor, multifocality, and histopathological type were the most relevant prognostic predictive features for development of distant metastases.

Cervical lymph node thyroglobulin measurement in washout of fine-needle aspirates for diagnosis of papillary thyroid cancer metastases

BACKGROUND

Patients with papillary thyroid cancer (PTC) and enlarged cervical lymph nodes (CLNs) are usually assessed by fine-needle aspiration biopsy cytology (FNAB-C). Thyroglobulin (Tg) is frequently detected in washout of fine-needle aspirates (FNA) of these lymph nodes. The aim of this study was to evaluate the accuracy of the measurement of FNAB-Tg in the washout of FNAB in combination with FNAB-C to detect CLN metastases in PTC.

METHODS

We retrospectively evaluated 163 surgically proven CLNs. Ultrasound-guided FNAB-C and FNAB-Tg measurements were performed and the ultrasound features were evaluated.

RESULTS

The sensitivity, specificity and accuracy of FNAB-C, FNAB-Tg and FNAB-C/FNAB-Tg in diagnosis of metastatic CLNs were 85.7, 87.8 and 71.6%, were 80.5, 87 and 82.8% and were 97.1, 96.3 and 95.7%, respectively. The diagnostic sensitivity, specificity and accuracy of FNAB-C/FNAB-Tg for metastatic CLNs was significantly higher than that of FNAB-C or FNAB-Tg alone (p < 0.01).

CONCLUSION

Combined US-guided FNAB-C and FNAB-Tg can improve the accuracy for diagnosis of metastatic CLNs in patients with PTC.

Postoperative recurrence of papillary thyroid carcinoma with lymph node metastasis

BACKGROUND AND OBJECTIVES

The purpose of this study was to retrospectively analyze the features of patients with papillary thyroid carcinoma (PTC) presenting with neck lymph node (LN) metastasis.

METHODS

The study enrolled 909 patients with PTC who had undergone total thyroidectomy. After a median follow-up of 14.6 years, 73 (8.0%) patients died of thyroid cancer. A total of 536 patients had the tumor confined to the thyroid (intra-thyroid), 111 had lymph node (LN) metastasis, 225 showed soft tissue invasion, and 37 had distant metastasis.

RESULTS

Compared with the intra-thyroid group, the group with LN metastases showed larger tumor size, higher postoperative thyroglobulin levels, advanced TNM stage, higher recurrence rates (5.2% vs. 31.5%), and higher disease-specific mortality (1.3% vs. 12.6%). Of the 111 patients with PTC and LN metastases, 35 (31.5%) were diagnosed with recurrence during a mean follow-up period of 16.9 ± 0.6 years. Among the 35 patients with recurrent PTC, 14 (40.0%) died of thyroid cancer. The mortality group was characterized by older, mostly male patients who presented with larger initial tumor size compared with survivors.

CONCLUSIONS

In patients with PTC, the rates of recurrence and cancer mortality were higher in the group with LN metastasis than that in the intra-thyroid tumor group.

Factors related to mortality in patients with papillary and follicular thyroid cancer in long-term follow-up

PURPOSE

Differentiated thyroid cancer (DTC) includes papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC). They have different biological behavior but are frequently analyzed together in studies. We aimed to identify factors associated with mortality in those two different cancer subtypes.

METHODS

Case series study, with clinical-pathological analysis of the characteristics of 424 patients with PTC and 89 patients with FTC, correlating them to survival rates in a single institution.

RESULTS

Patients were followed from 1983 to 2011. Mean follow-up time was 9.4 years for FTC (range 1-36.6 years) and 6.8 years for PTC (range 1.1-30.7 years). Mean age at diagnosis was 51.2 ± 15.5 for FTC and 41 ± 14.7 years for PTC. 50.62% of FTC nodules sized 1.1-4 cm and 20% of PTC sized ≤1 cm. Cox multiple regression analysis evidenced distant metastasis at diagnosis (p = 0.0038; relative risk (RR) 41.247, 95% confidence interval (CI) 3.317-512.986), lymph node metastasis at diagnosis (p = 0.0081; RR 50.98, 95% CI 2.783-934.026) and vascular/lymphatic invasion (p = 0.0039; RR 40.424, 95% CI 3.287-497.177) as factors related to mortality in FTC patients. For PTC, the factors were distant metastasis at diagnosis (p < 0.0001; RR 32.5, 95% CI 6.676-158.543) and degree of differentiation (poor versus well differentiated, p = 0.003; RR 10.4, 95% CI 2.218-49.487).

CONCLUSION

The common factor that influenced mortality for FTC and PTC patients was distant metastasis at diagnosis, increasing mortality rate by 41 times in FTC and 30 times in PTC patients. The different factors influencing mortality for different DTC types highlight the importance of analyzing them separately.

Analysis of the prognostic significance of lymph node related characteristics in papillary thyroid carcinoma patients presenting with pre- or intra-operative evidence of cervical lymph node metastases

Objective:

To identify the prognostic significance of specific lymph node related characteristics for disease persistence and recurrence in patients with pre- or intra-operative evidence of neck metastases and no other risk factors.

Method and results

Sixty-eight patients were identified; 50 per cent had persistent or recurrent disease. All underwent the same treatment strategy. There were no statistically significant differences in any of the patient- or tumour-related parameters when patients with and without persistence or recurrence were compared. Patients with recurrent or persistent disease had significantly larger (>3 cm) metastatic lymph nodes, but there were no differences regarding other lymph node related parameters (i.e. number, extracapsular extension, number of lymph nodes with extracapsular extension, and central vs lateral neck location). On multivariate analysis, however, none of the parameters were predictive of persistent or recurrent disease.

Conclusion:

In papillary thyroid carcinoma patients with no other risk factors, pre- or intra-operative evidence of cervical metastases was associated with a very high rate of disease persistence or recurrence. Specific lymph node characteristics were not shown to have prognostic significance.

Sonographic features of cervical lymph nodes after thyroidectomy for papillary thyroid carcinoma

OBJECTIVES

Unlike the preoperative findings in patients with papillary thyroid carcinoma, the postoperative sonographic features of cervical lymph nodes have not been established. This study aimed to assess the sonographic features of metastatic lymph nodes after thyroidectomy for papillary thyroid carcinoma.

METHODS

The study population consisted of 104 consecutively registered patients who had undergone thyroidectomy for papillary thyroid carcinoma and underwent sonographically guided fine-needle aspiration of lymph nodes in the neck. The sonographic features of each lymph node were retrospectively evaluated by a single radiologist. The confirmation methods for the 115 lymph nodes included surgery (n = 35), measurement of thyroglobulin levels in the aspirates (n = 2), malignant cytologic analysis (n = 10), and benign cytologic analysis with sonographic follow-up over 12 months (n = 68). We determined the diagnostic indices of individual sonographic features for differentiating between metastatic and benign lymph nodes by comparing these features with the final diagnoses.

RESULTS

Of the 104 patients, 67 underwent at least 1 cycle of radioisotope therapy after thyroidectomy. The malignancy rate for the lymph nodes was 42.6% (49 of 115). A significant relationship was found between malignancy and the presence of an intranodal cystic component, intranodal microcalcifications, diffusely increased echogenicity, a microlobulated margin, a round shape, loss of echogenic hila, and mixed or central vascularity on color Doppler sonography (P < .05).

CONCLUSIONS

The sonographic features of metastatic cervical lymph nodes in postoperative patients with papillary thyroid carcinoma were similar to those in preoperative patients.

Is Every Patient Followed up as a Papillary Thyroid Cancer Patient Really That?

We report the case of a 64-year-old man followed up for two years as suffering from differentiated thyroid cancer (DTC). In the patient's follow up, despite thyroglobulin level and I-131 whole body scan results being normal, metastases were identified at the 4th thoracic vertebra corpus by MR. Histopathological findings were carcinoma metastases. F-18 FDG PET/CT showed increased metabolic activity in the right renal mass, bilaterally in the surrenal gland, multiple lymph nodes in the thoracic and abdominal para-aortic region and in multiple vertebral and pelvic bones. An excisional biopsy of the right renal mass was reported as renal cell carcinoma. Immunohistochemical staining performed retrospectively to the first thyroid preparation showed renal cell carcinoma metastases. Consequently, any patient who presents with a thyroid nodule can also be considered as possibly suffering from metastatic disease. F-18 FDG PET/CT can provide valuable information in finding the primary focus and metastases.

CONFLICT OF INTEREST

None declared.

Prognostic evaluation of patients with multicentric papillary thyroid microcarcinoma

BACKGROUND/PURPOSE

Patients with papillary thyroid microcarcinoma (PTMC) often have an excellent prognosis. We hypothesize that patients with multicentric PTMC are associated with good clinical outcome, although multicentricity in papillary thyroid carcinoma may be associated with poor prognosis.

METHODS

Retrospective analysis of multicentric PTMC cases in one medical center enrolled from 1987 to 2008 was conducted. At the end of follow-up, patients were classified as "recurrence-free" or "recurrence or persistent disease". The tumor-node-metastasis (TNM) staging system was used, and (T1, N0, M0) was regarded as "early clinical stage", whereas (T3-4, any N, any M) or (any T, N1, or M1) was regarded as "advanced clinical stage".

RESULTS

There were 61 patients with a median age of 45 years. After a median follow-up period of 7.3 years (range: 2.1-22.1 years), the overall cause-specific survival rate was 98.36%. The patients with tumor diameters < 0.5 cm were all recurrence-free. Advanced clinical stage, especially distant metastasis, was highly associated with recurrence or persistent disease.

CONCLUSION

Our results demonstrate excellent prognosis in multicentric PTMC patients. No patients with tumor diameter < 0.5 cm had recurrence or persistent disease. Tumor size is an important risk factor in patients with multicentric PTMC.

Nodal metastasis in well-differentiated follicular carcinoma of the thyroid: Its incidence and clinical significance

The clinical significance of nodal metastasis in well-differentiated follicular carcinoma (WD-FC) of the thyroid remains a controversial issue. This study aimed to clarify clinical and pathological characteristics of WD-FC with nodal metastasis, based on the new WHO classification. We examined 249 WD-FC cases diagnosed between 1983 and 2004 in our hospital. Poorly differentiated follicular carcinoma was not included in this study. Of the 249 WD-FC cases, 9 (3.6%) revealed nodal metastasis. The incidences of nodal metastasis in minimally invasive and widely invasive cases were 2.0 and 9.8%, respectively. In four patients, nodal metastasis was detected in the ipsilateral lymph nodes during the initial surgery. A total of 6 patients presented with nodal metastasis 2-10 years after the initial operation, and 3 patients with bilateral and large nodal metastases were relatively young. No patients succumbed to the carcinoma. Primary lesions of WD-FC with nodal metastasis were microscopically conventional, and there were no findings predicting nodal metastasis. We hypothesized that the incidence of nodal metastasis in WD-FC, based on the new WHO classification, was lower compared with previous reports. Younger individuals may be at a higher risk of large bilateral nodal metastasis. The presence of nodal metastasis did not affect the long-term outcome of follicular carcinoma.

[Usefulness of the immunohistochemical analysis of several molecular markers in the characterization of papillary thyroid carcinoma with initial lymph node metastasis]

INTRODUCTION AND OBJECTIVE

Regional lymph node metastases (LNM) are a common finding in papillary thyroid cancer (PTC). Approximately half of patients have LNM at diagnosis. The aim of this study was to analyze immunohistochemically the combined expression of different PTC-related molecules in order to identify cases with a tendency to show LNM.

PATIENTS AND METHODS

Thirty-five patients were included in the study. The patients were distributed in two groups. Group I included 19 patients with no histological evidence of LNM at diagnosis. Group II included 16 patients with histological evidence of cervical LNM. Samples were stained for RET/PTC, EGFR, p16(INk4a), p21(cip1), p27(kip1), BCL2, and pAKT.

RESULTS

Expression of p21(cip1), p27(kip1), p16(INk4a), Bcl-2, and pAKT showed no differences between the two groups. However, RET/PTC and EGFR expression showed significant differences: in both cases, staining was more frequent in patients with LNM. Simultaneous positivity of RET/PTC and EGFR was a discriminative marker in patients with LNM. Finally, the combination of RET/PTC negative, EGFR negative and p16(INk4a) negative was found in none of the patients with LNM but in nearly half of those in group I.

CONCLUSIONS

Immunohistochemical analysis of several molecular markers could be useful in the phenotypic characterization of PTC. Application of these markers could enhance diagnosis and improve the management of patients with thyroid cancer.

Treatment strategy of papillary thyroid carcinoma in children and adolescents: clinical significance of the initial nodal manifestation

BACKGROUND

Risk factors and treatment strategy in younger patients with papillary thyroid carcinoma are still controversial.

METHODS

We reviewed 120 consecutive papillary thyroid carcinoma patients younger than 20 years who underwent initial surgery between 1977 and 2004 (14 male and 106 female subjects; mean age, 16.3 years; mean follow-up, 11.6 years). Outcomes were evaluated initially, and risk factors for disease-free survival (DFS) were analyzed statistically. Cox proportional multivariate analysis revealed that initial nodal manifestation (P < .001, hazard ratio 2.97) was the most statistically significant risk factor for DFS. The outcomes were then compared between four subgroups on the basis of the initial nodal manifestation and node dissection: 17 patients in group A (no lymphadenopathy, no or only prophylactic central dissection), 30 patients in group B (no lymphadenopathy, prophylactic modified neck dissection, MND), 46 patients in group C (nonpalpable lymphadenopathy detected by radiological or operative findings, therapeutic MND), and 27 patients in group D (palpable lymphadenopathy, therapeutic MND).

RESULTS

Subtotal/total thyroidectomy and radioactive iodine therapy were performed for 47.1 and 0% in group A, 33.3 and 0% in group B, 43.4 and 10.9% in group C, and 85.1 and 48.1% in group D, respectively. In groups A, B, C, and D, 0%, 3.3%, 28.3%, and 48.1% developed recurrence, respectively (P < .001). DFS Kaplan-Meier curves differed significantly among the four subgroups (P < .0005).

CONCLUSIONS

Initial nodal manifestation is useful to predict DFS in younger papillary thyroid carcinoma patients. Our findings will be beneficial to determine the treatment strategy. Conservative therapy is considered acceptable for patients without risk factors.

BRAFV600E mutation in papillary thyroid carcinoma: a potential target for therapy?

This article reviews the therapeutic significance of the close genotype-phenotype association in papillary thyroid carcinoma, namely regarding the association between genetic alterations in RET, BRAF or RAS genes and the histopathological variants of papillary thyroid carcinoma. Based upon the aforementioned review on morphology and molecular pathology, the most recent prognostic and therapeutic data are reviewed and the role of targeted therapies, namely those interfering with BRAF-activated pathways are discussed, which may play a role in the treatment of patients with papillary thyroid carcinoma unresponsive to radioactive iodine.

Higher serum TSH in thyroid cancer patients occurs independent of age and correlates with extrathyroidal extension

BACKGROUND

It has previously been shown that higher serum TSH is associated with increased thyroid cancer incidence and advanced-stage disease. In the healthy adult population, mean TSH increases with age. As age over 45 years is a known prognostic indicator for thyroid cancer, it is important to know whether higher TSH in patients with thyroid cancer occurs independent of age.

OBJECTIVE

To determine the relationship between higher TSH, cancer and age.

DESIGN

A retrospective cohort study.

PATIENTS AND METHODS

A total of 1361 patients underwent thyroid surgery between May 1994 and December 2007 at a single institution. Of these patients, 954 had pathological data, preoperative TSH and complete surgical history available. Data were analysed in relation to age and TSH.

RESULTS

Mean TSH was significantly higher in cancer patients regardless of age < 45 years or >or= 45 years (P = 0.046 and P = 0.027, respectively). When examining age groups < 20, 20-44, 45-59 and >or= 60 years, there was a trend of rising mean TSH with age. Despite the rise in the benign subgroups, mean TSH was consistently higher in those with cancer vs. those without. On multivariate analysis, higher TSH was independently associated with cancer (P = 0.039) and pathological features of Hashimoto's thyroiditis (P = 0.001) but not with age (P = 0.557). On multivariate analysis of high-risk features associated with poor prognosis, there was a significant association between higher TSH and extrathyroidal extension (P = 0.002), whereas there was no clear relationship with age, tumour size > 4 cm, and distant metastases.

CONCLUSION

Independent of age, thyroid cancer incidence correlates with higher TSH. Higher TSH is associated with extrathyroidal extension of disease.

Understanding the relationship between age and thyroid cancer

Unique among malignancies, age is a key prognostic indicator for well-differentiated thyroid cancer. Patients aged <45 years can have the same degree of disease involvement and a distinctly different prognosis than those aged >45. Although the reason for the association between age and outcome is not entirely clear, it does imply that there is something intrinsic to either the cancer or the treatment that is age dependent. This article explores the characteristics of the normal thyroid and thyroid cancer that are age dependent. It then provides theories for the relationship between advanced age and poor prognosis, in addition to treatment options tailored to age at diagnosis.

Papillary thyroid cancer: pathological parameters as prognostic factors in different classes of age

OBJECTIVE

To analyze aspects of a series of papillary thyroid carcinomas and evaluate the prognostic features specific to different age classes.

STUDY DESIGN

Retrospective study.

SUBJECTS AND METHODS

From 2000 to 2005, 2709 patients underwent a total thyroidectomy for papillary thyroid carcinoma in our department. Patients were divided into three groups: <18 years (G1), 19 to 45 years (G2), and >46 years (G3). Histologic and clinical features were statistically evaluated.

RESULTS

Tumor size was larger in G1 when compared with both G2 and G3 (P < 0.0001). Infiltration of the thyroid capsule and node metastases were higher in G1 than both G2 and G3 (P < 0.0001). The Tall-cell variant was more represented in G2 and G3.

CONCLUSION

In the pediatric population, papillary carcinoma is a more aggressive disease. Because pediatric cancers have a better prognosis than their adult counterparts, this does not influence patient outcome. Age can then be considered the most important factor in determining prognosis.

Use of preoperative lymphoscintigraphy and intraoperative gamma-probe detection for identification of the sentinel lymph node in patients with papillary thyroid carcinoma

AIMS

Lymph node metastases for papillary thyroid carcinoma are associated with an increased incidence of locoregional recurrence. The use of preoperative lymphoscintigraphy and intraoperative gamma probe detection to localize the sentinel lymph node in papillary thyroid carcinoma was investigated.

METHODS

From February 2004 to December 2005 the sentinel lymph node technique was studied in 64 consecutive patients with cytological evidence of papillary thyroid carcinoma. The day before surgery, patients were submitted to US-guided peri-tumoural injection of the radiotracer and a lymphoscintigraphy was performed. In the operating room a total thyroidectomy was done, and thanks to a hand-held gamma probe the sentinel lymph node and all lymph nodes, belonging to the sentinel node compartment, were removed.

RESULTS

The gamma probe identified the sentinel lymph node in 62 patients (96.8%). We found 48 (77.5%) sentinel lymph node without metastases; 12 (19.3%) with metastases and 2 (3.2%) with micrometastases. In 7 cases (11.3%), with a negative sentinel lymph node, metastases in other nodes of the same region were recorded. In 22 cases (34.3%) the ultrasound give an erroneous indication (P=0.004). Five patients (8.0%), 4 with multifocal cancer, had a positive postoperative lymphoscintigraphy.

CONCLUSION

This study shows that the sentinel lymph node technique for papillary thyroid carcinoma is feasible, repeatable, and more accurate than preoperative ultrasound. In cases of multifocal thyroid lesions more patients should be enrolled to establish the utility of the radio-guided technique.

Papillary thyroid carcinoma with lymph node metastases

Papillary thyroid cancer (PTC) is the most frequently occurring human thyroid cancer with good prognosis following appropriate treatment. Lymph node (LN) metastases are the main way through which PTC spread cancer cells. The mechanisms underlying PTC with local invasion, LN metastases and distant metastases are not well investigated. Tumor secrete cytokines, such as vascular endothelial growth factor (VEGF)-C and -D bind to VEGF receptors on lymphatic endothelial cells and induce proliferation (budding) from nearby lymphatic capillaries and growth of new lymphatic capillaries. About one-third of patients can be diagnosed at the time of surgical findings. Different image studies, such as ultrasonography with fine needle aspiration cytology, scintigraphic localization and positron emission tomography were reported to detect LN metastases. Important factors in predicting LN metastases are vascular invasion, male gender, absence of tumor capsule, and perithyroid involvement. Tumor recurrence in LN after primary treatment of PTC had an independent and highly significant negative effect on survival in patients over 45 year-old. Recombinant adeno-associated virus-mediated gene transfer of sVEGFR3-Fc is a feasible therapeutic scheme for blocking lymphogenous metastasis. In conclusion, aggressive surgical procedures performed by experienced surgeons or postoperative radioactive iodine therapy to minimize local recurrence of LN for PTC patients with high risk.

Follicular thyroid carcinoma: From diagnosis to treatment

Unusual presentations with bone, lung or soft tissue metastases in initial diagnosis of follicular thyroid carcinoma have been reported occasionally. This implies how difficult it is to diagnosis this type of cancer at the pre-operative or intra-operative stage of treatment. Fine needle aspiration cytology has been shown to be an ineffective method for diagnosing vascular or capsule invasion of follicular thyroid cancer. Multiple frozen sections, usually 5 to 12 depending on the size of the tumor, can achieve a diagnostic accuracy of 98%. Clinical application of various gene expressions in thyroid follicular tumors by needle aspiration using in situ hybridization requires further investigation. Although radioactive iodide (131I) has been used as the standard treatment for follicular thyroid carcinoma with distant metastases, the effectiveness of 131I treatment for follicular thyroid carcinoma depends on the differentiation of cancer cells. The possibility of 131I for thyroid remnant ablation replacing a secondary operation for follicular thyroid carcinoma has been debated. Recent studies applied more expressions of sodium iodide symporters to attain the effect of 131I treatment and slow the proliferation of thyroid cancer cell which, in turn, slows the progression of follicular carcinoma. Consensus for the surgical procedures for the specific prognostic risks for follicular thyroid carcinoma is needed. Dedifferentiated, anti-angiogenic, or gene therapies for follicular thyroid cancer with distant metastases or anaplastic transformation comprise the principal directions in future research for this cancer.

Retrospective analysis of predictive factors for recurrence after curatively resected papillary thyroid carcinoma

PURPOSE

This retrospective study analyzes the predictive factors after curative surgery for papillary thyroid carcinoma (PTC).

METHODS

We analyzed 386 patients who underwent a curative operation for PTC in our hospital between 1977 and 1997, subject to the inclusion criteria.

RESULTS

According to univariate analysis, pathological lateral cervical lymph node involvement (P < 0.0001), dedifferentiation of the tumor (P < 0.002), male sex (P < 0.0001), a large tumor (P < 0.005), and an age of over 50 years (P < 0.05) were significant factors. Cox's proportional hazard model showed that a man (P < 0.05), aged over 50 years (P < 0.05), who had a large primary tumor (P < 0.05) with dedifferentiation (P < 0.05), and pathological lateral cervical lymph node metastasis (P < 0.005) was more likely to have recurrence of PTC.

CONCLUSIONS

Determining whether lymph node metastasis exists could be useful for predicting recurrence in patients who have undergone curative resection of PTC.

Tumor suppressor gene allelic loss profiles of the variants of papillary thyroid carcinoma

Papillary thyroid carcinoma (PTCa) is a relatively common, indolent tumor that usually has an excellent prognosis. While the diagnosis of conventional PTCa is relatively straightforward, encapsulated tumors with follicular growth pattern and unusual or incomplete cytologic features of papillary carcinoma can be diagnostically challenging. Encapsulated, noninvasive tumors are particularly controversial as the differential diagnosis includes a nonneoplastic nodule, a benign follicular adenoma, and papillary carcinoma. In this study, we performed molecular genotyping to identify loss of heterozygosity of tumor suppressor genes in conventional PTCa and in several different morphologic variants, including follicular variant, tall cell variant, and oncocytic variant. Our data demonstrate that conventional PTCas have the lowest frequency of allelic loss (7%), as compared with follicular, oncocytic, and tall cell variants (19%, 34%, and 20%, respectively). Frequency of allelic loss increased with increasing size of the tumors, but did not correlate with age, gender, extrathyroidal extension, or lymph node metastases. Though it is unlikely that these results will enable the distinction between different variants of papillary carcinoma, the finding of significant rates ofallelic loss in the variants of PTCa provides additional evidence of malignancy and may be useful in distinguishing encapsulated tumors from nonneoplastic or benign nodules.

Diagnosis of neck recurrences in patients with differentiated thyroid carcinoma

BACKGROUND

The follow-up of patients with differentiated thyroid carcinoma (DTC) is traditionally carried out with (131)I whole body scan ((131)I WBS) and serum thyroglobulin (Tg) measurement. Neck ultrasonography (US) is also used.

METHODS

We compared the roles of Tg measurement (IRMA assay) after l-thyroxine (T4) withdrawal, (131)I WBS, and US in the diagnosis of DTC neck recurrences. Diagnosis of DTC neck recurrences was based on fine-needle aspiration biopsy (FNAB) or on histologic results. Four hundred ninety-four DTC patients (120 males, 374 females; mean age, 49.3 years), submitted to total thyroidectomy and subsequent radioablative (131)I treatment, underwent serum Tg measurement off T4 therapy, (131)I WBS, and neck US at our institution. Mean (+/- SD) follow-up time was 55.1 +/- 37.7 months. Neck DTC recurrences were detected in 51 (10.3%) patients (34 females, 17 males; mean age, 49.5 years).

RESULTS

Neck recurrences occurred after 44.6 +/- 21.4 months from initial treatment. Serum Tg levels increased (> or = 2 ng/mL) off T4 therapy in 29 patients (sensitivity 56.8%), (131)I WBS showed neck uptake in 23 patients (sensitivity 45.1%) and coexisting distant metastases were detected in 9 of 23 patients, and US identified neck recurrence in 48 patients (sensitivity 94.1%). Of these 48 neck recurrences, 19 were found in the laterocervical compartment and 29 in the central neck compartment.

CONCLUSIONS

Traditional techniques for the surveillance of DTC patients are not as sensitive as US in the detection of neck recurrences. Neck US detects recurrences in patients with undetectable serum Tg levels and negative IWBS and should be performed as the first-line test in the follow-up of all DTC patients.

Cystic lymph node metastases in papillary thyroid carcinoma

OBJECTIVE

The aim of this study was to illustrate and discuss the sonographic spectrum of surgically proven cystic nodal metastases from papillary thyroid carcinoma. By correlative evaluation of the sonographic imaging findings to gross pathology and histology, our purpose was to provide useful hints to differentiate cystic lymph node metastases from other benign cystic neck lesions such as branchial cysts.

MATERIALS AND METHODS

Sonographic examinations of 74 patients (47 women, 27 men; mean age, 49 years) with 97 histologically confirmed cystic lymph nodes metastases from papillary thyroid carcinoma were included in the study. The anatomic relationship of the nodes relative to the primary tumor was recorded, and all cystic nodes were qualitatively categorized as either simple (purely cystic) or complex (thickened outer wall, internal nodules, internal septations, and calcifications). All imaging findings were compared with gross pathologic specimens.

RESULTS

Most of the cystic metastases were ipsilateral to the primary tumor (87.8%) and located in the mid or lower jugular chain (73.2%). In 14.9% of all patients, cystic lymph node metastases were the initial manifestation of disease. Only 6.2% of all lymph node metastases were purely cystic (all of these occurred in patients less than 35 years old). Of the 91 complex metastases, a thickened outer wall was present in 35.2% of patients, internal nodules in 42.9%, and internal septations in 57.1%. No calcifications were seen in the 91 complex metastases, and two or more findings were seen in 23.1%. All sonographic findings were verified by surgery.

CONCLUSION

In most of the patients, cystic lymph node metastases are characterized sonographically by the presence of a thickened outer wall, internal echoes, internal nodularity, and septations. However, in younger patients, the lymph nodes might appear purely cystic, thereby mimicking branchial cysts and thus requiring biopsy for final diagnosis and therapy planning.