Central lymph node metastasis is an important prognostic factor in patients with papillary thyroid microcarcinoma

Risk stratification for central lymph node metastasis in mono-focal papillary thyroid carcinoma patients with encapsulated tumor as confirmed by preoperative ultrasound: a multi-center analysis

PURPOSES

Mono-focal papillary thyroid carcinoma (PTC) patients with encapsulated tumor have traditionally been considered as low central lymph node metastasis (CLNM) risk subgroup. The aim of the research was to quantitatively predict the probability of CLNM for mono-focal PTC patients with encapsulated tumor as confirmed by preoperative ultrasound based on pre- and post-operative indexes respectively to guide the selection of prophylactic central lymph node dissection (CLND) and follow-up strategies.

METHODS

A total of 1014 mono-focal PTC patients with encapsulated tumor as confirmed by preoperative ultrasound from three medical centers were retrospectively analyzed, with 534 patients served as Training group and 480 patients as Validation group.

RESULTS

Multivariate analyses showed that age < 55 years old, male, clinical maximum tumor diameter (cMTD) > 0.5 cm, pathological maximum tumor diameter (pMTD) > 0.5 cm, and the presence of microscopic thyroid capsular invasion (mTCI) were independent CLNM risk factors. These were used to construct two nomograms that can effectively predict the central neck involvement in mono-focal PTC patients with encapsulated tumor. The first nomogram (pre-model) provides quantitative assessment on the necessity of prophylactic CLND, while the second nomogram (post-model) informs postoperative follow-up strategies.

CONCLUSIONS

Meticulous and comprehensive stratification flow charts that quantitatively evaluate the risk of central lymph node metastasis both pre- and post-operatively were constructed for mono-focal PTC patients with encapsulated tumor as confirmed by preoperative ultrasound, which may benefit both clinical decision-making of prophylactic CLND and postoperative follow-up strategies for the management of neck regions.

Ultrasound and clinical factors predicting central lymph node metastases in patients with unilateral multifocal papillary thyroid carcinoma

OBJECTIVE

This retrospective study involving a large dataset of unilateral multifocal papillary thyroid carcinoma (UM-PTC) sought to identify factors that predict central lymph node metastases (CLNM) in patients.

METHODS

We identified a cohort of 158 patients who underwent cervical ultrasonography followed by UM-PTC diagnosis based on postoperative pathology. The relationship between CLNM and UM-PTC clinical ultrasound features was evaluated using univariate and multivariate analyses. Receiver operating characteristic (ROC) curve analysis was used to determine the ability of total tumor diameter (TTD) to predict CLNM.

RESULTS

Among the 158 UM-PTC patients, the incidence of CLNM was 29.7% (47/158). Univariate and multivariate analyses revealed that a number of similarity of sonographic features (NSSF) ≥4 (odds ratio [OR] = 11.335, 95% confidence interval [CI]: 3.95-32.50, p = 0.000), microcalcifications (OR = 3.54, 95% CI: 1.30-9.70, p = 0.014), a TTD of ≥2 cm (OR = 4.48, 95% CI: 1.62-12.34, p = 0.004), number of nodules ≥3 (OR = 13.17, 95% CI: 3.24-53.52, p = 0.000), and Lateral cervical lymph node metastasis (LLNM) (OR = 5.57, 95% CI: 1.59-19.48, p = 0.007) were independently associated with CLNM in UM-PTC. ROC curve analysis revealed that the TTD cut-off of 1.795 cm had a sensitivity of 0.723 and a specificity of 0.676 for predicting CLNM.

CONCLUSIONS

Patients with UM-PTC are at high risk of CLNM. NSSF ≥4, microcalcifications, TTD of ≥2 cm, LLNM, and a number of nodules ≥3 were independently associated with CLNM. Our data show that ultrasound may guide surgical decisions in the treatment of UM-PTC.

Comprehensive Long-Read Sequencing Analysis Discloses the Transcriptome Features of Papillary Thyroid Microcarcinoma

CONTEXT

Papillary thyroid microcarcinoma (PTMC) is the most common type of thyroid cancer. It has been shown that lymph node metastasis is associated with poor prognosis in patients with PTMC.

OBJECTIVE

We aim to characterize the PTMC transcriptome landscape and identify the candidate transcripts that are associated with lateral neck lymph node metastasis of PTMC.

METHODS

We performed full-length transcriptome sequencing in 64 PTMC samples. Standard bioinformatic pipelines were applied to characterize and annotate the full-length expression profiles of 2 PTMC subtypes. Functional open reading frame (ORF) annotation of the known and novel transcripts were predicted by HMMER, DeepLoc, and DeepTMHMM tools. Candidate transcripts associated with the pN1b subtype were identified after transcript quantification and differential gene expression analyses.

RESULTS

We found that skipping exons accounted for the more than 27.82% of the alternative splicing events. At least 42.56% of the discovered transcripts were novel isoforms of annotated genes. A total of 39 193 ORFs in novel transcripts and 18 596 ORFs in known transcripts were identified. Distribution patterns of the characterized transcripts in functional domain, subcellular localization, and transmembrane structure were predicted. In total, 1033 and 1204 differentially expressed genes were identified in the pN0 and pN1b groups, respectively. Moreover, novel isoforms of FRMD3, NOD1, and SHROOM4 were highlighted for their association with pN1b subtype.

CONCLUSION

Our data provided the global transcriptome landscape of PTMC and also revealed the novel isoforms that associated with PTMC aggressiveness.

Techniques for Thyroidectomy and Functional Neck Dissection

Thyroidectomy is a commonly performed surgery for thyroid cancer, Graves' disease, and thyroid nodules. With the increasing incidence of thyroid cancer, understanding the anatomy and surgical techniques is crucial to ensure successful outcomes and minimize complications. This review discusses the anatomical considerations of the thyroid and neck, including lymphatic drainage and the structures at risk during thyroidectomy. Emphasis is placed on the significance of cautious dissection to preserve critical structures, such as the parathyroid glands and recurrent laryngeal nerve. Neck dissection is also explored, particularly in cases of lymph node metastasis, in which its proper execution is essential for better survival rates. Additionally, this review evaluates various thyroidectomy techniques, including minimally invasive approaches, highlighting their potential benefits and limitations. Continuous surgical knowledge and expertise updates are necessary to ensure the best results for patients undergoing thyroidectomy.

A nomogram based on multimodal ultrasound and clinical features for the prediction of central lymph node metastasis in unifocal papillary thyroid carcinoma

OBJECTIVES

To build a predictive model for central lymph node metastasis (CLNM) in unifocal papillary thyroid carcinoma (UPTC) using a combination of clinical features and multimodal ultrasound (MUS).

METHODS

This retrospective study, included 390 UPTC patients who underwent MUS between January 2017 and October 2022 and were divided into a training cohort (n = 300) and a validation cohort (n = 90) based on a cut-off date of June 2022. Independent indicators for constructing the predictive nomogram models were identified using multivariate regression analysis. The diagnostic yield of the 3 predictive models was also assessed using the area under the receiver operating characteristic curve (AUC).

RESULTS

Both clinical factors (age, diameter) and MUS findings (microcalcification, virtual touch imaging score, maximal value of virtual touch tissue imaging and quantification) were significantly associated with the presence of CLNM in the training cohort (all P < .05). A predictive model (MUS + Clin), incorporating both clinical and MUS characteristics, demonstrated favourable diagnostic accuracy in both the training cohort (AUC = 0.80) and the validation cohort (AUC = 0.77). The MUS + Clin model exhibited superior predictive performance in terms of AUCs over the other models (training cohort 0.80 vs 0.72, validation cohort 0.77 vs 0.65, P < .01). In the validation cohort, the MUS + Clin model exhibited higher sensitivity compared to the CLNM model for ultrasound diagnosis (81.2% vs 21.6%, P < .001), while maintaining comparable specificity to the Clin model alone (62.3% vs 47.2%, P = .06). The MUS + Clin model demonstrated good calibration and clinical utility across both cohorts.

CONCLUSION

Our nomogram combining non-invasive features, including MUS and clinical characteristics, could be a reliable preoperative tool to predict CLNM treatment of UPTC.

ADVANCES IN KNOWLEDGE

Our study established a nomogram based on MUS and clinical features for predicting CLNM in UPTC, facilitating informed preoperative clinical management and diagnosis.

Clinical value of dual-energy CT for predicting occult metastasis in central neck lymph nodes of papillary thyroid carcinoma

OBJECTIVES

To predict the probability of occult lymph node metastasis (OLNM) in the central cervical by analyzing the dual-energy computed tomography (DECT) parameters derived from papillary thyroid carcinoma (PTC).

METHODS

Data were retrospectively collected from patients with pathologically confirmed PTC who underwent arterial and venous phases of enhanced DECT with concurrent central neck lymph node dissection (CLND). Three clinical features, three shape-related features, and twenty-six DECT-derived parameters were measured. The univariate and multivariate analyses were applied to select the relevant parameters and develop the nomogram.

RESULTS

A total 140 cases with negative diagnosis of cervical central lymph node metastases by preoperative evaluation were included, among which 88 patients with metastasis (OLNM +) and 52 patients without metastasis (OLNM -) were finally confirmed by pathology. (1) Anteroposterior/transverse diameter ratio (A/T) derived from the PTC focus had significant difference between the OLNM + and OLNM - groups (p < 0.05). (2) In the arterial phase, iodine concentration (ICarterial), normalized iodine concentration (NICarterial), effective atomic number (Zeff-arterial), electron density (EDarterial), and slope of energy curve (karterial) from PTC focus showed significant difference (all p < 0.05) between the two groups. In the venous phase, only the CT value under the 40 keV (HU40keVvenous) had differences (p < 0.05). (3) The nomogram was produced to predict the probability of OLNM, and the AUC, sensitivity, and specificity in the training and test cohort were 0.830, 75.0%, 76.9%, and 0.829, 65.9%, 84.6%, respectively.

CONCLUSIONS

DECT parameters combined with shape-related feature derived from PTC might be used as predictors of OLNM in the central neck.

CLINICAL RELEVANCE STATEMENT

Preoperative imaging evaluation combining shape-related features and dual-energy CT parameters could serve as a reference to discern occult lymph node metastasis in central neck during the surgically planning of papillary thyroid carcinoma.

KEY POINTS

• Papillary thyroid carcinoma (PTC) patients may have occult lymph node metastasis (OLNM) in the central neck, which is extremely difficult to find by preoperative imaging examination. • Dual-energy CT quantitative evaluation has higher accuracy than conventional CT and can predicting OLNM in the central neck of PTC. • Dual-energy CT quantitative parameters and morphology of PTC can serve as a useful tool in predicting OLNM in the central neck, and as a guide for personalized treatment.

Risk factors associated with preferential lateral lymph node metastasis in papillary thyroid carcinoma

BACKGROUND

Lateral lymph node metastasis (LLNM) is common in patients with papillary thyroid cancer (PTC), usually occurring after central lymph node metastasis (CLNM). However, some patients experience LLNM without first developing CLNM. This study aimed to identify the risk factors for developing LLNM without CLNM.

METHODS

We retrospectively reviewed 421 patients diagnosed with PTC who underwent lobectomy or total thyroidectomy with central and ipsilateral lateral lymph node dissection. We collected clinicopathological data and used univariate and multivariate logistic regression analyses to determine the risk factors associated with LLNM without CLNM.

RESULTS

The LLNM without CLNM frequency was 18.3% (77/421). Univariate analyses demonstrated that age over 55 years, primary tumor in the upper portion of the thyroid, the number of central lymph node (CLN) and LLNM, primary tumor size, and the summed size of multi-foci tumors smaller than 1 cm were significantly associated with LLNM without CLNM (p < 0.05). Multivariate analysis revealed that LLNM without CLNM was more likely to occur in patients aged ≥55 years (odds ratio [OR], 2.309; 95% confidence interval [CI], 1.133-4.704; p = 0.021), and primary tumor in the upper portion of the thyroid (OR, 0.524; 95% CI, 0.295-0.934; p = 0.028).

CONCLUSION

The lymph node metastasis pattern in patients with PTC is not constant. Therefore, surgeons should evaluate the lateral lymph nodes, especially in patients older than 55 years or when the primary tumor is in the upper portion of the thyroid.

Predictive nomogram for central lymph node metastasis in papillary thyroid microcarcinoma based on pathological and ultrasound features

Background

Central lymph node metastases (CLNM) in papillary thyroid microcarcinoma (PTMC) are common, but management through prophylactic central lymph node dissection (pCLND) remains controversial. In this study, the independent predictors of CLNM in PTMC were retrospectively studied based on ultrasound and pathological data, and we aim to establish the prediction model to predict CLNM in PTMC.

Methods

This study included a total of 1,506 patients who underwent thyroid surgery for PTMC at the First Affiliated Hospital of Chongqing Medical University from 2015 to 2018. Ultrasound and clinicopathological features were summarized and analyzed. Univariate and multivariate analyses were performed to determine the risk factors associated with CLNM. The prediction model is established and verified according to the multivariate analysis results. The Kaplan-Meier curve was used to evaluate the effect of CLNM on survival.

Results

The CLNM rate was 44.5% (670/1,506). Multivariate analysis showed that men, younger age, smaller diameter, ETE, microcalcification, without Hashimoto's thyroiditis, and multifocal were independent risk predictors of CLNM. Nomogram has a good discriminative ability (C-index: 0.755 in the validation group), and the calibration effect is good. In the DCA curve, the CLNM prediction model performed better net benefit given any high-risk thresholds. The median follow-up time was 30 months (12-59 months), 116 cases were lost, and the follow-up rate was 92.8% (1,506/1,622). Of the 1,506 patients included, 12 (0.8%) experienced recurrence.

Conclusion

The likelihood of CLNM can be objectively quantified before surgery by using this reliable and accurate nomogram that combines preoperative ultrasound with clinicopathological features. Clinicians can use this nomogram to assess central lymph node status in patients with PTMC and consider prophylactic CND in patients with high scores.

Clinical and ultrasonic risk factors for high-volume central lymph node metastasis in cN0 papillary thyroid microcarcinoma: A retrospective study and meta-analysis

OBJECTIVE

Papillary thyroid microcarcinoma (PTMC) comprises more than 50% of all newly detected cases of papillary thyroid carcinoma (PTC). High-volume lymph node metastasis (involving >5 lymph nodes) (hv-LNM) is associated with PTMC recurrence. In half of the clinically node-negative (cN0) PTMC patients, central lymph node metastasis (CLNM) is pathologically present. However, clinical risk factors for high-volume CLNM (hv-CLNM) in cN0 PTMC have not been defined well. Therefore, we aimed to obtain evidence for hv-CLNM risk factors in cN0 PTMC.

DESIGN

Data on patients who visited our hospital between January 2020 and December 2021 were collected; a preoperative diagnosis of cN0 and a postoperative pathological confirmation of PTMC were obtained. After filtering by inclusion versus exclusion criteria, the obtained data (N = 2268) were included in the meta-analysis. Relevant studies published as of 10 April 2022, were identified from the Web of Science, PubMed, WANFANG, and CNKI databases. These eligible studies were included in the meta-analysis and the association between clinicopathological factors and hv-CLNM in cN0 PTMC was assessed. SPSS and MetaXL were used for statistical analyses.

RESULTS

The meta-analysis included 10 previous studies (11,734 patients) and 2268 patients enroled in our hospital for a total of 14,002 subjects. The results of which suggested that younger age (<40, odds ratio [OR] = 3.28, 95% confidence interval [CI] = 2.75-3.92, p < .001 or <45 odds ratio [OR] = 2.93, 95% CI = 2.31-3.72, p < .001), male sex (OR = 2.81, 95% CI = 2.25-3.52, p < .001), tumour size >5 mm (OR = 1.85, 95% CI = 1.39-2.47, p < .001), multifocality (OR = 1.88, 95% CI = 1.56-2.26, p < .001), extrathyroidal extension (OR = 2.58, 95% CI = 2.02-3.30, p < .001), capsule invasion (OR = 2.02, 95% CI = 1.46-2.78, p < .001), microcalcification (OR = 3.25, 95% CI = 2.42-4.36, p < .001) and rich blood flow (OR = 1.65, 95% CI = 1.21-2.25, p = .002) were the significant factors related to an elevated hv-CLNM risk in cN0 PTMC patients. Hashimoto thyroiditis (OR = 0.76, 95% CI = 0.55-1.07, p = .114), irregular margin (versus regular margin, OR = 0.96, 95% CI = 0.68-1.33, p = .787) and hypoechoic (versus nonhypoechoic, OR = 1.27, 95% CI = 0.84-1.92, p = .261) showed no significant association with hv-CLNM.

CONCLUSIONS

Younger age, tumour size >5 mm, males, extrathyroidal extension, multifocality, microcalcification, capsular invasion, and rich blood flow were the significant clinicopathological risk factors for hv-CLNM risk in cN0 PTMC patients. These predictors may compensate for the sensitivity of imaging diagnosis in the preoperative period, thus helping in the effective identification of PTMCs with an invasive phenotype.

Clinical and Ultrasonographic Features of Papillary Thyroid Carcinoma Located in the Isthmus

ABSTRACT

The aim of this research was to investigate the clinical and ultrasonographic features of papillary thyroid carcinoma (PTC) in the isthmus. A total of 823 patients with 823 PTCs including 133 in the isthmus and 690 in the lateral lobe were included in our study. All patients were confirmed by postoperative pathology. The clinical and ultrasonographic characteristics were retrospectively analyzed and compared. Univariate analysis and multivariate logistic regression analysis were performed. Multifactor analyses showed that PTC in the isthmus was significantly different from PTC originating from the lateral lobe in aspect ratio, microcalcification, extrathyroid extension, lymph node metastases, and lymph node density ( P < 0.05, for all). There were no significant differences in age, sex, tumor size, margin, halo, echogenicity, and homogeneity ( P > 0.05, for all). The results indicated that the sonographic appearances of PTC in the isthmus were relatively atypical; however, it had a higher incidence of extrathyroidal extension, central lymph node metastasis, and a tendency of higher lymph node density. Therefore, more careful ultrasound evaluation should be performed for these nodules.

Nomogram based on preoperative conventional ultrasound and shear wave velocity for predicting central lymph node metastasis in papillary thyroid carcinoma

OBJECTIVE

To establish a nomogram for predicting cervical lymph node metastasis (CLNM) based on the preoperative conventional ultrasound (US) and shear wave velocity (SWV) features of papillary thyroid carcinoma (PTC).

METHODS

A total of 101 patients with pathologically confirmed thyroid nodules were enrolled. These patients were divided into the CLNM-positive (n = 40) and CLNM-negative groups (n = 61). All patients underwent the preoperative conventional US and shear wave elastography (SWE) evaluation, and the US parameters and SWV data were collected. The association between SWV ratio and CLNM was compared to assess the diagnostic efficacy of SWV ratio alone as opposed to SWV ratio in combination with the conventional US for predicting CLNM.

RESULTS

There were significant differences in shape, microcalcification, capsule contact, SWV mean, and SWV ratio between the CLNM-positive and CLNM-negative groups (P < 0.05). Logistic regression analysis showed that taller-than-wide shape, microcalcification, capsule contact, and SWV ratio > 1.3 were risk factors for CLNM; Logistic(P)=-6.93 + 1.647 * (microcalcification)+1.138 * (taller-than-wide-shape)+1.612 * (capsule contact)+2.933 * (SWV ratio > 1.3). The area under the curve (AUC) of the receiver operating characteristic (ROC) of the model for CLNM prediction was 0.87, with 81.19% accuracy, 77.5% sensitivity, and 85.25% specificity.

CONCLUSION

The nomogram based on conventional US imaging in combination with SWV ratio has the potential for preoperative CLNM risk assessment. This nomogram serves as a useful clinical tool for active surveillance and treatment decisions.

Exploring risk factors for cervical lymph node metastasis in papillary thyroid microcarcinoma: construction of a novel population-based predictive model

BACKGROUND

Machine learning was a highly effective tool in model construction. We aim to establish a machine learning-based predictive model for predicting the cervical lymph node metastasis (LNM) in papillary thyroid microcarcinoma (PTMC).

METHODS

We obtained data on PTMC from the SEER database, including 10 demographic and clinicopathological characteristics. Univariate and multivariate logistic regression (LR) analyses were applied to screen the risk factors for cervical LNM in PTMC. Risk factors with P < 0.05 in multivariate LR analysis were used as modeling variables. Five different machine learning (ML) algorithms including extreme gradient boosting (XGBoost), random forest (RF), adaptive boosting (AdaBoost), gaussian naive bayes (GNB) and multi-layer perceptron (MLP) and traditional regression analysis were used to construct the prediction model. Finally, the area under the receiver operating characteristic (AUROC) curve was used to compare the model performance.

RESULTS

Through univariate and multivariate LR analysis, we screened out 9 independent risk factors most closely associated with cervical LNM in PTMC, including age, sex, race, marital status, region, histology, tumor size, and extrathyroidal extension (ETE) and multifocality. We used these risk factors to build an ML prediction model, in which the AUROC value of the XGBoost algorithm was higher than the other 4 ML algorithms and was the best ML model. We optimized the XGBoost algorithm through 10-fold cross-validation, and its best performance on the training set (AUROC: 0.809, 95%CI 0.800-0.818) was better than traditional LR analysis (AUROC: 0.780, 95%CI 0.772-0.787).

CONCLUSIONS

ML algorithms have good predictive performance, especially the XGBoost algorithm. With the continuous development of artificial intelligence, ML algorithms have broad prospects in clinical prognosis prediction.

Predictive Factors of Recurrence of Papillary Thyroid Microcarcinomas: Analysis of 2,538 Patients

Introduction  The incidence of papillary thyroid microcarcinoma (PTMC) has increased, and its treatment remains controversial.

Objective  To identify the clinical and pathological factors predictive of tumor recurrence.

Methods  We retrospectively analyzed 2,538 consecutive patients treated for PTMC, most submitted to total thyroidectomy (98%) followed by radioactive iodine (RAI) ablation (51.7%) at a cancer center from 1996 to 2015. The patients were stratified according to the American Thyroid Association (ATA) risk categories (low, intermediate, or high), and the clinicopathological features were evaluated by multivariate Cox regression analysis to identify independent prognostic factors for recurrence.

Results  After a mean follow-up of 58 months (range: 3 to 236.5 months), tumor recurrence was diagnosed in 63 (2.5%) patients, mostly in the lymph nodes. Distant metastasis occurred in 2 (0.1%) patients. There were no cancer-related deaths. The multivariate analysis showed that age < 55 years ( p  = 0.049; hazard ratio [HR]: 2.54; 95% confidence interval [95%CI]: 0.95 to 0.99), multifocality ( p  = 0.032; HR: 1.76; 95%CI: 1.05 to 2.96), and the presence of lymph-node metastasis ( p  < 0.001; HR: 3.69; 95%CI: 2.07–6.57) were independent risk factors for recurrence. Recurrence was observed in 29 (1.5%) out of 1,940 low-risk patients, 32 (5.4%) out of 590 intermediate-risk patients, and in 2 (25%) out of 8 high-risk patients.

Conclusions  The prognosis of PTMC is excellent, favoring a conservative treatment for most patients. Age < 55 years, multifocality, and node metastasis at diagnosis, as well the ATA staging system effectively predict the risk of recurrence. The presence of these risk factors can help identify patients who should be considered for more aggressive management and more frequent follow-up.

Extent of Surgery and the Prognosis of Unilateral Papillary Thyroid Microcarcinoma

It remains controversial whether patients with papillary thyroid microcarcinoma (PTMC) benefit from total thyroidectomy (TT) or thyroid lobectomy (TL). We aimed to investigate the impact of extent of surgery on the prognosis of patients with unilateral PTMC. Patients were obtained from the Surveillance, Epidemiology, and End Results database from 2004 to 2015. Cancer-specific survival (CSS) and overall survival (OS) were evaluated by Cox regression and Kaplan-Meier curves with propensity score matching. Of 31167 PTMC patients enrolled, 22.2% and 77.8% of which underwent TL and TT, respectively. Patients with TT were more likely to be younger, females, present tumors of multifocality, extrathyroidal extension, cervical lymph node metastasis (CLNM), distant metastasis, and receive radioactive iodine (RAI) compared with those receiving TL. The multivariate Cox regression model showed that TT was not associated with an improved CSS and OS compared with TL with hazard ratio (HR) and 95% confidence interval (CI) of 0.53 (0.25-1.12) and 0.86 (0.72-1.04), respectively. In addition, the Kaplan-Meier curves further confirmed the similar survival between TL and TT after propensity score matching. The subgroup analysis showed that TT was associated with better CSS for patients < 55 years, those with tumors of gross extrathyroidal extension, CLNM (N1b), and cases not receiving RAI with HR 95% CI of 0.13 (0.02-0.81), 0.12 (0.02-0.66), 0.11 (0.02-0.64) and 0.36 (0.13-0.90), respectively. TT predicted a trend of better OS for patients with N1b and distant metastasis after adjustment. In addition, TT was associated with better CSS than TL for patients with risk factors like N1b combined with gross extrathyroidal extension, and/or multifocality after matching. In conclusion, TL may be enough for low-risk PTMC patients. TT may improve the prognosis of unilateral PTMC patients with 2 or more risk clinicopathologic factors like CLNM, multifocality, extrathyroidal extension and a younger age compared with TL.

Added Value of Postoperative Radioiodine Scan for Staging and Risk Stratification in Papillary Thyroid Microcarcinoma

Objective

The complete staging and risk stratification of Papillary thyroid microcarcinoma (PTMC) is usually not done due to its theoretically low recurrence rates. This study aimed to determine the value of postoperative radioiodine diagnostic scan and SPECT/CT for the accurate staging and risk stratification in PTMC patients.

Methodology

This study was a retrospective review of PTMC patients from January 2014 to May 2017 who underwent I-131 scans. All PTMC patients were initially staged by the 8^th edition AJCC/TNM staging system and risk-stratified, based on clinical information, histopathology and stimulated thyroglobulin (sTg). After I-131 scan, staging and risk stratification were re-assessed. The proportion of patients who ended up with a higher stage and risk stratification were reported.

Results and Conclusion

Fifty-two patients were included. The overall upgrading of cancer stage was 7.7 %. The overall higher risk stratification was 19.2% with radioiodine-avid lymph node, lung, and bone metastases. Neck and paratracheal node metastases were found in 37.3% of the initial low-risk patients with sTg less than 5 ng/mL. Lung metastasis was found in the initial intermediate-risk patient. The I-131 scan helps to localize metastatic lesions and results in a higher stage in 50% of the initial high-risk patients. This study provides some evidence showing the value of postoperative radioiodine WBS for accurate staging and risk stratification in PTMC patients. Larger studies with analytical design should be further performed to prove its significant utility.

Application of Machine Learning Algorithms to Predict Central Lymph Node Metastasis in T1-T2, Non-invasive, and Clinically Node Negative Papillary Thyroid Carcinoma

Purpose: While there are no clear indications of whether central lymph node dissection is necessary in patients with T1-T2, non-invasive, clinically uninvolved central neck lymph nodes papillary thyroid carcinoma (PTC), this study seeks to develop and validate models for predicting the risk of central lymph node metastasis (CLNM) in these patients based on machine learning algorithms.

Methods: This is a retrospective study comprising 1,271 patients with T1-T2 stage, non-invasive, and clinically node negative (cN0) PTC who underwent surgery at the Department of Endocrine and Breast Surgery of The First Affiliated Hospital of Chongqing Medical University from February 1, 2016, to December 31, 2018. We applied six machine learning (ML) algorithms, including Logistic Regression (LR), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Decision Tree (DT), and Neural Network (NNET), coupled with preoperative clinical characteristics and intraoperative information to develop prediction models for CLNM. Among all the samples, 70% were randomly selected to train the models while the remaining 30% were used for validation. Indices like the area under the receiver operating characteristic (AUROC), sensitivity, specificity, and accuracy were calculated to test the models' performance.

Results: The results showed that ~51.3% (652 out of 1,271) of the patients had pN1 disease. In multivariate logistic regression analyses, gender, tumor size and location, multifocality, age, and Delphian lymph node status were all independent predictors of CLNM. In predicting CLNM, six ML algorithms posted AUROC of 0.70–0.75, with the extreme gradient boosting (XGBoost) model standing out, registering 0.75. Thus, we employed the best-performing ML algorithm model and uploaded the results to a self-made online risk calculator to estimate an individual's probability of CLNM (https://jin63.shinyapps.io/ML_CLNM/).

Conclusions: With the incorporation of preoperative and intraoperative risk factors, ML algorithms can achieve acceptable prediction of CLNM with Xgboost model performing the best. Our online risk calculator based on ML algorithm may help determine the optimal extent of initial surgical treatment for patients with T1-T2 stage, non-invasive, and clinically node negative PTC.

Web-Based Ultrasonic Nomogram Predicts Preoperative Central Lymph Node Metastasis of cN0 Papillary Thyroid Microcarcinoma

BACKGROUND

Many clinicians are facing the dilemma about whether they should apply the active surveillance (AS) strategy for managing Clinically Node-negative (cN0) PTMC patients in daily clinical practice. This research plans to construct a dynamic nomogram based on network, connected with ultrasound characteristics and clinical data, to predict the risk of central lymph node metastasis (CLNM) in cN0 PTMC patients before surgery.

METHODS

A retrospective analysis of 659 patients with cN0 PTMC who had underwent thyroid surgery and central compartment neck dissection. Patients were randomly (2:1) divided into the development cohort (439 patients) and validation cohort (220 patients). The group least absolute shrinkage and selection operator (Group Lasso) regression method was used to select the ultrasonic features for CLNM prediction in the development cohort. These features and clinical data were screened by the multivariable regression analysis, and the CLNM prediction model and web-based calculator were established. Receiver operating characteristic, calibration curve, Clinical impact curve and decision curve analysis (DCA) were used to weigh the performance of the prediction model in the validation set.

RESULTS

Multivariable regression analysis showed that age, tumor size, multifocality, the number of contact surface, and real-time elastography were risk factors that could predict CLNM. The area under the curve of the prediction model in the development and validation sets were 0.78 and 0.77, respectively, with good discrimination and calibration. A web-based dynamic calculator was built. DCA proved that the prediction model had excellent net benefits and clinical practicability.

CONCLUSIONS

The web-based dynamic nomogram incorporating US and clinical features was able to forecast the risk of preoperative CLNM in cN0 PTMC patients, and has good predictive performance. As a new observational indicator, NCS can provide additional predictive information.

A Nomogram Based on Clinical and Ultrasound Characteristics to Predict Central Lymph Node Metastasis of Papillary Thyroid Carcinoma

BACKGROUND

The status of lymph nodes in the central compartment is crucial to determining the surgical strategies for papillary thyroid carcinoma (PTC). We aimed to develop a nomogram for predicting central lymph node metastasis (CLNM).

METHODS

A total of 886 PTC patients who underwent total thyroidectomy or lobectomy with central neck dissection (CND) from July 2019 to June 2020 were retrospectively retrieved. Clinical and ultrasound features were collected. Univariate and multivariate analysis were performed to determine risk factors of CLNM. A nomogram for predicting CLNM was developed, internal and external calibration was performed for the established model.

RESULTS

Variables (sex, chronic lymphocytic thyroiditis, tumor size, the number of foci, tumor location, margin) significantly associated with CLNM were included in the nomogram. The nomogram showed excellent calibration in the training group and validation group, with area under curves of 0.806 (95% CI, 0.771 to 0.825), and 0.799 (95% CI, 0.778-0.813) respectively.

CONCLUSION

Through this accurate and easy-to-use nomogram, the possibility of CLNM can be objectively quantified preoperatively. Clinicians can use this nomogram to evaluate the status of lymph nodes in PTC patients and consider prophylactic CND for those with high scores.

Management of cN0 papillary thyroid microcarcinoma patients according to risk-scoring model for central lymph node metastasis and predictors of recurrence

BACKGROUND

The role of routine prophylactic central neck dissection (pCND) in clinically lymph node-negative (cN0) papillary thyroid microcarcinoma (PTMC) patients remains controversial. This retrospective study aimed to identify the clinical and pathologic factors of central lymph node metastasis (CLNM) and recurrence in PTMC patients.

METHODS

A total of 371 cN0 PTMC patients from two hospitals were retrospectively analyzed. All patients underwent thyroidectomy plus pCND between January 2010 and January 2018. Clinicopathological features were collected, univariate and multivariate analyses were performed to determine the risk factors of CLNM. A scoring model was constructed on the basis of the results of independent risk factors of CLNM. The Cox proportional hazards model was used to analyze the risk factors of recurrence.

RESULTS

CLNM occurred in 123 (33.2%) patients. Multivariate analysis showed male, tumor size > 0.75 cm, multifocality, extrathyroidal extension (ETE) and tumor in the middle/lower pole were independent risk predictors of CLNM (P < 0.05). A seven-point risk-scoring model was established to predict the stratified CLNM in cN0 PTMC patients. Multivariate Cox regression model showed ETE, vascular invasion and CLNM were independent risk predictors of recurrence (P < 0.05).

CONCLUSION

Our study suggested that routine pCND should be performed for cN0 PTMC patients with score ≥ 3 according to the risk-scoring model. Moreover, patients with risk factors of recurrence should consider more complete treatment and more frequent follow-up.

Ultrasonography for the Prediction of High-Volume Lymph Node Metastases in Papillary Thyroid Carcinoma: Should Surgeons Believe Ultrasound Results?

Background

Lymph node metastasis (LNM) often occurs in papillary thyroid carcinoma (PTC); the efficacy of ultrasound for predicting high-volume lymph node metastases (LNMs) in patients with PTC remains unexplored.

Methods

The medical records of 2073 consecutive PTC patients were reviewed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate the efficacy of ultrasound. Risk factors for LNM/high-volume LNMs and lymph node involvement on ultrasound (usLNM) were identified by univariate and multivariate analyses.

Results

Of all the patients, 936 (45.2%) patients had LNMs, and 254 (12.3%) patients had high-volume LNMs. The sensitivity of ultrasound for detecting LNM/high-volume LNMs was 27.9% and 63.8%, respectively; the specificity was 93.1% and 90.3%, respectively. The NPV for ultrasound in detecting high-volume LNMs was 94.7%. In multivariate analysis, male sex (OR = 2.108, p < 0.001), tumor diameter > 1.0 cm (OR = 2.304, p < 0.001) and usLNM (+) (OR = 12.553, p < 0.001) were independent clinical risk factors for high-volume LNMs. Tumor diameter > 1 cm (OR = 3.036, p < 0.001) and male sex (OR = 1.642, p < 0.001) were independent clinical risk factors for usLNM; a skilled sonographer (OR = 1.121, p = 0.358) was not significantly associated with usLNM.

Conclusions

Lymph node involvement found by ultrasound has great predictive value for high-volume LNMs; the NPV is very high for patients without lymph node involvement on ultrasound. The ultrasound results do not appear to be influenced by the experience of the sonographer.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05755-0) contains supplementary material, which is available to authorized users.

Papillary thyroid carcinoma: an ultrasound-based nomogram improves the prediction of lymph node metastases in the central compartment

OBJECTIVES

To develop a nomogram based on postoperative clinical and ultrasound findings to quantify the probability of central compartment lymph node metastases (CLNM).

METHODS

A total of 952 patients with histologically confirmed papillary thyroid carcinoma (PTC) were included in this retrospective study and assigned to three groups based on sex and age. The strongest predictors for CLNM were selected according to ultrasound imaging features, and an ultrasound (US) signature was constructed. By incorporating clinical characteristics, a predictive model presented as a nomogram was developed, and its performance was assessed with respect to calibration, discrimination and clinical usefulness.

RESULTS

Predictors contained in the nomogram included US signature, US-reported LN status and age. The US signature was constructed with tumour size and microcalcification. The nomogram showed excellent calibration in the training dataset, with an AUC of 0.826 (95% CI, 0.765-0.887) for male patients, 0.818 (95% CI, 0.746-0.890) for young females and 0.808 (95% CI, 0.757-0.859) for elder females. For male and young female patients, application of the nomogram to the validation cohort revealed good discrimination, with AUCs of 0.813 (95% CI, 0.722-0.904) and 0.814 (95% CI, 0.712-0.915), respectively. Conversely, for elderly female patients, the nomogram failed to show good performance with an AUC of 0.742 (95% CI, 0.661-0.823).

CONCLUSION

This ultrasound-based nomogram may serve as a useful clinical tool to provide valuable information for treatment decisions, especially for male and younger female patients.

KEY POINTS

• Age, gender, US-reported LN status and US signature were the strongest predictors of CLNM in PTC patients and informed the development of a predictive nomogram. • Microcalcification was the strongest predictor in the US signature, as CLMN was identified in approximately 92% of patients characterised by diffuse microcalcification. • Stratified by sex and age, this nomogram achieved good performance in predicting CLNM, especially in male and young female patients. This prediction tool may be useful as an imaging marker for identifying CLNM preoperatively in PTC patients and as a guide for personalised treatment.

The clinicopathologic characteristics of familial and sporadic papillary thyroid carcinoma in Turkish patients

Background/aim

The aim of this study is to investigate clinicopathologic features of familial papillary thyroid carcinoma (fPTC) and compare them with sporadic papillary thyroid carcinoma (sPTC) in Turkish patients. A retrospective analysis of the papillary thyroid carcinoma (PTC) cases, with or without family history with a follow-up around 10 years was performed.

Materials and methods

A series of patients with fPTC (82 fPTC families with 146 affected individuals) were compared with patients with sPTC (n = 112). The clinicopathologic features [(age, gender, histologic subtype, tumour size, bilaterality, multifocality, extrathyroidal extension (ETE), lymph node metastasis (LNM)] and treatment procedures (lymph node dissection, radioactive iodine ablation), and the outcomes like recurrences in the neck region, distant metastasis, and the need for reoperation were compared between the groups.

Results

When the groups were compared, there was no significant difference in age (P = 0.449), and tumour size (P = 0.898) between familial and sporadic PTC patients. fPTC group had a significantly higher risk of male gender (P=0.001), bilaterality (P = 0.004), multifocality (P = 0.011), LNM (P = 0.013), ETE (P = 0.040), and distant metastasis (P ≤ 0.0001) than the sPTC group. However, recurrence rate was similar between the 2 groups (P = 0.436).

Conclusion

The results of this study confirms a more aggressive nature in fPTC patients, in terms of bilaterality, multifocality, ETE, LNM, and distant metastasis, compared to sPTC patients in Turkish population.

Predictive Factors for Lateral Lymph Node Metastasis and Skip Metastasis in Papillary Thyroid Carcinoma

In papillary thyroid cancer (PTC) patients, cervical lymph node metastases are common, which disseminate sequentially from the central neck to the lateral neck. However, there is also a chaotic pattern of lymph node metastasis occasionally. In this study, we summarized 653 PTC patients who underwent thyroidectomy and central lymph node dissection with or without lateral lymph node dissection from two hospitals to investigate the pattern and risk factors of lateral lymph node metastasis (LLNM) and skip metastasis. LLNM was significantly associated tumor size > 1 cm, presence of extrathyroidal extension, tumors in the upper-lateral pole, and the number of metastatic lymph nodes in the central compartment. The frequency of skip metastasis was 22.5% (20 of 89 patients). Multivariate analyses showed tumor size ≤ 1 cm, and tumors in the upper-lateral pole were separately and independently associated with the risk of skip metastasis. Presence of LLNM affected the recurrence-free survival (RFS). RFS did not show the significantly difference between patients with LLNM and skip metastasis. Despite the low incidence of skip metastasis, attention should be paid to the possibility of LLNM even in the absence of central lymph node metastases. Besides, for patients with risk factors of LLNM or skip metastasis, detailed preoperative examination for the lateral compartment, especially the level III, is essential.

Risk Factors of Metastatic Lymph Nodes in Papillary Thyroid Microcarcinoma

INTRODUCTION

Papillary thyroid microcarcinoma (PTMC) usually has an indolent course, but some have worse prognostic factors, such as the presence of central (6.9%-51.5%) and lateral (3%-49.6%) lymph node metastases. The aim of this study is to analyze the factors associated with PTMC with metastatic lymph nodes and its long-term prognosis.

METHODS

Retrospective study whose study population consists of patients with PTMC (size ≤1cm). Patients with previous thyroid surgery, other synchronous malignancies and ectopic location of the PTMC were excluded. Two groups were compared: PTMC without metastatic lymph nodes (group 1) and PTMC with metastatic lymph nodes (group 2). A multivariate analysis using a logistic regression model and a Kaplan-Meier survival analysis with log-rank test were performed.

RESULTS

Out of the 161 selected patients, 9.3% (n=15) had metastatic lymph nodes. Multifocality (OR 5.284, 95%CI 1.056-26.443; P=.043) and extrathyroidal extension (OR 7.687, 95%CI 1.405-42.050; P=.019) were associated with the presence of metastatic lymph nodes. In PTMC with metastatic lymph nodes, more aggressive treatments were performed: lymphadenectomy (4.8% vs. 100%; P<.001) and radioactive iodine (24.7% vs. 100%; P<.001). During a mean follow-up of 119.8±65 months, one recurrence was detected in group 2 (0% vs. 6.7%; P=.093). No patients died due to the disease.

CONCLUSIONS

Multifocality and extrathyroidal extension of PTMC were associated with the presence of metastatic lymph nodes. Metastatic PTMC, with more aggressive treatments, presents an excellent long-term prognosis.

Management of Clinically Solitary Papillary Thyroid Carcinoma Patients According to Risk-Scoring Model for Contralateral Occult Carcinoma

OBJECTIVE

The aim of this study was to investigate risk factors of occult carcinoma in clinically solitary papillary thyroid carcinoma (PTC) patients, and to put emphasis on the predictive value of risk-scoring model to determine the optimal scope of surgery.

METHODS

A total of 573 clinically solitary PTC patients who underwent total thyroidectomy (TT) from two hospitals were retrospectively analyzed. Clinicopathological features were collected, univariate and multivariate analyses were performed to determine risk factors of occult carcinoma. The Cox proportional hazards model was used to analyze the risk factors of recurrence. A scoring model was constructed according to independent risk factors of contralateral occult carcinoma.

RESULTS

19.2% of clinically solitary PTC patients had occult carcinoma, among which 3.7% patients had ipsilateral occult carcinoma and 15.5% patients had contralateral occult carcinoma. Factors such as male, the presence of benign nodule, and vascular invasion increase the risk of ipsilateral occult carcinoma. Tumor size >1 cm, the presence of benign nodule, extrathyroidal extension, central lymph node metastasis, lateral lymph node metastasis are independent predictors of contralateral occult carcinoma. Contralateral occult carcinoma is the independent predictor of recurrence. A 10-point risk-scoring model was established to predict the contralateral occult carcinoma in clinically solitary PTC patients.

CONCLUSION

Lobectomy is sufficient for clinically solitary PTC patients with risk factors of ipsilateral occult carcinoma. For clinically solitary PTC patients with score ≥4, careful preoperative evaluations are required to rule out the contralateral occult carcinoma. Even if contralateral occult carcinoma is not detected preoperatively, TT is recommended for high-risk patients.

Risk factors for high-volume lymph node metastases in cN0 papillary thyroid microcarcinoma

Background

Lymph node metastasis (LNM) often occurs in clinical lymph node negative (cN0) papillary thyroid microcarcinoma (PTMC). The risk factors for LNM, especially for high-volume LNM, were investigated in this study.

Methods

The medical records of 1,974 consecutive PTMC patients admitted to the Peking Union Medical College Hospital (PUMCH) from 2013 to 2015 were reviewed. Their clinicopathological features were collected. Univariate and multivariate analyses were performed to identify the risk factors for LNM/high-volume LNM.

Results

Of all the patients, cervical lymph node metastases were detected in 690 patients (34.95%), and high-volume LNM was detected in 75 patients (3.80%). The results of univariate analysis revealed that sex, age, chronic thyroiditis, multifocality, and tumor diameter were significantly correlated with LNM (P<0.05) and that sex, age, multifocality, and tumor diameter were significantly correlated with high-volume LNM (P<0.05). Multivariate logistic regression analysis demonstrated that male sex [odds ratio (OR) =1.657, P<0.001], multifocality (OR =1.601, P<0.001), and tumor diameter >0.5 cm (OR =1.770, P<0.001) were independent risk factors for LNM; age of 40-59 years old (OR =0.427, P<0.001), age ≥60 years old (OR =0.291, P<0.001), and chronic thyroiditis (OR =0.562, P<0.001) were independent protective factors for LNM. For high-volume LNM, male sex (OR =2.250, P=0.002), tumor diameter >0.5 cm (OR =3.664, P=0.013) and multifocality (OR =2.034, P=0.004) were independent risk factors, whereas age ≥40 years old (OR =0.240, P<0.001) was an independent protective factor.

Conclusions

Lymph node metastases are common in cN0 PTMC, whereas high-volume LNM is rare. Active surveillance may be reasonable for patients with tumor diameter ≤0.5 cm, age ≥40 years old, female sex and isolated lesions.

Predicting factors of lateral neck lymph node metastases in patients with papillary thyroid microcarcinoma

The incidence of papillary thyroid microcarcinoma (PTMC) has increased dramatically in recent years. Compared with central lymph node metastases, lateral neck lymph node (LNLN) metastases in patients with PTMC were less studied. The aim of the present study is to analyze the predicting factors associated with LNLN metastases in patients with PTMC.A total of 3514 patients underwent thyroid surgery at our hospital from January 2017 to December 2017, and 936 patients with PTMC were selected and assessed retrospectively. They were further divided into 2 groups based on whether LNLN metastases existed or not. The relationship between LNLN metastases and clinicopathologic features of PTMC was analyzed.LNLN metastases were confirmed in 126 patients. Univariate and multivariate analyses found 5 independent factors associated with LNLN metastases. They were tumor size (≥0.7 cm) [odds ratio (OR) = 1.960, 95% confidence interval (95% CI) 1.227-3.131; P = .005], multifocality (OR = 2.254, 95% CI 1.398-3.634; P = .001), tumor location (upper portion) (OR = 6.312, 95% CI 3.853-10.340; P < .001), thyroid cancer family history (OR = 7.727, 95% CI 2.227-26.818; P = .001), and central lymph node metastases (OR = 11.810, 95% CI 6.547-21.302; P < .001).The findings of our study indicated that LNLN metastases were not rare in patients with PTMC, and tumor size (≥0.7 cm), multifocality, tumor location (upper portion), thyroid cancer family history, and central lymph node metastases were independent factors for LNLN metastases. In order to perform individualized management, LNLN should be meticulously evaluated when these features are detected.

Determine the Optimal Extent of Thyroidectomy and Lymphadenectomy for Patients With Papillary Thyroid Microcarcinoma

Background: The optimal extent of surgery, including lymph node dissection, remains controversial in papillary thyroid microcarcinoma (PTMC). Determining risk factors of central lymph node metastasis (CLNM) and recurrence-free survival (RFS) may help surgeons determine individualized surgery. Methods: A total of 353 patients with PTMC were retrospectively analyzed, including 263 with overt PTMC and 90 with incidental PTMC. The recurrence rates between different extents of thyroidectomy were compared. The relationship between CLNM and clinicopathologic factors was analyzed. The Cox regression model was used to determine the risk factors for RFS. Results: Lobectomy/total thyroidectomy (TT) with central neck dissection (CND) was performed in 263 overt PTMC patients, and lobectomy/partial thyroidectomy was performed in 90 incidental PTMC patients. In 263 overt PTMC patients, 93 (26.3%) had CLNM only and 13 (3.7%) had both CLNM and lateral lymph node metastases (LLNM). Multifocal PTMC patients who underwent lobectomy had a higher rate of thyroid bed and lymph node recurrence than patients who underwent TT (P < 0.05). Independent predictors for CLNM were age <45 years, tumor size >5 mm and presence of extrathyroidal extension (ETE). Tumor size >5 mm, multifocality, presence of ETE, presence of CLNM, and presence of LLNM were the significant factors related to the RFS. Conclusion: Fine-needle aspiration biopsy is advised to distinguish incidental PTMC from the benign nodules. For multifocal PTMC patients, TT should be performed to reduce recurrence. Routine prophylactic CND can be recommended in PTMC patients with independent risk factors of CLNM. Aggressive surgery and close follow-up are essential for patients with risk factors of RFS.

RISK FACTORS FOR CENTRAL LYMPH NODE METASTASES IN PATIENTS WITH PAPILLARY THYROID MICROCARCINOMA

OBJECTIVES

Papillary thyroid carcinoma with a maximum tumor diameter no more than 10 mm is defined as papillary thyroid microcarcinoma (PTMC). The proportion of newly diagnosed PTMCs has increased significantly in recent years. Different guidelines have different comments about optimal management of PTMC, especially on prophylactic central lymph node (CLN) dissection. The aim of the present study was to analyze the risk factors for CLN metastases in patients with PTMC.

METHODS

A total of 4,389 patients underwent thyroid surgery at our center from January 2017 to March 2018, and 2,129 patients with PTMC were selected and assessed retrospectively. The relationship between CLN metastases and clinicopathologic features of PTMC were analyzed by both univariate and multivariate analyses.

RESULTS

Of the 2,129 patients with PTMC, CLN metastases were confirmed by pathology in 923 patients. Univariate and multivariate analyses found several independent factors associated with CLN metastases. They were male gender (odds ratio [OR], 1.694; 95% confidence interval [CI], 1.386 to 2.071; P<.001), younger age (<45 years) (OR, 2.687; 95% CI, 2.196 to 3.288; P<.001), larger tumor size (>5 mm) (OR, 2.168; 95% CI, 1.782 to 2.636; P<.001), positive CLN metastases via ultrasound (OR, 4.939; 95% CI, 3.534 to 6.902; P<.001), and multifocality (OR, 1.424; 95% CI, 1.176 to 1.724; P<.001).

CONCLUSION

CLN metastases are common in PTMC patients. Male gender, younger age (<45 years), larger tumor size (>5 mm), positive CLN metastases via ultrasound, and multifocality are independent risk factors for CLN metastases. Our data should be considered in the decision-making process related to performing CLN dissection.

ABBREVIATIONS

CLN = central lymph node; PTC = papillary thyroid carcinoma; PTMC = papillary thyroid microcarcinoma.

Risk factors of central lymph node metastasis in papillary thyroid carcinoma: A retrospective cohort study

OBJECTIVE

The aim of this study was to explore the risk factors that were associated with central lymph node metastases (CLNM) in papillary thyroid carcinoma (PTC) patients.

METHODS

A total of 180 patients with PTC who underwent surgery in our hospital between January 2014 and December 2016 were identified retrospectively. The relationship between clinicopathological factors and CLNM were analyzed by univariate and multivariate logistic regression.

RESULTS

The incidence of CLNM was 67.8% (122/180) in PTC patients. Univariate analysis showed that multifocality (p = 0.002), HT (p < 0.001) and LVI (p < 0.001) were significant associated with CLNM. No significant associations were found between factors and CLNM, including age, gender, tumor size and ETE. Multivariate logistic regression analysis showed that multifocality (p = 0.011), HT (p < 0.001) and LVI (p < 0.001) were independent predictors of CLNM in PTC patients.

CONCLUSIONS

Our study identified several independent risk factors predicting CLNM in PTC patients, such as multifocality, HT and LVI. The CLNM is very common in PTC patients, and routine prophylactic central neck dissection (PCND) may recommended in PTC patients with those risk factors of CLNM.

Sonographic features of papillary thyroid microcarcinoma predicting high-volume central neck lymph node metastasis

OBJECTIVE

To study the correlations between the sonographic features of papillary thyroid microcarcinoma (PTMC) and the presence of high-volume lymph node metastasis.

METHOD

Medical records of 2363 PTMC patients were reviewed form October 2013 to December 2015. All the patients with lymph node metastasis identified by histopathology were included. Preoperative sonographic features, such as multifocality, tumour size, echogenicity, calcification, vascularity of papillary microcarcinoma, and capsule invasion, were recorded. Univariate and multivariate analyses were performed to investigate the relationships between sonographic features and high-volume lymph node metastasis (number of metastatic lymph nodes >5).

RESULTS

In total, 152 patients had high-volume central lymph node metastasis (6.4%, 152/2363). Multiple logistic regression analysis showed that the preoperative ultrasonic features of microcalcifications (OR = 3.33, p = 0.022), larger tumour size (>7 mm) (OR = 2.802, p < 0.001), and capsule invasion (OR = 2.141, p = 0.006) were independent risk factors for high-volume lymph node metastasis in the central compartment of PTMC.

CONCLUSION

The sonographic features of primary papillary microcarcinoma of the thyroid are correlated with high-volume central lymph node metastasis.

A meta-analysis on the effect of operation modes on the recurrence of papillary thyroid microcarcinoma

Whether total thyroidectomy reduces the recurrence rate in patients with papillary thyroid microcarcinoma (PTMC) is currently controversy. Conclusions of sporadic, inconsistent, and mono-institutional studies need a meta-analysis to evaluate. 525 relevant studies were obtained from initial search on PubMed, 511 studies were excluded by inclusion and exclusion criteria. Eligible data were extracted from each included study. The Odds ratios (ORs) and 95% confidence interval (CI) were used to assess the difference in the recurrence rates between PTMC patients treated with total thyroidectomy and non-total thyroidectomy. OR and 95% CI were calculated using a fixed-effects or a random-effects model. The Q statistic was used to evaluate homogeneity and Beggs test was used to assess publication bias. 14 studies meeting the inclusion criteria were included in this meta-analysis. The over all recurrence rates of pooled patients with total thyroidectomy and non-total thyroidectomy were 2.83% and 2.84% respectively. Primary random-effects model analysis showed, no significant difference of recurrence rates existed between two operation modes (OR = 0.732, 95% CI: 0.444 - 1.208), while, high heterogeneity among studies was found, I-squared index (I2) = 40.2%. After remove one study with high heterogeneity, the OR of the pooled recurrence rates of the total thyroidectomy and the non-total thyroidectomy groups was 0.786 (95% CI: 0.363 - 1.701), further suggesting no significant difference of the recurrence rate exists between two operation modes. Our meta-analysis demonstrated postoperative recurrence of PTMC is not reduced by total thyroidectomy, non-total thyroidectomy is also a good choice to treat PTMC patients.

Risk factors of central lymph node metastasis of papillary thyroid carcinoma: A single-center retrospective analysis of 3273 cases

Due to the lack of an accurate preoperative diagnostic method of central lymph node metastasis (CLNM) of papillary thyroid cancer (PTC), the prophylaxis of central lymph node dissection remains controversial. The present study investigated the clinicopathological features of PTC patients and the risk factors of CLNM. The clinicopathological features of PTC patients with respect to sex, age, initial symptoms, observation, tumor diameter, multifocality, extrathyroidal invasion, and pathological data combined with other thyroid diseases, were analyzed retrospectively. The risk factors of CLNM were analyzed by Chi-squared test and multivariate logistic regression model. The CLNM rate of PTC was 40.6% (1331/3273). On average, 7.0 (4.0, 12.0) central lymph nodes were dissected, and 3.70 (±3.8) lymph nodes were proved to be metastatic. Univariate analysis showed that sex (P < .001), age (P < .001), tumor diameter (P < .001), extrathyroid invasion (P < .001), multifocality (P = .001), concurrent nodular goiter (P < .001), initial symptoms (P < .001), and observation or not (P < .001) were related to CLNM. The observation time was neither related to CLNM (P = .469) nor extrathyroidal invasion (P = .137). Tumors localized in the lower part of the thyroid were the risk factors for CLNM (P < .001) while multifocality was unrelated (P = .68). The metastasis rate of bilateral multiple regions > unilateral multiple regions > single region (P = .003). Multivariate logistic regression analysis showed that sex, age, tumor diameter, extrathyroidal invasion, and observation were independent risk factors of CLNM. Male, younger age, large tumor size, and extrathyroidal invasion were independent risk factors for CLNM. CLNM was related to multiple regions occupied by tumors in the thyroid but unrelated to multifocality. The tumor occupying a single region and localized in the lower part of thyroid could be used as a predictive factor for CLNM. For tumors that could not be diagnosed as benign or malignant, observation may be an option, since no evidence of disease progression was presented during observation.

Risk prediction in children and adults less than 45 years old with papillary thyroid cancer

The incidence of papillary thyroid cancer is increasing faster than any other cancer in young patients. The purpose of this review is to discuss the most recent determinants of risk of recurrence and compromised outcomes in this population. Areas covered: This review discusses the most updated data on patient age, including children and young adults, extent of disease and subsequent dynamic staging over time, molecular markers for disease aggressiveness, adequacy of surgical resection and surgeon volume, and novel therapies for advanced non-resectable disease as predictors of patient outcomes. Expert commentary: Young patients enjoy excellent outcomes, with long-term survivorship, but face higher risks of short-term complications and disease recurrence. Thoughtful evaluation of the extent of disease, tumor features associated with more aggressive behavior, the presence of locoregional or distant metastases, and an understanding of molecular changes in their tumors are important areas of consideration. High-volume surgeons should work collaboratively with endocrinologists, radiologists, and pathologists specializing in thyroid cancer to help patients achieve excellent outcomes. Emerging data challenging the status quo regarding the relative importance of patient age, tumor features, and dynamic risk-adjustment for overall prognosis of these patients will likely impact future care and staging systems.

Relationships between clinicopathological prognostic factors in papillary thyroid microcarcinoma: a refined analysis based on 428 cases

A clear definition of the prognostic factors for papillary thyroid microcarcinoma (PTMC) is still debatable, as the tumor characteristics which indicate a high risk of metastasis are little known. We investigated the clinicopathological profile of a large group of PTMC, aiming to ascertain possible relationships between a set of clinicopathological characteristics and four parameters expressing tumor extension and aggressiveness (namely lympho-vascular invasion, thyroid capsule invasion, extrathyroidal extension and lymph node metastasis). For 428 patients, the following data were retrospectively documented: sex, age, tumor size, histological variant, associated thyroid pathology, location (subcapsular, intraparenchymal), unilateral or bilateral involvement, number of foci, lympho-vascular invasion, thyroid capsule invasion, extrathyroidal extension and lymph node metastasis. Data were analyzed using univariate and multivariate logistic regression analysis. Multivariate analysis confirmed that the tumor size is a negative prognostic factor for lympho-vascular invasion, thyroid capsule invasion, extrathyroidal extension and lymph node metastasis. We also demonstrated a strong relationship between the subcapsular location and lympho-vascular and capsule invasion, and extrathyroidal extension. The multifocality was correlated only with thyroid capsule invasion and extrathyroidal extension. Regarding the histological variants, the only validated correlation was between the oncocytic variant and extrathyroidal extension. Our work contributes to the validation of PTMC prognostic factors, useful in stratification of PTMC in high or low risk classes, and able to explain the behavioral differences in the tumor development.

Identification of risk factors of central lymph node metastasis and evaluation of the effect of prophylactic central neck dissection on migration of staging and risk stratification in patients with clinically node-negative papillary thyroid microcarcinoma

OBJECTIVE

The first aim of this study was to explore the risk factors that were associated with central lymph node metastasis (CLNM) in patients with clinically node-negative papillary thyroid microcarcinoma (cN₀ PTMC) after prophylactic central neck dissection (PCND). The second aim was to evaluate the influence of PCND on migration of TNM staging and risk stratification (RS) in patients with cN₀ PTMC.

METHODS

A total of 295 cN₀ PTMC patients who underwent thyroidectomy with PCND in the Department of General Surgery at Guangdong General Hospital between March 2014 to December 2015 were assessed retrospectively. The relations of CLNM with clinicopathologic characteristics of cN₀ PTMC were analyzed by univariate and multivariate logistic regression. The effect of PCND on migration of TNM staging and RS was also observed.

RESULTS

The incidence of CLNM was 42.4% (125 of 295 cases) in patients with cN₀ PTMC. Univariate analysis showed that age (P=0.000), ultrasonographic tumor size (P=0.009), pathologic tumor size (P=0.005), and multifocality (P=0.031) were significantly associated with the incidence of CLNM. No significant correlations were found between the presence of CLNM and other variables such as gender (P=0.399), bilaterality (P=0.118), capsular invasion (P=0.111), lymphovascular invasion (P=0.184), extent of thyroidectomy (P=0.319) and lymphadenectomy (P=0.458). Multivariate logistic regression analysis revealed that age <45 years (P=0.000) and multifocality (P=0.033) were independent predictors of CLNM in patients with cN₀ PTMC. Because of the identification of CLNM in the implementation of PCND, 42 (14.2%) patients were upstaged, and 118 (40.0%) patients upgraded in RS.

CONCLUSIONS

CLNM is highly prevalent in cN₀ PTMC. Age <45 years and multifocality are independent risk factors of CLNM in cN₀ PTMC patients. PCND can identify CLNM, which allows more accurate TNM staging/RS and may have an important impact on postoperative treatment in cN₀ PTMC patients.

Mapping the distribution of nodal metastases in papillary thyroid carcinoma: Where exactly are the nodes?

OBJECTIVE

To characterize nodal disease of patients presenting with papillary thyroid carcinoma (PTC) STUDY DESIGN: Retrospective chart review.

METHODS

PTC patients who underwent thyroidectomy and/or neck dissection (revision/primary) from 2004 to 2009 at a tertiary-care hospital were reviewed. Preoperative computed tomography (CT) scan and ultrasonography were utilized to identify macroscopic, clinically apparent nodal metastasis (cN+). Demographic data, type of surgery, nodal disease, and primary tumor information were recorded.

RESULTS

Of 416 patients reviewed, 35% had cN+ on initial presentation (IP); of these, 88% and 50% had central (CND) and lateral nodal disease (LND), respectively. The presence of ectopic nodal (END) metastases (nodal disease outside typical CND or LND locations) was absent on IP but occurred in 9% of patients with nodal recurrence. END was typically found in the retropharyngeal area but also was noted in the sublingual region, subcutaneous location, axilla, and chest wall. Extrathyroidal extension (ETE) was found in 8.9% without nodal disease, 33.1% with nodal disease, and 57.1% with END (P < 0.0001). Primary tumor size greater than 4 cm (P = 0.05) was associated with nodal disease.

CONCLUSION

This report represents a large series describing characteristics of the primary PTC tumor and associated nodal disease not only in the central and lateral neck but also in the ectopic locations. Our results suggest that a significant proportion of patients will have nodal disease in the central compartment on IP, especially younger patients. ETE and tumor size are associated with macroscopic nodal disease (including END). Nine percent of the patients with nodal recurrence had ectopic nodes occurring in various locations, most commonly in the retropharynx. CT scan can assist with identification and surgical planning of recurrent nodal disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1959-1964, 2017.

Clinicopathological features for predicting central and lateral lymph node metastasis in papillary thyroid microcarcinoma: Analysis of 66 cases that underwent central and lateral lymph node dissection

Currently the surgical approach for papillary thyroid microcarcinoma (PTMC), particularly the range of lymph node dissection, remains controversial. The present study aims to evaluate the risk factors for central and lateral lymph node metastasis (CLNM and LLNM) for appropriate clinical decision of neck lymph node dissection in PTMC. A total of 66 cases of PTMC that underwent unilateral or bilateral lobectomy plus prophylactic cervical lymph node dissection were collected for clinicopathological evaluation, including age, gender, tumor size, subtypes, extrathyroidal invasion, multifocality, calcifications, loss of cellular polarity/cohesiveness (LOP/C) in the invasive front, CLNM and LLNM, and retrospectively analysis. Univariate analysis revealed that LOP/C was significantly associated with CLNM (P=0.001) and LLNM (P<0.0001). The male gender was a risk factor of CLNM (P=0.04), while the age <45 years, tumor size >0.5 cm and multifocality were high-risk factors of LLNM (P=0.022, 0.044 and 0.005, respectively). Multivariable analysis revealed that LOP/C was significantly associated with CLNM [P=0.007, odds ratio (OR)=7.765, 95% confidence interval (CI)=1.773–33.996] and LLNM [P=0.029, OR=5.717, 95% CI=1.190–27.470]. Both multivariable analysis and χ² test revealed that CLNM was another important high-risk factor of LLNM (P=0.021, OR=5.444, 95% CI=1.290–22.969, χ²=17.867, P<0.001). The present study revealed that prophylactic central lymph node dissection is essential for PTMC surgery and that prophylactic lateral lymph node dissection is recommend for patients with LOP/C and CLNM, which can be performed by intraoperative frozen section pathological examination. This must be considered discreetly in the case of patients with age <45 years, tumor size >0.5 cm and multifocal lesions.

Predictors of Regional Lymph Node Recurrence after Initial Thyroidectomy in Patients with Thyroid Cancer

Background. Regional lymph node recurrence (RLNR) is common in patients with thyroid cancer but clinicopathological predictors are unclear. We aimed to clarify these predictors and identify patients who would benefit from prophylactic lymph node dissection the most. Method. 343 patients with different types of thyroid cancer were analyzed retrospectively. All patients underwent total thyroidectomy between 2007 and 2013. Results. The median ± interquartile range of patients' age was 40 ± 25 years. 245 (71.4%) patients were female. Regarding the risk of regional lymph node recurrence, we found that male gender, age ≥45 years, non-PTC (i.e., medullary, follicular, and anaplastic types) histopathology, T3 (i.e., tumor size >4 cm in the greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension), stage IVa, and isolated cervical lymphadenopathy as initial manifestation (ICL) are significant risk factors. T3 (p < 0.001; odds ratio = 156.41, 95% CI [55.72–439.1]) and ICL (p < 0.001; odds ratio = 77.79, 95% CI [31.55–191.81]) were the strongest predictors of regional lymph node recurrence. Conclusion. We found easily achievable risk factors for RLNR in thyroid cancers patients. We suggested that patients with specific clinicopathological features like male gender, age ≥45 years, larger tumor size, and extrathyroidal extension be considered as prophylactic lymphadenectomy candidates.

Metastatic Lymph Node Ratio of Central Neck Compartment Has Predictive Values for Locoregional Recurrence in Papillary Thyroid Microcarcinoma

OBJECTIVES

This study aimed to evaluate the significance of metastatic lymph node ratio (the ratio between the metastatic lymph node and the harvested lymph nodes; MLNR) in the central neck for the prediction of locoregional recurrence in patients with papillary thyroid microcarcinoma.

METHODS

After reviewing medical records of papillary thyroid microcarcinoma patients who received total thyroidectomy with central neck node dissection, 573 consecutive adult patients were enrolled in this study, with a follow-up period of more than 36 months. Regarding the risk of recurrence, multivariate analyses were performed with the following variables; sex, age, multiplicity of the primary tumor, presence of pathological extrathyroidal extension, the level of postoperative stimulated serum thyroglobulin, the number of harvested lymph nodes, the number of lymph node metastasis and MLNR.

RESULTS

The MLNR showed a predictive significance for the locoregional recurrence (P<0.05). Most recurrences were occurred in the lateral neck (n=12, 80%) with a median interval of 20 months. The lowest cutoff value of the MLNR for a meaningful separation of disease recurrence was 0.44 (hazard ratio, 8.86; 95% confidence interval, 1.49 to 52.58; P=0.001).

CONCLUSION

When the MLNR is higher than 0.44, there is an increased risk of locoregional recurrence mostly in the lateral neck. Therefore, MLNR of the central neck in a permanent or frozen biopsy may be helpful in decision making in the extent of thyroidectomy and/or the need for contralateral central neck lymph nodes dissection.

Features Predictive of Distant Metastasis in Papillary Thyroid Microcarcinomas

BACKGROUND

The recent increase in the incidence of thyroid cancer has been mainly attributed to papillary thyroid microcarcinomas (PTMCs), and many studies have suggested conservative strategies for the diagnosis and treatment of PTMC. However, PTMCs may be associated with distant metastasis. This study aimed to evaluate the clinicopathological features and identify the risk factors for distant metastasis in patients with PTMCs.

METHODS

The medical records of 8808 patients who were diagnosed with PTMC from 1999 to 2012 were reviewed, and 12 (0.1%) patients with distant metastasis were identified. Forty-one PTMC patients who initially had lateral cervical lymph node (LN) metastasis and were cured with no evidence of a distant metastasis were also selected as a control group.

RESULTS

Of the 12 patients with distant metastasis, nine had synchronous metastasis and three had metachronous metastasis. All 12 patients had primary tumors >0.5 cm and cervical LN metastasis at initial surgery. Ten patients had clinically apparent lateral cervical LN metastases, while two patients had only microscopic involvement of a central LN. Four patients died of thyroid carcinoma. Disease-specific mortality was associated with old age, large metastatic LNs with extranodal extension, and aggressive pathologic subtype of metastatic LNs. When the clinicopathological features of the patients with distant metastasis were compared with the control patients, the presence of extranodal extension and change to an aggressive pathologic subtype of metastatic LNs were significantly associated with distant metastasis and persistent structural distant PTMC metastasis.

CONCLUSIONS

Most patients with PTMC demonstrate excellent clinical outcomes, and distant metastases rarely occur. However, distant metastasis of PTMC can be fatal. Performing a meticulous pathologic examination of metastatic LNs to identify the presence of extranodal extension and the pathologic subtype of metastatic LNs helps to assess the risk of a distant metastasis in patients with PTMC.

Clinical risk factors for central lymph node metastasis in papillary thyroid carcinoma: a systematic review and meta-analysis

BACKGROUND

Prophylactic central lymph node dissection (CLND) in clinically node-negative patients remains controversial, and predictive factors for central lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) are not well defined. Herein, we conducted a systematic review to quantify the clinicopathologic factors predictive for CLNM in patients with PTC.

METHODS

A systematic search of electronic databases (PubMed, Embase, Cochrane CENTRAL, Scopus and Wanfang Database) for studies published until July 2014 was performed. Cohort, case-control studies and randomized controlled trials that examined clinical risk factors of CLNM were included.

RESULTS

Twenty-five studies (4 prospective and 21 retrospective studies) involving 7,719 patients met final inclusion criteria. From the pooled analyses, male gender (OR 1.93, 95% CI 1.40 to 2.64), tumour multifocality (OR 1.93, 95% CI 1.62 to 2.30), tumour size >0.5 cm (OR 3.48, 95% CI 2.24 to 5.41), capsular invasion (OR 1.91, 95% CI 1.36 to 2.67), extrathyroidal extension (OR 2.42, 95% CI 1.58 to 3.71), lymphovascular invasion (OR 13.29, 95% CI 5.61 to 31.48) and lateral lymph node metastasis (OR 14.33, 95% CI 5.34 to 38.50) were significantly associated with increased risk of CLNM, while age >45 years (OR 0.65, 95% CI 0.51 to 0.83) and lymphocytic thyroiditis (OR 0.70, 95% CI 0.53 to 0.92) resulted in decreased risk of CLNM. Bilaterality and tumour location were not significantly associated with CLNM development (all P > 0.05).

CONCLUSIONS

Our analysis identified several clinicopathologic factors associated with CLNM. These findings may guide the necessity and extent of prophylactic CLND and ultimately improve the outcomes of patients with PTC.

Impact of tumor size on subclinical central lymph node metastasis in papillary thyroid microcarcinoma depends on age

BACKGROUND

The aim of this study is to evaluate whether the associations between clinicopathologic factors of papillary thyroid microcarcinoma (PTMC), especially tumor size, and subclinical central lymph node metastasis (LNM) are dependent on patient age.

METHODS

The medical records of 428 patients who underwent thyroid surgery for PTC measuring ≤1 cm were reviewed. All patients were clinically lymph node negative and underwent thyroidectomy with unilateral or bilateral central lymph node dissection. Univariate and multivariate analyses were performed to identify clinicopathologic factors associated with central LNM.

RESULTS

Central LNM was identified in 96 of 428 (22.4%) patients. Mean tumor size was significantly greater in patients with than without central LNM (0.74 ± 0.22 cm vs. 0.64 ± 0.23 cm, P = 0.001). Tumor size > 0.5 cm was significantly predictive of central LNM. Subgroup analysis according to age groups showed that tumor size was an independent predictor of subclinical central LNM only in patients aged ≥45 years.

CONCLUSIONS

Factors predictive of central LNM in patients with PTMC differed by age. PTMC size was an independent predictor of subclinical central LNM only in patients aged ≥45 years.

Predictive factors of central lymph node metastasis in papillary thyroid carcinoma

PURPOSE

The aim of this study was to evaluate the correlation between central lymph node (CLN) metastasis and clinicopathologic characteristics of papillary thyroid cancer (PTC). In addition, we investigated the incidence and risk factors for contralateral CLN metastasis in unilateral PTC. This study suggests the appropriate surgical extent for CLN dissection.

METHODS

A prospective study of 500 patients with PTC who underwent total thyroidectomy and prophylactic bilateral CLN dissection was conducted.

RESULTS

Of 500 patients, 255 had CLN metastases. The rate of CLN metastasis was considerably higher in cases of younger patients (<45 years old) (P < 0.001; odds ratio [OR], 2.357) and of a maximal tumor size greater than 1 cm (P < 0.001; OR, 3.165). Ipsilateral CLN metastasis was detected in 83.1% of cases (133/160) of unilateral PTC, only contralateral CLN metastases in 3.7% of cases (6/160), and bilateral CLN metastases in 13.1% of cases (21/160). The rate of contralateral CLN metastasis was considerably higher in cases of PTC with a large tumor size (≥1 cm) (P = 0.019; OR, 4.440) and with ipsilateral CLN metastasis (P = 0.047; OR, 2.613).

CONCLUSION

Younger age (<45 years old) and maximal tumor size greater than 1 cm were independent risk factors for CLN metastasis. Maximal tumor size greater than 1 cm and presence of ipsilateral CLN macrometastasis were independent risk factors for contralateral CLN metastasis. Therefore, both CLN dissections should be considered for unilateral PTC with a maximal tumor size greater than 1 cm or presence of ipsilateral CLN macrometastasis.

Intrathyroidal tumors presenting with extranodal extension: what are we missing?

Extranodal extension (ENE) is an indicator of poor prognosis in well-differentiated thyroid cancer (WDTC). We have demonstrated that extrathyroidal extension (ETE) predicts ENE in patients with positive lymph nodes, indicating concordance between primary tumor and lymph node biology. In an effort to determine if there were other histologic features of the primary tumors that indicated an aggressive biology, we examined a subset of patients with intrathyroidal (T1/T2) disease whose lymph nodes had ENE. A review was conducted from January 2004 to March 2013. The histologic features of ETE-negative/ENE-positive tumors (group A, 12 cases) were compared with a random sample of ETE-negative/ENE-negative node-positive patients (group B, 27 cases). Cases were reviewed for size, capsule presence, infiltration, sclerosis, lymphocytic thyroiditis (LT), psammoma bodies, lymphovascular invasion (LVI), perineural invasion (PNI), architecture/cytomorphology, and focality. Size was compared using the Mann-Whitney test, while the remaining features were compared using a Fischer exact test. The breakdown of pathologic features of groups A/B were as follows: 2.28 cm/1.46 cm mean tumor size, 90 %/67 % unencapsulated, 100 %/89 % infiltrative, 100 %/89 % sclerotic, 60 %/52 % LT, 30 %/59 % positive psammoma bodies, 0 %/11 % LVI, 0 %/4 % PNI, 90 %/96 % classic architecture, 50 %/44 % multifocal. Neither size (p = 0.072) nor the other nine histologic features examined reached statistical significance. None of the histologic features appeared to significantly predict ENE. Further examination of intrathyroidal tumors at a molecular level is necessary to determine if there are any identifiable features of intrathyroidal tumors that predict ENE and thus a more aggressive phenotype.

Should a family history of papillary thyroid carcinoma indicate more aggressive therapy in patients with this tumor?

OBJECTIVE

To determine whether the currently recommended therapy for papillary thyroid carcinoma (PTC) that show no classical factors indicating a poor prognosis is also effective in cases with a family history of this tumor.

SUBJECTS AND METHODS

Forty-two patients were studied; 10 were submitted to lobectomy and 32 to total thyroidectomy, including 23 without lymph node dissection and 9 with lymph node dissection. None of the patients received radioiodine or was maintained under TSH suppression.

RESULTS

No case of recurrence was detected by imaging methods and there was no increase in thyroglobulin or antithyroglobulin antibodies during follow-up (24 to 72 months).

CONCLUSION

The treatment usually recommended for patients with PTC does not need to be modified in the presence of a family history of this tumor if no factors indicating a poor prognosis are present (tumor ≤2 cm, non-aggressive histology, no extensive extrathyroid invasion or important lymph node involvement, complete tumor resection, no evidence of persistent disease after surgery).