Male Sex Is an Independent Predictor of Recurrence-Free Survival in Middle Eastern Papillary Thyroid Carcinoma

Prognostic factors of papillary and follicular carcinomas based on pre-, intra-, and post-operative findings

Graphical abstract

Abstract

Papillary and follicular thyroid carcinomas (PTC and FTC) are prominent malignancies that originate from thyroid follicular cells. PTC is usually diagnosed via preoperative cytology, and large tumor size, clinical node metastasis, and distant metastasis constitute preoperative prognostic factors. Gross extrathyroidal and extranodal tumor extensions have a significant prognostic impact, are evaluated intraoperatively, and are useful for determining the extent of surgery. Aggressive variants, such as tall cell and hobnail variants, a high Ki-67 labeling index (LI), and somatic gene mutations are prognostic factors in postoperative pathological and molecular examinations. In contrast, FTC is generally diagnosed based on postoperative pathology. Large tumor size and M factors have prognostic value; however, the findings of pathological examinations are very important. FTCs are classified as minimally invasive, encapsulated angioinvasive, and widely invasive FTCs. Widely invasive FTC with vascular invasion (VI) and encapsulated angioinvasive FTCs with extensive VI have a poor prognosis, whereas widely invasive FTC without VI has an excellent prognosis, which is similar to that of minimally invasive FTC. This indicates that VI is a considerably more important prognostic marker than capsular invasion. For postoperative follow-up, dynamic markers such as the thyroglobulin-doubling rate (DR), metastatic tumor volume-DR, and change in the neutrophil-to-lymphocyte ratio are important and are useful for evaluating the effectiveness of treatments, such as radioactive iodine therapy and molecular targeted therapy, for recurrent lesions. For clinicians, it is important to accurately evaluate prognostic markers of PTC and FTC in the pre-, intra-operative, and post-operative phases.

Predicting factors and clinical outcome of biochemical incomplete response in middle eastern differentiated thyroid carcinoma

PURPOSE

The aim of this study was evaluate biochemical incomplete response (BIR) in Middle Eastern differentiated thyroid cancer (DTC), identify factors that could predict BIR before radioactive iodine (RAI) ablation and to investigate the long-term clinical outcome of DTC patient exhibiting BIR to initial therapy.

METHODS

We retrospectively evaluated 1286 DTCs from Middle Eastern ethnicity who underwent total thyroidectomy and RAI therapy. Demograpic and clinico-pathological factors predicting BIR were evaluated. The outcome of these patients was analyzed using primary outcome of structural disease and disease-free survival (DFS).

RESULTS

With a median follow-up of 10 years, 266 (20.7%) patients had BIR. High pre-ablation stimulated thyroglobulin (presTg), presence of lymph node metastasis, male gender and delayed initial RAI therapy (≥3 months) after thyroidectomy were significant independent predictors of BIR. Upon evaluating long-term clinical outcomes in 266 patients with BIR, we found 36.8% of patients developed structural disease. Male sex (OR = 1.56; 95% CI = 1.05-2.30; p = 0.0272) and increasing Tg after initial therapy (OR = 4.25; 95% CI = 1.93-10.82; p = 0.0001) were independent risk factors for structural disease in patients with BIR. DFS was significantly worse if both these risk factors existed concomitantly (p < 0.0001).

CONCLUSION

To achieve the fair efficacy of RAI therapy, early prediction of BIR before RAI ablation is desirable. Our finding of the clinico-pathological factors (high presTg level, LNM, delayed RAI therapy and male gender) could serve as easy and robust early predictors of BIR. In addition, DTC patients exhibiting BIR had a high risk of structural disease and hence personalized management approach would be preferable for BIR patients to ensure best clinical outcome.

Polymorphisms of DNA Repair Genes in Thyroid Cancer

The incidence of thyroid cancer, one of the most common forms of endocrine cancer, is increasing rapidly worldwide in developed and developing countries. Various risk factors can increase susceptibility to thyroid cancer, but particular emphasis is put on the role of DNA repair genes, which have a significant impact on genome stability. Polymorphisms of these genes can increase the risk of developing thyroid cancer by affecting their function. In this article, we present a concise review on the most common polymorphisms of selected DNA repair genes that may influence the risk of thyroid cancer. We point out significant differences in the frequency of these polymorphisms between various populations and their potential relationship with susceptibility to the disease. A more complete understanding of these differences may lead to the development of effective prevention strategies and targeted therapies for thyroid cancer. Simultaneously, there is a need for further research on the role of polymorphisms of previously uninvestigated DNA repair genes in the context of thyroid cancer, which may contribute to filling the knowledge gaps on this subject.

Unexpected 99mTc-pertechnetate avidity of lymph node metastases predicts better response to radioiodine therapy in differentiated thyroid cancer patients with lymph node metastases

OBJECTIVE

To investigate the value of 99mTc-pertechnetate scan in postoperative differentiated thyroid cancer (DTC) patients with lymph node (LN) metastases (LNM) uptake 99mTc-pertechnetate, especially the predictive value to their response to radioiodine-131 (131I) therapy.

METHODS

This retrospective study collected 752 patients with DTC and LNM treated at Zhejiang Cancer Hospital between May 2012 and December 2017. Depending on the ability of LNM uptake 99mTc-pertechnetate, the patients were grouped as the 99mTc-pertechnetate-avid (n=88) vs. 99mTc-pertechnetate-non-avid (n=664) groups. And Propensity score matching (PSM) was performed at a 1:4 ratio to reduce confounding bias.

RESULTS

In the PSM analysis, the 1:4 matched cohort comprised 752 patients (88 with 99mTc-pertechnetate-avid LNM, 664 with 99mTc-pertechnetate-non-avid LNM). Patients' age, initial 131I activity and frequency of iodine therapy were included as covariates. After PSM analysis, 363 patients (99mTc-pertechnetate-avid group, n=83; 99mTc-pertechnetate-non-avid group, n=280) were successfully matched. Among the 363 PSM-matched patients, 48/83 (57.8%) in the 99mTc-pertechnetate-avid group and 158/280 (56.4%) in the 99mTc-pertechnetate-non-avid group had two or more 131I treatments. The nsTg and the percentage of changes in ssTg between the 99mTc-pertechnetate-avid and 99mTc-pertechnetate-non-avid groups were significantly different ([0.05 (0.04 to 0.90) vs. 0.40 (0.04 to 4.92), p=0.018] and [-88% (-98%, -50%) vs. -66% (-86%, -30%), p < 0.001], respectively). No significant differences were observed between the two groups in the other parameters (age, pathological type, distant metastasis, follow-up time, AJCC TNM stage, initial 131I treatment activity, and 131I treatment frequency) after PSM (all p > 0.05).

CONCLUSION

In patients with DTC and LNM, LNM uptake of 99mTc-pertechnetate is a rare phenomenon. Patients with 99mTc-pertechnetate-avid LNMs were more likely to benefit from 131I therapy, even after adjustment for age, 131I treatment frequency, and initial 131I activity.

Evaluating the Effectiveness of Triiodothyronine Suppression and Withdrawal Versus Thyrogen Injections in Thyroid Cancer Assessments

Objective This study aimed to evaluate the specificity and effectiveness of triiodothyronine (T3) suppression and withdrawal, as compared to the conventional diagnostic approach using Thyrogen recombinant thyroid-stimulating hormone (TSH) injections, in the assessment of thyroid cancer patients post-thyroidectomy. Methods In this retrospective study, 18 patients diagnosed with thyroid cancer at a tertiary care hospital (Mediclinic City Hospital) in Dubai were included. The patients underwent total thyroidectomy, iodine ablation, and neck ultrasound. The cohort's clinical characteristics were analyzed, and histopathological examination of thyroid nodules was performed. In this study, paired T-tests were applied to evaluate the before-and-after impact of T3 and Thyrogen treatments on TSH and thyroglobulin (TG) levels in individual patients. To further analyze the effectiveness of these treatments, independent T-tests were conducted, allowing for a comparison of TSH and TG levels between different treatment groups within the patient cohort. This approach provided a comprehensive assessment of the treatments' effects on key thyroid indicators. Additionally, the diagnostic accuracy of T3 withdrawal and Thyrogen post-test on TG levels was assessed using statistical measures including sensitivity, specificity, and predictive values. Results The cohort had a mean age of 42.1 years and a female predominance. Distinct clinical profiles were observed across different thyroid cancer subtypes. Histopathological analysis confirmed typical features of papillary carcinoma variants. Significant changes in TSH levels post-treatment were noted, with T3 treatments showing a marked increase in TSH and TG levels, although changes in TG levels were not always statistically significant. Diagnostic test evaluation showed a sensitivity of 77.78%, a specificity of 83.33%, and an overall accuracy of 80.00% for T3 withdrawal and Thyrogen post-test on TG. Conclusion The study provides comprehensive insights into the clinical profiles and treatment responses in thyroid cancer patients post-thyroidectomy. The effectiveness of T3 and Thyrogen treatments in altering TSH and TG levels was established, with significant implications for patient management. The diagnostic tests for T3 withdrawal and Thyrogen post-test on TG demonstrated high accuracy, underlining their clinical utility in the post-treatment evaluation of thyroid cancer patients.

Male Sex Is Not a Risk Factor for Prognosis in Postoperative Thyroid Cancer Patients: A Propensity Score Matching Study

PURPOSE

To study whether male sex is a risk factor for prognosis in patients with differentiated thyroid cancer after 131I treatment using the propensity score matching (PSM) method.

METHODS

From April 2016 to October 2021, 1948 postoperative differentiated thyroid cancer patients aged 43 (interquartile range: 34, 54) years who received 131I treatment were retrospectively enrolled and divided into male (n = 645) and female groups (n = 1303). The PSM method was adopted to process all data to reduce the influence of data bias and confounding variables. The Mann-Whitney U test and χ2 test were used for data analysis. Multivariate logistic regression was used to analyze the risk factors affecting prognosis, and the receiver operating characteristic curve was used to analyze the relationship between stimulated thyroglobulin (sTg) level, 131I dose, and poor prognosis.

RESULTS

Before PSM, the proportion of male patients with poor prognosis was significantly higher than that of female patients. After PSM, there was no difference in the proportion of poor prognosis between male and female groups. Multivariate logistic regression analysis showed that male sex; high T stage, N1b stage, and M1 stage; high sTg level; and high 131I dose were risk factors for poor prognosis before PSM. After PSM, high T stage, M1 stage, high sTg level, and 131I dose were still risk factors but male sex was no longer a risk factor for poor prognosis.

CONCLUSIONS

After the reduction of selection bias by PSM, male sex was no longer a risk factor for prognosis after 131I treatment of differentiated thyroid cancer. In addition, high T stage (T3 + T4 stage), M1 stage, sTg ≥10.15 ng/mL, and 131I dose ≥260 mCi were risk factors for poor prognosis.

Risk-stratified Distant Metastatic Thyroid Cancer with Clinicopathological Factors and BRAF/TERT Promoter Mutations

OBJECTIVE

To assess the prognostic value of clinicopathological factors as well as BRAF and TERT promoter mutations in predicting distant metastasis in patients with papillary thyroid cancer.

DESIGN

The status of BRAF and TERTp mutations were available in 1,208 thyroid cancer patients who received thyroidectomy at Jiangyuan Hospital Affiliated to Jiangsu Institute of Nuclear Medicine from January 2008 to December 2021. Based on inclusion criteria, 99 distant metastasis thyroid cancers (DM-TCs) and 1055 patients without DM (Non-DM-TCs) were retrospectively reviewed.

RESULTS

After univariate and multivariate analyses, a risk model was established for DM prediction based on factors: T3/T4 stage, lymph node metastasis (LNM) number over 5, and BRAF/TERT mutations (TLBT). It was defined based on the number of TLBT factors: low risk (no risk factor, n=896), intermediate risk (1 risk factor, n=199), and high risk (≥2 risk factors, n=59). Notably, compared with patients with low and intermediate risks, patients assigned to high TLBT risk have a shorter time of DM disease-free survival. Except for gene mutation, other factors were also included in the 2015 American Thyroid Association (ATA) risk guideline. Comparing with the ATA risk category, this risk model showed a better performance in predicting DM-TCs.

CONCLUSIONS

This study proposes a TLBT risk classifier consisting of T3/T4 stages, LNM (n>5), and BRAF+TERTp mutations for predicting DM-TCs. TLBT risk stratification may help clinicians make personalized treatment management and follow-up strategies.

Survival differences between women and men in the non-reproductive cancers: Results from a matched analysis of the surveillance, epidemiology, and end-results program

Background

Men with non-reproductive cancers have a discrepant outcome compared to women. However, they differ significantly in the incidence of cancer type and characteristics.

Methods

Patients with single primary cancer who were 18 years or older and whose data were gathered and made accessible by the Surveillance, Epidemiology, and End Results (SEER) program were included in this retrospective analysis. Kaplan-Meier curves and Cox regression before and after propensity score matching were performed to analyze the risk survival by sex.

Results

Among the 1,274,118 patients included [median (range) age, 65 year (18-85+) years; 688,481 (54.9%) male]. The median follow-up was 21 months (0-191). Substantial improvements in survival were observed for both sexes during the years of inclusion analyzed, with no difference between them, reaching a reduction of almost 17% of deaths in 2010, and of almost 28% in 2015, compared to 2004. The women had a median survival of 74 months and overall mortality of 48.7%. Males had a median survival of 30 months (29.67-30.33) with an overall mortality of 56.2%. The PSM showed a reduced difference (6 months shorter median survival and 2.3% more death in men), but no change in hazards was observed compared to the unmatched analysis [adjusted HR: 0.888 (0.864-0.912) vs. 0.876 (0.866-0.886) in unmatched].

Conclusions

The discrepancy in survival between men and women is not explained only by the incidence of more aggressive and more advanced cancers in the former.

X-linked inhibitor of apoptosis protein (XIAP) predicts disease-free survival in BRAFV600E mutant papillary thyroid carcinoma in middle eastern patients

BACKGROUND

X-linked inhibitor of apoptosis (XIAP) is the most potent caspase inhibitory IAP family member and its over-expression is implicated in aggressive behavior of various solid tumors, including papillary thyroid carcinoma (PTC). BRAFV600E mutation is the most common oncogenic event in PTC and is also known to be associated with aggressive clinico-pathological characteristics. In this study, we investigated the prevalence of XIAP expression in more than 1600 PTCs from Middle Eastern ethnicity and its prognostic value to predict disease-free survival (DFS), in combination with the BRAFV600E mutation.

METHODS

Clinical data, XIAP expression by immunohistochemistry and BRAF mutation status were analyzed in 1640 Saudi PTC patients seen at our institute between 1988 - 2020.

RESULTS

BRAFV600E mutation was found in 910 of 1640 patients (55.5%) and was significantly correlated with older age, extrathyroidal extension, bilaterality, multifocality and lymph node metastasis, but was not an independent predictor of DFS. XIAP was over-expressed in 758 of 1640 (46.2%) and was associated with aggressive clinico-pathological features. It was also found to be an independent prognostic marker for DFS (HR = 1.28, 95% CI = 1.02 - 1.60, P = 0.0342). XIAP overexpression was correlated with presence of BRAFV600E mutation in PTC patients. Interestingly, we found the ability to predict shorter DFS was 2.7-fold higher in PTCs with over-expression of XIAP and BRAFV600E mutation compared to patients with high XIAP and wild-type BRAFV600E status (HR = 2.74, 95% CI = 2.19 - 3.44, p < 0.0001).

CONCLUSION

XIAP expression is an independent predictor of prognosis in Middle Eastern PTC patients. Combination of XIAP expression and BRAFV600E mutation can synergistically improve the DFS prediction in PTC patients, which may help clinicians to establish the most appropriate initial care and long-term surveillance strategies.