Site-Specific Metastasis and Survival in Papillary Thyroid Cancer: The Importance of Brain and Multi-Organ Disease

State of the Art in 3D Culture Models Applied to Thyroid Cancer

Thyroid cancer (TC) is the prevalent endocrine tumor with a rising incidence, particularly in higher-income countries, leading to an increased interest in its management and treatment. While overall, survival rates for TC are usually favorable, advanced cases, especially with metastasis and specific histotypes, pose challenges with poorer outcomes, advocating the need of systemic treatments. Targeted therapies have shown efficacy in both preclinical models and clinical trials but face issues of resistance, since they usually induce partial and transient response. These resistance phenomena are currently only partially addressed by traditional preclinical models. This review explores the limitations of traditional preclinical models and emphasizes the potential of three-dimensional (3D) models, such as transwell assays, spheroids, organoids, and organ-on-chip technology in providing a more comprehensive understanding of TC pathogenesis and treatment responses. We reviewed their use in the TC field, highlighting how they can produce new interesting insights. Finally, the advent of organ-on-chip technology is currently revolutionizing preclinical research, offering dynamic, multi-cellular systems that replicate the complexity of human organs and cancer-host interactions.

Thyroid Cancer: A Review

Importance

Approximately 43 720 new cases of thyroid carcinoma are expected to be diagnosed in 2023 in the US. Five-year relative survival is approximately 98.5%. This review summarizes current evidence regarding pathophysiology, diagnosis, and management of early-stage and advanced thyroid cancer.

Observations

Papillary thyroid cancer accounts for approximately 84% of all thyroid cancers. Papillary, follicular (≈4%), and oncocytic (≈2%) forms arise from thyroid follicular cells and are termed well-differentiated thyroid cancer. Aggressive forms of follicular cell-derived thyroid cancer are poorly differentiated thyroid cancer (≈5%) and anaplastic thyroid cancer (≈1%). Medullary thyroid cancer (≈4%) arises from parafollicular C cells. Most cases of well-differentiated thyroid cancer are asymptomatic and detected during physical examination or incidentally found on diagnostic imaging studies. For microcarcinomas (≤1 cm), observation without surgical resection can be considered. For tumors larger than 1 cm with or without lymph node metastases, surgery with or without radioactive iodine is curative in most cases. Surgical resection is the preferred approach for patients with recurrent locoregional disease. For metastatic disease, surgical resection or stereotactic body irradiation is favored over systemic therapy (eg, lenvatinib, dabrafenib). Antiangiogenic multikinase inhibitors (eg, sorafenib, lenvatinib, cabozantinib) are approved for thyroid cancer that does not respond to radioactive iodine, with response rates 12% to 65%. Targeted therapies such as dabrafenib and selpercatinib are directed to genetic mutations (BRAF, RET, NTRK, MEK) that give rise to thyroid cancer and are used in patients with advanced thyroid carcinoma.

Conclusions

Approximately 44 000 new cases of thyroid cancer are diagnosed each year in the US, with a 5-year relative survival of 98.5%. Surgery is curative in most cases of well-differentiated thyroid cancer. Radioactive iodine treatment after surgery improves overall survival in patients at high risk of recurrence. Antiangiogenic multikinase inhibitors and targeted therapies to genetic mutations that give rise to thyroid cancer are increasingly used in the treatment of metastatic disease.

Metastatic papillary thyroid carcinoma in pleural effusion: a case report and review of the literature

INTRODUCTION

Papillary thyroid carcinoma accounts for the most common type of thyroid cancer of well-differentiated type. Papillary thyroid carcinoma is featured by biologically low-grade and less aggressive tumors with a survival rate of 10 years in most of the diagnosed cases. Papillary thyroid carcinoma can be presented with the involvement of cervical lymph nodes in about 50% of the patients, yet distant spread is very uncommon.

CASE PRESENTATION

Herein, we discuss a Saudi male patient in his early 50s with a history of papillary thyroid carcinoma who presented to the emergency department complaining of shortness of breath and a radiological finding of hydrothorax. Cytologic examination together with immune-histochemical staining and molecular studies of pleural effusion aspiration concluded the definitive diagnosis of metastatic papillary thyroid carcinoma in the pleural space.

CONCLUSIONS

Papillary thyroid carcinoma seldom causes metastatic niches in the pleural space; this is a rare clinical presentation, nevertheless, a differential diagnosis of thyroid metastasis needs to be excluded. A definitive diagnosis of metastatic papillary thyroid carcinoma can be made using clinical presentation, cytologic examination, immunohistochemical investigation, and molecular testing. The most common mutation found in papillary thyroid carcinoma cases is the V600E mutation found in the BRAF gene, yet these patients have a relatively low probability of cancer recurrence. Patients with papillary thyroid carcinoma who have the BRAF mutation frequently experience metastases and relapses of the disease after the cancer has progressed aggressively. To help with therapy planning and the introduction of BRAF inhibitors, genetic testing for BRAF mutation may therefore prove to be a useful tool, especially in cases of aggressive subtypes of TC.

Agrin is a novel oncogenic protein in thyroid cancer

Agrin (AGRN) is a matricellular glycoprotein involved in extracellular signal transduction. AGRN is involved in tumorigenesis and cancer progression; however, the role of AGRN in thyroid cancer (TC) remains unclear. In the present study, using cell lines derived from various subtypes of TC including CGTH, FTC-133 and BcPAP and transcriptomic data from patients with TC, the role of AGRN in TC was analyzed by migration, invasion, viability and proliferation assays as well as Western blot with EMT markers. AGRN expression was significantly increased in thyroid tumors and cell lines derived from various TC subtypes. The highest AGRN expression was found in follicular and papillary thyroid carcinoma subtypes. Immunocytochemistry revealed nuclear AGRN localization in normal (NTHY) and TC cells. Silencing of AGRN decreased viability, proliferation, migration and invasion of TC cell lines by upregulating vimentin and downregulating N-cadherin and E-cadherin. Furthermore, the expression of AGRN was associated with neutrophil infiltration in thyroid tumors. In conclusion, the present results indicated that increased AGRN expression promoted tumorigenic phenotypes of TC cells, while AGRN expression was associated with immune infiltration in thyroid tumors. AGRN may represent a target for future cancer therapy and requires further evaluation.

Unusual metastasis of papillary thyroid carcinoma to the spine: A case report

Papillary thyroid carcinoma (PTC) is the most common thyroid carcinoma and generally has an excellent prognosis. However, there are few cases of distant metastasis, especially to the spine, which are associated with significantly worse outcomes. Here, we present a 40-year-old male with back pain and weakness in both legs. The patient also complained of neck masses months prior to the neurological symptoms. On investigations, he was found to have multiple vertebral lesions with histopathology results of papillary thyroid carcinoma metastasis.

Thyroid collision tumour with pulmonary metastases treated effectively with nedaplatin and paclitaxel chemotherapy: A case report

Collision tumour of the thyroid is a rare entity for which surgical resection is the primary treatment. We present here a case of a collision thyroid tumour of oncocytic and papillary carcinoma with lung metastases occurring in a 62-year-old woman who initially presented with a rapidly enlarging cervical mass and dyspnoea. The patient had extensive venous tumour thrombosis in the internal jugular and subclavian veins. The patient received six cycles of combined chemotherapy with nedaplatin and paclitaxel which significantly reduced the size of the metastases in the lungs. Following discharge from the hospital, the patient was treated with oral anlotinib and at 14 months follow up she had not experienced any serious side effects and the metastases in her lung and thyroid surgery areas were well controlled.

Osseous Metastases in Thyroid Cancer: Unveiling Risk Factors, Disease Outcomes, and Treatment Impact

Bone is the second most common site of metastasis in patients with thyroid cancer (TC) and dramatically impacts overall survival and quality of life with no definitive cure, yet there is no extensive study of the demographic and clinical risk factors in the recent literature. Data regarding 120,754 TC patients with bone metastasis were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses were used to identify the risk factors of bone metastasis occurring in various histologies of TC. Cox regression was performed to analyze the influence of bone metastasis on overall survival. Hazard ratios were computed to analyze the association between bone metastasis and the primary outcomes. Of the 120,754 records collected from the SEER database from 2000 to 2019, 976 (0.8%) presented with bone metastasis, with occurrence being the greatest in patients of age ≥ 55 years (OR = 5.63, 95%CI = 4.72-6.71), males (OR = 2.60, 95%CI = 2.27-2.97), Blacks (OR = 2.38, 95%CI = 1.95-2.9) and Asian or Pacific Islanders (OR = 1.90, 95%CI = 1.58-2.27), and single marital status. TC patients presenting with bone metastasis (HR = 2.78, 95%CI = 2.34-3.3) or concurrent bone and brain metastases (HR = 1.62, 95%CI = 1.03-2.55) had a higher mortality risk. Older age, gender, race, and single marital status were associated with bone metastasis and poorer prognosis in TC patients at initial diagnosis. Understanding such risk factors can potentially assist clinicians in making early diagnoses and personalized treatment plans, as well as researchers in developing more therapeutic protocols.

Mouse Models to Examine Differentiated Thyroid Cancer Pathogenesis: Recent Updates

Although the overall prognosis of differentiated thyroid cancer (DTC), the most common endocrine malignancy, is favorable, a subset of patients exhibits aggressive features. Therefore, preclinical models that can be utilized to investigate DTC pathogenesis and novel treatments are necessary. Various mouse models have been developed based on advances in thyroid cancer genetics. This review focuses on recent progress in mouse models that have been developed to elucidate the molecular pathogenesis of DTC.

Long-term survival of patients with intracranial metastases from thyroid cancer presenting with seizures: a case report and literature review

Background

Thyroid cancer has low incidence and mortality. While metastatic cancer is the most common type of intracranial cancer, patients with intracranial metastases from thyroid cancer very rarely present with seizures. Here, we describe a case study and review the neurological symptoms and histopathology of intracranial metastases from thyroid cancer.

Case Description

A 38-year-old woman was diagnosed with intracranial metastases from papillary thyroid cancer, with the chief symptom being generalized seizures. The bilateral frontal masses were completely resected in 2 operations, after which the patient was treated with whole-brain radiotherapy and tyrosine kinase inhibitors (TKIs). It has now been over 13 years since thyroid cancer resection and 51 months since she was diagnosed with intracranial metastases from papillary thyroid cancer. The long-term survival might be due to the effective and prompt treatment. Through literature review, we found the incidence of intracranial metastases from different subtypes of thyroid cancer to be inconsistent with epidemiological findings in thyroid cancer.

Conclusions

Intracranial metastases of thyroid cancer should be considered when the patient has a history of thyroid cancer with seizures. A combination of surgery, radiation therapy, and TKI drugs may prolong survival.

BRAFV600E and TERT promoter C228T mutations on ThyroSeq v3 analysis of delayed skin metastasis from papillary thyroid cancer: a case report and literature review

BACKGROUND

Skin metastasis from papillary thyroid cancer (PTC) is a rare entity that can occur up to decades after treatment of the primary tumor. Here, we present a patient who developed skin metastasis 10 years after treatment of her primary tumor and describe the molecular findings of the metastatic lesion.

CASE PRESENTATION

A 44-year-old female with a history of PTC who underwent a total thyroidectomy and radioactive iodine (RAI) treatment 10 years ago presented with a 1.3-cm skin lesion along the prior thyroidectomy scar. A biopsy revealed metastatic PTC, and the patient underwent surgical excision of the lesion. ThyroSeq molecular testing showed the copresence of BRAF^V600E mutation and TERT promoter C228T mutation. The patient subsequently received one round of adjuvant RAI therapy.

CONCLUSIONS

A high index of suspicion is warranted in patients with a history of PTC who develop a skin lesion, even several years after remission of the primary disease. In patients with high-risk mutations, such as BRAF^V600E and TERT promoter C228T mutations, long-term surveillance of disease recurrence is particularly important.

Oligometastatic disease from differentiated thyroid cancer: best treatment schemes

PURPOSE OF REVIEW

Patients with slowly progressive and/or symptomatic oligometastatic radioactive iodine refractory (RAIR) differentiated thyroid carcinomas (DTCs) are candidates to receive locoregional treatment to delay the start of systemic therapy with multikinase inhibitors. Information provided by the recent literature has not been extensively reviewed in previous published works, thus we aim to bridge this gap.

RECENT FINDINGS

We present for each metastatic site the different locoregional treatment options, contraindications and potential adverse events. Some techniques can be combined together, whereas others are discouraged in certain situations, requiring a high level of expertise and multidisciplinarity in the treatment algorithm.

SUMMARY

Different techniques of radiation therapy and interventional radiology allow to control the metastatic spread. However, as no clinical trials are available to compare the treatment schemes in terms of safety and potential impact on the prognosis, the most appropriate option for each patient should be selected within a multidisciplinary decision making, taking into account the clinical conditions and the pattern/rapidity of metastatic disease.

Survival prognostic factors for differentiated thyroid cancer patients with pulmonary metastases: A systematic review and meta-analysis

Background

The prognostic factors for differentiated thyroid cancer (DTC) patients with pulmonary metastases (PM) remain scantly identified and analyzed. Therefore, this systematic review and meta-analysis were performed to identify and summarize the prognostic factors in adult DTC patients with PM to help distinguish patients with different prognoses and inform the rational treatment regimens.

Method

We performed a comprehensive search of the relevant studies published in the Cochrane Library, PubMed, Scopus, Embase, Wanfang database, VIP database, China National Knowledge Infrastructure, and Google Scholar from their inception until February 2021. The pooled hazard ratios (HR) for overall survival and/or progression-free survival (PFS) with 95% confidence intervals were applied to evaluate and identify the potential prognostic factors. Pooled OS at different time points were also calculated for the available data. A random-effects model was used in the meta-analysis.

Results

The review and meta-analysis included 21 studies comprising 2722 DTC patients with PM. The prognostic factors for poor OS were: age over 40 years (HR=7.21, 95% confidence interval [CI] 1.52-34.10, P=0.01, N=788), age over 45 years (HR=2.18, 95% CI 1.26-3.77, P<0.01, N=601), male gender (HR=1.01, 95% CI 1.01-1.19, P=0.03, N=1396), follicular subtype of thyroid cancer (HR=1.63, 95% CI 1.36-1.96, P<0.01, N=2110), iodine non-avidity (HR=3.10, 95% CI 1.79-5.37, P<0.01, N=646), and metastases to other organs (HR=3.18, 95% CI 2.43-4.16, P<0.01, N=1713). Factors associated with poor PFS included age over 45 years (HR=3.85, 95% CI 1.29-11.47, P<0.01, N=306), male gender (HR=1.36, 95% CI 1.06-1.75, P=0.02, N=546), iodine non-avidity (HR=2.93, 95% CI 2.18-3.95, P<0.01, N=395), pulmonary metastatic nodule size over 10mm (HR=2.56, 95% CI 2.02-3.24, P<0.01, N=513), and extra-thyroidal invasion (HR=2.05, 95% CI 1.15-3.67, P=0.02, N=271). The pooled 1, 3, 5, 10, 15, and 20-years OS were 95.24%, 88.46%, 78.36%, 64.86%, 56.57%, and 51.03%, respectively.

Conclusions

This review and meta-analysis identified the prognostic factors of DTC patients with PM. Notably, FTC, metastases to other organs, and iodine non-avidity were particularly associated with poor prognosis. The identified prognostic factors will help guide the clinical management of DTC patients with PM.

Systematic review registration

https://inplasy.com/inplasy-2022-2-0026/, identifier (INPLASY202220026).

Papillary Thyroid Carcinoma With Breast and Bone Metastasis

Papillary thyroid carcinoma is the most common thyroid malignant tumor and usually has a fine prognosis. The most common metastatic site is the cervical lymph node, and distant metastasis is rare. This report describes a female patient with papillary thyroid carcinoma who presented with multiple metastases in the cervical lymph nodes, breast, and spine. The patient's disease course lasted 11 years, and eventually metastatic cancer led to the patient's death. We also analyzed the survival rate and median survival time of papillary thyroid carcinoma with multiple organ metastases using data in the literature.

Incomplete response to therapy in intermediate- and high-risk thyroid cancer

CONTEXT

The American Thyroid Association (ATA) risk stratification system predicts risk of recurrence of differentiated thyroid cancer (DTC). Although the majority of patients achieve an excellent response, patients with intermediate- or high-risk DTC are at a significant risk of developing incomplete responses. We undertook this work to understand the factors associated with development of biochemically or structurally incomplete response in these two risk subgroups of DTC.

PATIENTS AND METHODS

We retrospectively reviewed 287 consecutive patients with intermediate- (213 patients) or high-risk (74 patients) DTC. All patients underwent total thyroidectomy with (223 patients) or without (64 patients) lymph node dissection and 94% of them received at least one dose of I-131ablation/therapy. Univariate and multivariate analysis and Kaplan Meier analysis were used to compare patients who achieved an excellent response with those who continued to have biochemically or structurally incomplete responses.

RESULTS

In univariate and multivariate analyses, age (P 0.002, Odds ratio 4.8, 95% CI: 1.8-12.9), tumor size (P 0.027, Odds ratio 1.30, 95% CI: 1.03-1.64) and distant metastases (P &lt; 0.0001, Odds ratio 44.6, 95% CI: 10.7-184.5) were significantly associated with the risk of developing biochemically or structurally incomplete statuses. Patients ≥ 55 years, tumors &gt; 2.5 cm and presence of distant metastasis were associated with higher risk of incomplete response and death from DTC. However, when this analysis was performed on intermediate and high-risk groups separately, only age was consistently associated with risk of biochemically or structurally incomplete response in either and both groups.

CONCLUSION

Age is a strong predictor of biochemically and structurally incomplete responses in patients with intermediate and high-risk DTC.

Metastatic BRAF V600E-Mutated Thyroid Carcinoma: Molecular/Genetic Profiling Brings a New Therapeutic Option

We describe a case of a 46-year-old woman diagnosed with localized PTC 20 years ago, having already undergone several treatments with iodine-131 and then treatment with lenvatinib for metastatic disease, to which she developed intolerance. In 2020, in addition to pleural, thoracic, and abdominal lymph node metastasis, progression with symptomatic vertebral bone metastasis was detected, which led to the equation of new therapeutic options. In this context, a genetic/molecular test was carried out, which identified the BRAF V600E mutation and enabled the start of treatment with dabrafenib/trametinib since June 2020. This treatment allowed functional gain, symptomatic relief, and stabilization of the disease. It demonstrates how, in rare tumors, the personalized medicine approach can bring new treatment possibilities.

Construction and Validation of Prognosis Nomogram for Metastatic Lung Squamous Cell Carcinoma: A Population-Based Study

Purpose: This study aimed to establish a nomogram to predict overall survival in lung squamous cell carcinoma patients with metastasis for clinical decision-making. Methods: We investigated lung squamous cell carcinoma patients diagnosed with stage M1 in the Surveillance, Epidemiology, and Final Results database between 2010 and 2015. They were divided into training cohort and validation cohort. In the training cohort, statistically significant prognostic factors were identified using univariate and multivariate Cox regression analysis, and an individualized nomogram model was developed. The model was evaluated by C-index, area under the curve, calibration plot, decision curve analysis, and risk group stratification. Results: In total, 9910 patients were included in our study, including 6937 in the training cohort and 2937 in the validation cohort. Factors containing age, T stage, N stage, bone metastasis, brain metastasis, liver metastasis, surgery, chemotherapy, and radiotherapy were independent prognostic factors for overall survival and were used in the construction of the nomogram. The C-index in the training cohort and validation cohort were 0.711 (95% confidenc interval: 0.705-0.717) and 0.707 (95% confidenc interval: 0.697-0.717), respectively. The time-dependent area under the curve of both groups was higher than 0.7 within 5 years. Calibration plots indicated that the nomogram-predicted survival was consistent with the recorded 6-month, 1-year, and 2-year prognoses. Furthermore, decision curve analysis revealed that the nomogram was clinically useful and had a better discriminative ability to recognize patients at high risk than the TNM criteria-based tumor staging. And then we developed an overall survival risk classification system based on the nomogram total points for each patient, which divided all patients into a high-risk group and a low-risk group. Finally, we implemented this nomogram in a free online tool. Conclusion: We constructed a nomogram and a corresponding risk classification system predicting the overall survival of lung squamous cell carcinoma patients with metastasis. These tools can assist in patients’ counseling and guide treatment decision-making.

Development of a joint diagnostic model of thyroid papillary carcinoma with artificial neural network and random forest

Objective: Papillary thyroid carcinoma (PTC) accounts for 80% of thyroid malignancy, and the occurrence of PTC is increasing rapidly. The present study was conducted with the purpose of identifying novel and important gene panels and developing an early diagnostic model for PTC by combining artificial neural network (ANN) and random forest (RF).

Methods and results: Samples were searched from the Gene Expression Omnibus (GEO) database, and gene expression datasets (GSE27155, GSE60542, and GSE33630) were collected and processed. GSE27155 and GSE60542 were merged into the training set, and GSE33630 was defined as the validation set. Differentially expressed genes (DEGs) in the training set were obtained by “limma” of R software. Then, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis as well as immune cell infiltration analysis were conducted based on DEGs. Important genes were identified from the DEGs by random forest. Finally, an artificial neural network was used to develop a diagnostic model. Also, the diagnostic model was validated by the validation set, and the area under the receiver operating characteristic curve (AUC) value was satisfactory.

Conclusion: A diagnostic model was established by a joint of random forest and artificial neural network based on a novel gene panel. The AUC showed that the diagnostic model had significantly excellent performance.

Metastatic papillary thyroid cancer to cerebellum with incidental medullary microcarcinoma

Thyroid cancer is the most common endocrine cancer, with papillary thyroid carcinoma (PTC) accounting for the majority of these cases. Cerebellar metastasis is rarely the presenting feature and confers poor prognosis. Genetic mutations in this setting are most commonly TERTp, in contrast to BRAF^V600E in the majority of PTC. We report the case of an 82 year‐old male who presented with a symptomatic right cerebellar lesion and underwent surgical resection to demonstrate metastatic PTC. Extensive workup with computed tomography, neck ultrasound and FDG‐PET was suggestive of a left thyroid primary lesion, with FNA confirming PTC. However, total thyroidectomy demonstrated incidental microMTC (medullary thyroid microcarcinoma, defined as tumour <10mm) without any evidence of PTC, whereas the left level VI neck dissection demonstrated a 30mm nodule of PTC without identifiable normal thyroid or lymph node tissue.

Bone metastases in newly diagnosed patients with thyroid cancer: A large population-based cohort study

Background

Population-based estimates of the incidence and prognosis of bone metastases (BM) stratified by histologic subtype at diagnosis of thyroid cancer are limited.

Methods

Using multivariable logistic and Cox regression analyses, we identified risk factors for BM and investigated the prognostic survival of BM patients between 2010 and 2015 via the Surveillance, Epidemiology, and End Results (SEER) database.

Results

Among 64,083 eligible patients, a total of 347 patients with BM at the time of diagnosis were identified, representing 0.5% of the entire cohort but 32.4% of the subset with metastases. BM incidence was highest (11.6%) in anaplastic thyroid cancer (ATC), which, nevertheless, was highest (61.5%) in follicular thyroid cancer (FTC) among the subset with metastases. The median overall survival among BM patients was 40.0 months, and 1-, 3-, and 5-year survival rates were 65.2%, 51.3%, and 38.7%, respectively. Compared with papillary thyroid cancer (PTC), FTC (aOR, 6.33; 95% CI, 4.72–8.48), medullary thyroid cancer (MTC) (aOR, 6.04, 95% CI, 4.09–8.92), and ATC (aOR, 6.21; 95% CI, 4.20–9.18) significantly increased the risk of developing BM. However, only ATC (aHR, 6.07; 95% CI, 3.83–9.60) was independently associated with worse survival in multivariable analysis. Additionally, patients with BM alone (56.5%) displayed the longest median survival (66.0 months), compared with those complicated with one extraskeletal metastatic site (lung, brain, or liver) (35.2%; 14.0 months) and two or three sites (8.3%; 6.0 months). The former 5-year overall survival rate was 52.6%, which, however, drastically declined to 23.0% in patients with one extraskeletal metastatic site and 9.1% with two or three sites.

Conclusion

Closer bone surveillance should be required for patients with FTC, MTC, and ATC, and extraskeletal metastases at initial diagnosis frequently predict a poorer prognosis.

Impact of Lung Metastasis versus Metastasis of Bone, Brain, or Liver on Overall Survival and Thyroid Cancer-Specific Survival of Thyroid Cancer Patients: A Population-Based Study

We investigate the impact of lung metastasis versus metastasis of bone, brain, or liver on overall survival (OS) and thyroid cancer-specific survival (TCSS) in patients with thyroid cancer (TC). Therefore, de-identified SEER 18 registry data of primary TC patients diagnosed between 2010 and 2016 were analyzed. The primary outcome was the prognosis of TC patients with lung metastasis compared with other sites. The secondary outcomes included the prognosis comparison between patients with and without surgery and between single and multiple metastasis sites. Isolated lung metastasis was associated with worse OS and TCSS than bone metastasis (both p < 0.05) and was associated with worse OS than liver metastasis (p = 0.0467). Surgery performed either for the primary or distant site was associated with better OS and TCSS in patients with metastasis of lung or bone (p < 0.05). Isolated lung metastasis was related to better OS and TCSS than lung−liver, lung−brain, and lung−other multiple metastases. The multivariable analysis revealed that age < 55 years, surgery to the primary site, and to the distant site(s) were associated with better outcomes, while T4 and Tx were associated with worse outcomes. Nevertheless, it revealed that the other race (i.e., any race other than white, black, or unknown) and male gender were associated with better TCSS only (p < 0.05). Isolated lung metastasis is associated with a worse prognosis in TC patients compared with bone or liver metastasis. Surgery performed either for the primary or distant site(s) is associated with better survival outcomes in TC patients with metastasis of lung or bone.

Risk factors associated with disease-specific mortality in papillary thyroid cancer patients with distant metastases

PURPOSE

Papillary thyroid carcinoma (PTC) is among the most curable cancer types. Even though uncommon, some patients present distant metastatic disease at diagnosis or during the follow-up and most of them have long-term survival. However, there continues to be controversies regarding what clinicopathological features are associated with mortality in these patients. This paper evaluates the factors related to poor disease-specific survival (DSS) in patients with metastatic PTC.

METHODS

A retrospective cohort study included PTC patients with distant metastasis from a tertiary public oncological center. Clinicopathological features, treatment modalities, and outcome were reviewed.

RESULTS

Between 1986 and 2014, 108 patients were diagnosed with metastatic PTC. In the multivariate analysis male sex (HR = 2.65; 95%CI: 1.08-6.53; P = 0.033), radioiodine refractory disease (HR = 9.50; 95%CI: 1.23-73.38; P = 0.031) and metastasis at multiple sites (HR = 5.91; 95%CI: 1.80-19.32; P = 0.003) were independent risk factors for death in patients with metastatic PTC.

CONCLUSION

Male patients with metastatic PTC, with radioiodine refractory disease and metastasis at multiple sites have a high risk of death.

Current challenges in metastasis research and future innovation for clinical translation

While immense strides have been made in understanding tumor biology and in developing effective treatments that have substantially improved the prognosis of cancer patients, metastasis remains the major cause of cancer-related death. Improvements in the detection and treatment of primary tumors are contributing to a growing, detailed understanding of the dynamics of metastatic progression. Yet challenges remain in detecting metastatic dissemination prior to the establishment of overt metastases and in predicting which patients are at the highest risk of developing metastatic disease. Further improvements in understanding the mechanisms governing metastasis have great potential to inform the adaptation of existing therapies and the development of novel approaches to more effectively control metastatic disease. This article presents a forward-looking perspective on the challenges that remain in the treatment of metastasis, and the exciting emerging approaches that promise to transform the treatment of metastasis in cancer patients.

Concepts of Pathological Staging and Prognosis in Papillary Thyroid Carcinoma

American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (AJCC/UICC) staging and American Thyroid Association (ATA) risk predication system are the best predicators of mortality and cancer recurrence, respectively, in patients with differentiated thyroid carcinoma, including papillary thyroid carcinoma. In ATA risk stratification of differentiated thyroid carcinomas, clinical features, nodal features, and pathological features are assessed. Many of the features are also assessed in pathological staging. The prognostic stage grouping of papillary thyroid carcinoma in AJCC/UICC depends on the age of the patients as well as the standard parameters-extent of tumor (T), lymph node status (N), and presence of distant metastasis (M). Major changes noted in the current pathological staging protocol include the cut-off age from 45-year to 55-year in grouping of patients, use of gross invasion of strap muscles instead of minimal microscopic extrathyroidal extensions as T3b and downstage of many prognostic groups such as those with lymph node metastases (without distant metastases) from Stage III to Stage II. The staging protocol have moved many patients with papillary thyroid carcinoma into good prognostic groups for better predication of patients' survival rates and to avoid unnecessary treatment. This new approach has been verified by different groups globally, although modifications could be expected in the future for better prognostic assessment in patients with papillary thyroid carcinoma.

Can We Predict Differentiated Thyroid Cancer Behavior? Role of Genetic and Molecular Markers

Thyroid cancer is ranked in ninth place among all the newly diagnosed cancer cases in 2020. Differentiated thyroid cancer behavior can vary from indolent to extremely aggressive. Currently, predictions of cancer prognosis are mainly based on clinicopathological features, which are direct consequences of cell and tissue microenvironment alterations. These alterations include genetic changes, cell cycle disorders, estrogen receptor expression abnormalities, enhanced epithelial-mesenchymal transition, extracellular matrix degradation, increased hypoxia, and consecutive neovascularization. All these processes are represented by specific genetic and molecular markers, which can further predict thyroid cancer development, progression, and prognosis. In conclusion, evaluation of cancer genetic and molecular patterns, in addition to clinicopathological features, can contribute to the identification of patients with a potentially worse prognosis. It is essential since it plays a crucial role in decision-making regarding initial surgery, postoperative treatment, and follow-up. To date, there is a large diversity in methodologies used in different studies, frequently leading to contradictory results. To evaluate the true significance of predictive markers, more comparable studies should be conducted.

PPARγ Targets-Derived Diagnostic and Prognostic Index for Papillary Thyroid Cancer

Simple Summary

Through targeted next-generation sequencing of thyroid cancer-related genes in monozygotic twins with papillary thyroid cancer (PTC), we identified common variants of the gene encoding peroxisome proliferator activated receptor gamma (PPARG). Notably, the expression levels of PPARγ target genes were frequently deregulated in PTC compared to benign tissues and were closely associated with disease-specific survival (DSS) outcomes in a TCGA-PTC cohort. Machine learning-powered personalized scoring index comprising 10 PPARγ targets, termed as PPARGi, achieved a near-perfect accuracy in distinguishing cancers from benign tissues, and further identified a small subpopulation of patients at high-risk across different profiling platforms.

Abstract

In most cases, papillary thyroid cancer (PTC) is highly curable and associated with an excellent prognosis. Yet, there are several clinicopathological features that lead to a poor prognosis, underscoring the need for a better genomic strategy to refine prognostication and patient management. We hypothesized that PPARγ targets could be potential markers for better diagnosis and prognosis due to the variants found in PPARG in three pairs of monozygotic twins with PTC. Here, we developed a 10-gene personalized prognostic index, designated PPARGi, based on gene expression of 10 PPARγ targets. Through scRNA-seq data analysis of PTC tissues derived from patients, we found that PPARGi genes were predominantly expressed in macrophages and epithelial cells. Machine learning algorithms showed a near-perfect performance of PPARGi in deciding the presence of the disease and in selecting a small subset of patients with poor disease-specific survival in TCGA-THCA and newly developed merged microarray data (MMD) consisting exclusively of thyroid cancers and normal tissues.