Papillary Thyroid Cancer Prognosis: An Evolving Field

Prediction of lymph node metastasis in papillary thyroid carcinoma using non-contrast CT-based radiomics and deep learning with thyroid lobe segmentation: A dual-center study

Objectives

This study aimed to develop a predictive model for lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) patients by deep learning radiomic (DLRad) and clinical features.

Methods

This study included 271 thyroid lobes from 228 PTC patients who underwent preoperative neck non-contrast CT at Center 1 (May 2021-April 2024). LNM status was confirmed via postoperative pathology, with each thyroid lobe labeled accordingly. The cohort was divided into training (n = 189) and validation (n = 82) cohorts, with additional temporal (n = 59 lobes, Center 1, May-August 2024) and external (n = 66 lobes, Center 2) test cohorts. Thyroid lobes were manually segmented from the isthmus midline, ensuring interobserver consistency (ICC ≥ 0.8). Deep learning and radiomics features were selected using LASSO algorithms to compute DLRad scores. Logistic regression identified independent predictors, forming DLRad, clinical, and combined models. Model performance was evaluated using AUC, calibration, decision curves, and the DeLong test, compared against radiologists' assessments.

Results

Independent predictors of LNM included age, gender, multiple nodules, tumor size group, and DLRad. The combined model demonstrated superior diagnostic performance with AUCs of 0.830 (training), 0.799 (validation), 0.819 (temporal test), and 0.756 (external test), outperforming the DLRad model (AUCs: 0.786, 0.730, 0.753, 0.642), clinical model (AUCs: 0.723, 0.745, 0.671, 0.660), and radiologist evaluations (AUCs: 0.529, 0.606, 0.620, 0.503). It also achieved the lowest Brier scores (0.167, 0.184, 0.175, 0.201) and the highest net benefit in decision-curve analysis at threshold probabilities > 20 %.

Conclusions

The combined model integrating DLRad and clinical features exhibits good performance in predicting LNM in PTC patients.

The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging

V-flow is a dynamic ultrasound technique that visualizes perfusion patterns by displaying dynamic arrows that change in response to the flow of erythrocytes. Furthermore, it provides quantitative values for the maximum and mean velocity of blood flow as well as a percentage value for turbulence. The aim was to enhance the preoperative diagnostic accuracy of thyroid lesions by combining V-flow with established ultrasound modes.B-mode, CCDS, elastography, CEUS, and V-flow were performed on 101 patients. After the ultrasound examination, every nodule was confirmed as benign or malignant via histopathology. The Kruskal-Wallis test, ROC curve, and binary logistic regression were used for the statistical analysis.93 benign regressive thyroid nodules and 8 carcinomas were included in this study. The average mean velocity value for benign lesions was measured at 19.5 cm/s and at 10.7 cm/s for malignant lesions (p = 0.039). The average turbulence percentage was 26.1% for benign nodules and 46.7% for carcinomas (p = 0.016). Carcinomas exhibited a slower and more turbulent perfusion pattern compared to benign tumors. A V-flow-centered system achieves a sensitivity of 100.0% and a specificity of 84.9% in predicting malignancy. This system could have reduced the number of unnecessary thyroid surgeries for benign lesions in our patient group by 70%.The capillary perfusion of thyroid nodules represents a significant indicator of its status. By analyzing the velocity and turbulence level of microvascular blood flow, V-flow offers promising prospects for accurately distinguishing between benign and malignant thyroid lesions. When integrated into a comprehensive multimodal sonographic imaging approach, V-flow further enhances diagnostic accuracy. · V-flow allows for qualitative and quantitative analysis of microvascular perfusion. · Malignant tumors are associated with slower and more turbulent microvascular hemodynamics. · Combining V-flow with other ultrasound modes eases the diagnosis of thyroid carcinomas. · Brandenstein MK, Zhang L, Scharf G et al. The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging. Fortschr Röntgenstr 2025; 197: 436-446.

Evaluation of Changes in Clinicopathological Features and Prognosis in Patients with Thyroid Cancer

Background: In this study, we evaluated the changes in clinicopathological features and prognosis in patients with thyroid cancer in the last two decades using the Surveillance, Epidemiology, and End Results Database (SEER) data. Methods: Data from the SEER-12 registry (1992-2021) were analyzed, focusing on patients diagnosed with malignant thyroid cancer between 2001 and 2020. The study population was divided into Cohort 1 (2001-2010) and Cohort 2 (2011-2020). Cohorts 1 and 2 were compared regarding clinicopathological features and prognosis. Results: The study included 94,892 patients diagnosed with thyroid cancer between 2001 and 2020, with 39,265 patients in Cohort 1 and 55,627 in Cohort 2. Compared to Cohort 1, in Cohort 2 showed a statistically significant increase in the proportion of patients aged 60+ (+4.2%), male patients (+2.1%), and cases of papillary cancer (+5.3%) and regional disease (+3.7%) (all p < 0.001). Although Cohort 2 demonstrated an 8% improvement in survival compared to Cohort 1, this result was not statistically significant (p = 0.057). Prognostic factors were identified, such as disease stage at diagnosis, age, gender, and origin. Among pathological subtypes, the patients with papillary + FV had the best prognosis (HR: 0.78), compared to patients in the other group, mainly comprising anaplastic tumors and sarcomas, which had the worst prognosis (HR: 9.61). Conclusions: In this large-scale study of thyroid cancer patients, we found significant differences between the two cohorts. In Cohort 2, the proportion of patients aged ≥60 years, male, and with papillary thyroid cancer was increased. We found that age, sex, origin, histopathological subtype, and stage at diagnosis were prognostic factors in patients with thyroid cancer. Also, we observed a trend toward improved survival in Cohort 2.

Prediction of thyroid malignancy risk using clinical and ultrasonography features and a machine learning approach

OBJECTIVE

This study aims to develop and validate a predictive model for thyroid nodule malignancy risks using clinical and ultrasonography features and a machine learning (ML) approach.

METHODS

This retrospective study is based on the clinical and ultrasound characteristics of 1035 thyroid nodules (845 benign and 190 malignant) to develop and validate the risk prediction model. Employing multiple logistic regression, key features were selected in developing the model. Eight ML algorithms were evaluated for predicting the risks of malignancy. Finally, the predictive ability of the best-performing algorithm was compared against American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) and American Thyroid Association (ATA) guidelines.

RESULTS

Based on AUC criteria (88.3, 95% CI: 81.2-94.2), sensitivity (84.2, 95% CI: 71.1-94.7), specificity (92.3, 95% CI: 88.2-95.9), positive predictive value, (71.4, 95% CI: 60.4-83.3) and negative predictive value (96.3, 95% CI: 93.5-98.8), the XGBoost algorithm exhibited superior performance over the other ML algorithms and ACR TI-RADS and ATA. These criteria were obtained for ACR TI-RADS at 54.2%, 63.2%, 48.5%, 21.1%, and 84.8%, while for ATA, they were 44.3%, 76.3%, 27.2%, 18.4%, and 81.6%. In addition, the unnecessary fine-needle aspiration (FNA) rate with ACR TI-RADS and ATA was 43% and 63%, respectively-significantly higher than the 7% obtained with XGBoost.

CONCLUSIONS

This study demonstrated the capability of ML approaches in enhancing the accuracy of predicting thyroid malignancy risks as well as their potential benefits in optimizing healthcare resources by reducing unnecessary FNA rates. Using the proposed model through a web-based tool can facilitate clinical judgments in thyroid nodule management and personalized treatment.

KEY POINTS

Question Current risk assessment systems have limitations, with high unnecessary FNA rates compared to machine learning (ML) models. Findings The XGBoost algorithm was compared to other ML algorithms, ACR TI-RADS, and ATA and demonstrated superior performance. Clinical relevance This study demonstrated the capability of ML approaches in enhancing the accuracy of predicting thyroid malignancy. The proposed web-based tool to facilitate the prediction of thyroid nodule risk is available at https://aimedlab.ir/tnr .

Postoperative complications and long-term outcomes after total and subtotal thyroidectomy: a retrospective study

The choice between total thyroidectomy (TT) and subtotal thyroidectomy (STT) can affect postoperative complications and long-term outcomes in these patients. This study aimed to investigate postoperative complications and long-term outcomes in patients who underwent TT and STT. This retrospective study investigated 1.022 patients who admitted to Ghaem and Razavi hospitals, Mashhad, and underwent thyroidectomy between 2011 and 2017. Data related to postoperative complications, recurrence rate and overall survival were collected and analyzed. The data collection tool used in this research was a checklist. In this study, women accounted for 863 and men for 159 of the total population. The highest number of thyroidectomy surgeries was found in 2013 and in all years the majority of thyroidectomy surgeries were performed on women. The results demonstrated that 71.2% of the patients underwent TT and 28.8% underwent STT. The percentage rate of recurrent laryngeal nerve injury after thyroidectomy surgery (regardless of the type of selected surgery) was 6.1%, affecting 62 individuals. No significant relationship was observed between the type of selected surgery and damage to this nerve (P > 0.05). In addition, a statistically significant correlation was reported between thyroidectomy and suffering from hypocalcemia (P < 0.05). The study revealed that TT was associated with a higher postoperative complication rate compared to STT. Individual treatment plans must be developed based on the risks and benefits of each surgical approach.

Immune cells in thyroid adenoma and carcinoma: uncovering a hidden value of assessing tumor-host interplay and its potential application in thyroid cytopathology

Introduction

Although the role of tumor immune microenvironment (TIME) in thyroid cancer is well established, little data exists about the differences in immune cell presence in thyroid adenomas and carcinomas. We assume that immune cell density could be an additional diagnostic criterion for differentiating benign and malignant tumors in thyroid aspirates.

Aim

The current study compared the immune contexture of thyroid adenoma (TA) and thyroid carcinoma (TC) in histological and cytological specimens of III-V categories.

Materials and methods

This pilot study included 72 cases (36 of TA and 36 of TC) with verified histological diagnosis and pre-operative cytology corresponding to categories III, IV and V according to the Bethesda system for reporting thyroid cytology. The number of CD8+, CD68+ and CD163+ cells was assessed in histological samples of TA and TC with further comparison to cytological specimens. Besides, the expression of STAT6 and SMAD4 as potential regulators of TIME was evaluated in the study.

Results

TC demonstrated an immune-rich profile representing abundant tumor-associated CD8+ lymphocytes, CD68 and CD163+ macrophages. In contrast, TA represented mostly a low immune cell infiltration. The higher immunogenicity of TC was accompanied by the more profound expression of STAT6 and SMAD4 in tumor cells. The number of immune cells in cytological specimens correlated with CD8+ (r = 0.693; p < 0.001) and CD163+ cells (r = 0.559; p < 0.001) in histological samples, reflecting the differences in the tumor immune microenvironment between benign and malignant thyroid neoplasms.

Conclusion

TC demonstrated high immunogenicity compared to TA, which correlated to the number of immune cells in cytological specimens. The number of immune cells in thyroid cytology samples could be an additional criterion in cytological diagnostics for III-V Bethesda categories. Further investigations are needed to validate the findings of the study.

The evolving role of MRI in the detection of extrathyroidal extension of papillary thyroid carcinoma: a systematic review and meta-analysis

BACKGROUND

Papillary thyroid carcinoma (PTC) is the predominant form of thyroid cancer, and the presence of extrathyroidal extension (ETE) significantly impacts treatment decisions and prognosis. Accurate preoperative detection of ETE remains challenging, highlighting the need to evaluate advanced imaging techniques.This systematic review and meta-analysis aimed to investigate the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting extrathyroidal extension (ETE) among patients diagnosed with papillary thyroid carcinoma (PTC).

METHOD

We conducted a comprehensive search of global databases including PubMed, Web of Science, EMBASE, and the Cochrane Library, spanning from inception to November 03, 2024. We included studies that utilized preoperative MRI to evaluate the presence of ETE. Quality assessment was carried out using the Joanna Briggs Institute (JBI) standard checklists. Data analysis was performed using Comprehensive Meta-Analysis (CMA) software version 3. The study protocol was registered in PROSPERO (CRD42024499536).

RESULT

Six studies were included in our final quantitative analysis. The included studies were classified into two groups; the first group focused on evaluating the accuracy of MRI in detecting ETE, while the second group assessed the apparent diffusion coefficient (ADC). The accuracy of MRI for overall ETE, minimal ETE (mETE), and gross ETE (gETE) was 81.0% (95% CI: 76.9%-85.6%), 72.9% (95% CI: 66.2%-78.6%), and 83.3% (95% CI: 75.2%-89.1%), respectively. MRI demonstrated a statistically significant difference in detecting gETE compared to mETE (OR = 1.85, 95% CI: 1.01-3.37, P-value = 0.045). Our analysis showed that the ADC of the lesion for b-value 500 is lower in patients with ETE compared to those without ETE (SMD = 0.95, 95% CI: 0.28-1.62, P-value = 0.005).

CONCLUSION

Our findings demonstrate that MRI has substantial accuracy in detecting ETE in PTC, especially for gross ETE. This suggests MRI could be a valuable tool in preoperative planning, helping to guide surgical decision-making by more precisely identifying patients at higher risk. However, the limited number of studies underscores the need for further research to confirm MRI's role in routine clinical practice and to refine imaging protocols for more accurate differentiation between minimal and gross ETE.

The Potential Therapeutic Value of Aspirin in Anaplastic Thyroid Cancer

Background: several experimental findings and epidemiological observations indicated that aspirin/acetylsalicylic acid (ASA) may be endowed with anticancer effects against a variety of human malignancies, including thyroid carcinomas. Among these, undifferentiated/anaplastic thyroid carcinoma (ATC) is one of the most aggressive and lethal human cancers, refractory to all currently available therapies. Methods: we here evaluated in a preclinical setting the effects of ASA on a panel of three ATC-derived cell lines: the CAL-62, the 8305C, and the 8505C. Results: the data obtained demonstrated the ability of ASA to inhibit, in a dose- and time-dependent manner, the proliferation of all ATC cell lines investigated, with IC50 values comprised between 2.0 and 4.3 mM. Cell growth was restrained with the same efficacy when the ASA treatment was applied to three-dimensional soft-agar cultures. In addition, ASA significantly reduced migration and invasion in two of the three ATC cell lines. We finally investigated the effects of ASA on the MAPK and PI3K/Akt signaling pathways, which are often altered in ATC. The results showed that the phosphorylation status of the Akt1/2/3 kinases was significantly reduced following ASA treatment, while ERK1/2 phosphorylation was either unaffected or slightly upregulated. Conclusions: our findings support epidemiological evidence on the anticancer potential of ASA. On this basis, further investigations should be carried out to assess the usefulness of ASA as adjuvant therapy in patients affected by ATC.

The diagnosis and management of small and indeterminate lymph nodes in papillary thyroid cancer: preoperatively and intraoperatively

Although thyroid cancer is an indolent tumor with a favorable prognosis, lymph node metastasis (LNM) serves as a major concern for many patients. Because LNM is strongly correlated with recurrence, distant metastasis, and shortened survival, a precise and timely diagnosis and following appropriate management for LNM are necessary. However, significant challenges still exist in the diagnosis of small LNs (<1 cm in diameter), and their low volume makes it difficult to determine whether they are metastatic or benign. Therefore, the diagnostic technique for these small and indeterminate LNs (siLNs) has been one of the leading research subjects in recent years. The implementation of innovative technologies, such as contrast-enhanced ultrasonography, frozen section, and molecular detection, has brought great progress to the diagnosis of siLNs. Meanwhile, the strategies for managing siLNs in clinical practice have evolved considerably over the past several years, with several appropriate options recommended by guidelines. In this review, we aim to provide a systematic overview of the latest studies and potential evidence about effective approaches for detecting and evaluating siLNs. Furthermore, the following management modalities of siLNs in different situations are well discussed.

The Application of microRNAs in Papillary Thyroid Cancer: A Bibliometric and Visualized Analysis

Objective

Thyroid cancer is the most common malignant endocrine tumor, with papillary thyroid carcinoma (PTC) being the most prevalent type, accounting for 85% of thyroid cancer cases. Here, we conducted a bibliometric analysis of the literature in the field of microRNAs in PTC research to demonstrate current trends and research hotspots, and present a visual map of past and emerging trends.

Methods

We searched the Web of Scientific Core Collection (WoSCC) database for publications from 1999 to 2023 centered on this field. Next, we employed visualization tools such as VOSviewer, CiteSpace, and Microsoft Excel 2019 to present co-occurrence and co-citation analyses, trends, hotspots, and visual representations of contributions from authors, institutions, journals, and countries/regions.

Results

The bibliometric analysis encompassed the period from 1999 to 2023, with 994 papers from 54 countries/regions. The country with the most publications and highest total citations was the People's Republic of China, but the United States held the highest average citation rate. Among the top ten productive institutions, the Ohio State University (Ohio State Univ) was the most prominent contributor to this field. The JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM (J Clin Endocrinol Metab) ranked first in terms of citation counts and average citations among the top ten productive journals. In terms of keywords, "circular RNAs", "promotes", and "progression" have become prominent research areas.

Conclusion

This study elucidates current trends, hotspots, and emerging frontiers in miRNA research within PTC, and provides new insights and guidance for future identification of new PTC biomarkers and clinical trials.

Descriptive Analysis of Common Fusion Mutations in Papillary Thyroid Carcinoma in Hungary

Thyroid cancer is the most common type of endocrine malignancy. Papillary thyroid carcinoma (PTC) is its predominant subtype, which is responsible for the vast majority of cases. It is true that PTC is a malignant tumor with a very good prognosis due to effective primary therapeutic approaches such as thyroidectomy and radioiodine (RAI) therapy. However, we are often required to indicate second-line treatments to eradicate the tumor properly. In these scenarios, molecular therapies are promising alternatives, especially if specifically targetable mutations are present. Many of these targetable gene alterations originate from gene fusions, which can be found using molecular diagnostics like next-generation sequencing (NGS). Nonetheless, molecular profiling is far from being a routine procedure in the initial phase of PTC diagnostics. As a result, the mutation status, except for BRAF V600E mutation, is not included in risk classification algorithms either. This study aims to provide a comprehensive analysis of fusion mutations in PTC and their associations with clinicopathological variables in order to underscore certain clinical settings when molecular diagnostics should be considered earlier, and to demonstrate yet unknown molecular-clinicopathological connections. We conducted a retrospective fusion mutation screening in formalin-fixed paraffin-embedded (FFPE) PTC tissue samples of 100 patients. After quality evaluation by an expert pathologist, RNA isolation was performed, and then NGS was applied to detect 23 relevant gene fusions in the tumor samples. Clinicopathological data were collected from medical and histological records. To obtain the most associations from the multivariate dataset, we used the d-correlation method for our principal component analysis (PCA). Further statistical analyses, including Chi-square tests and logistic regressions, were performed to identify additional significant correlations within certain subsets of the data. Fusion mutations were identified in 27% of the PTC samples, involving nine distinct genes: RET, NTRK3, CCDC6, ETV6, MET, ALK, NCOA4, EML4, and SQSTM1. RET and CCDC6 fusions were associated with type of thyroidectomy, RAI therapy, smaller tumor size, and history of Hashimoto's disease. NCOA4 fusion correlated with sex, multifocality, microcarcinoma character, history of goiter, and obstructive pulmonary disease. EML4 fusion was also linked with surgical procedure type and smaller tumor size, as well as the history of hypothyroidism. SQSTM1 fusion was associated with multifocality and a medical history of thyroid/parathyroid adenoma. NTRK3 and ETV6 fusions showed significant associations with Hashimoto's disease, and ETV6, also with endometriosis. Moreover, fusion mutations were linked to younger age at the time of diagnosis, particularly the fusion of ETV6. The frequent occurrence of fusion mutations and their associations with certain clinicopathological metrics highlight the importance of integrating molecular profiling into routine PTC management. Early detection of fusion mutations can inform surgical decisions and therapeutic strategies, potentially improving clinical outcomes.

Leptin and insulin synergize with PIK3CA mutation to enhance PD-L1 mediated immunosuppression in thyroid cancer

The incidence of thyroid cancer keeps rising and obesity emerges as an important risk factor for thyroid cancer, but the underlying mechanism is far from clear. Here, we hypothesize that leptin and insulin, two hormones closely related to obesity, may contribute to the pathogenesis of thyroid cancer. By using a combination of assays like CRISPR KO, cancer cell-T cell co-culture, ApoLive-Glo™ multiplex assay and syngeneic mouse model, we show that PD-L1 protein levels are increased dose-dependently by leptin or insulin in multiple thyroid cancer cell lines. Leptin and insulin converge to activate the PI3K-AKT pathway to enhance PD-L1 expression and activity. In addition, we use CRISPR KO to generate human thyroid cancer cells expressing WT PIK3CA or PIK3CA-E545K mutant. PIK3CA- E545K mutation makes the thyroid cancer cells to produce more PD-L1 protein upon leptin or insulin treatment. Thus, leptin and insulin synergize with PIK3CA mutation to enhance PD-L1 expression. Dual blockade of leptin and insulin signaling pathways reduces tumor size in a syngeneic mouse model. Our study suggests that understanding the interaction between genetic mutation and obesity is crucial for comprehensively assessing thyroid cancer risk and developing effective treatment strategies.

DLK1-DIO3 region as a source of tumor suppressor miRNAs in papillary thyroid carcinoma

BACKGROUND

In previous studies, we demonstrated the downregulation of several miRNAs from the DLK1-DIO3 genomic region in papillary thyroid carcinoma (PTC). Due to the large number of miRNAs within this region, the individual contribution of these molecules to PTC development and progression remains unclear.

OBJECTIVE

In this study, we aimed to clarify the contribution of DLK1-DIO3-derived miRNAs to PTC.

METHODS

We used different computational approaches and in vitro resources to assess the biological processes and signaling pathways potentially modulated by these miRNAs.

RESULTS

Our analysis suggests that, out of more than 100 mature miRNAs originated from the DLK1-DIO3 region, a set of 12 miRNAs accounts for most of the impact on PTC development and progression, cooperating to modulate distinct cancer-relevant biological processes, such as cell migration, extracellular matrix remodeling, and signal transduction. The restoration of the expression of one of these miRNAs (miR-485-5p) in a BRAFT199A-positive PTC cell line impaired proliferation and migration, suppressing the expression of GAB2 and RAC1, validated miR-485-5p targets.

CONCLUSIONS

Overall, our results shed light on the role of the DLK1-DIO3 region, which harbors promising tumor suppressor miRNAs in thyroid cancer, and open prospects for the functional exploration of these miRNAs as therapeutic targets for PTC.

CXCR4 promotes migration, invasion, and epithelial-mesenchymal transition of papillary thyroid carcinoma by activating STAT3 signaling pathway

AIMS

Papillary thyroid cancer (PTC) is a serious threat to human health worldwide, while metastasis in the early phase limits therapeutic success and leads to poor survival outcomes. The CXC chemokine receptor type 4 (CXCR4) plays an important role in many cellular movements such as transcriptional modulation, cell skeleton rearrangement, and cell migration, and the change in CXCR4 levels are crucial in various diseases including cancer. In this study, we explored the role of CXCR4 in the migration and invasion of PTC and investigated the potential mechanisms underlying its effects.

SUBJECTS AND METHODS

We analyzed the expression levels of CXCR4 in PTC tissues and cell lines. Would healing migration, Transwell invasion assay in vitro, and tail-vein lung metastasis assay In vivo were performed to evaluated the migration and invasion abilities of PTC cells with stable CXCR4 knockdown or overexpression. Signal transducers and activators of transcription (STAT3) signaling pathway-related protein expressions were examined by Western blotting assays.

RESULTS

The results showed that CXCR4 was highly expressed in PTC cell lines and PTC tissues. CXCR4 knockdown in PTC cells dampened the migration, invasion, and epithelial-mesenchymal transition (EMT), whereas CXCR4 overexpression enhanced these properties. In vivo, we also found that CXCR4 promoted the metastasis of PTC. Mechanistic studies showed that CXCR4 played these vital roles through the STAT3 signaling pathway. Furthermore, PTC patients with high CXCR4 or p-STAT3 expression correlated with aggressive clinical characteristics such as extrathyroidal extension (ETE), and lymph node metastasis (LNM).

CONCLUSIONS

We provided evidence that CXCR4 might activate the STAT3 signaling pathway and further promote PTC development. Thus, CXCR4 might be a novel therapeutic target for PTC.

Overexpression of FHL1 suppresses papillary thyroid cancer proliferation and progression via inhibiting Wnt/β-catenin pathway

PURPOSE

The four and a half LIM domain protein 1 (FHL1) has been found to act as a tumor suppressor in several cancers. However, the clinical and functional significance, as well as underlying molecular mechanisms of FHL1 in papillary thyroid cancer (PTC) are largely unknown.

METHODS

Bioinformatics analyses, qRT-PCR and Western blotting were used to investigate the expression of FHL1 in PTC. Cell proliferation was measured using CCK8, Edu, colony formation, and flow cytometry assays. Cell migration and invasion were examined by wound healing and Transwell assays. qRT-PCR, Western blot, immunofluorescence and Top/Fop reporter assays were performed to assess the underlying mechanisms.

RESULTS

FHL1 expression was significantly downregulated in PTC. FHL1 downregulation negatively correlated with stage, T classification, and N classification of the patients. The downregulation of FHL1 is associated with poor prognosis. Overexpression of FHL1 inhibited PTC cells' proliferation, invasion, migration and Wnt/β-catenin pathway activity. LiCl partially restored the inhibitory effects of FHL1 on aggressive phenotypes and Wnt/β-catenin pathway activity of PTC cells.

CONCLUSION

FHL1 is downregulated in PTC and its expression is associated with better clinical outcomes for patients with the disease. FHL1 acts as a tumor suppressor via, at least partially, suppressing Wnt/β-catenin pathway.

Association of Lymph Nodes Positive Rate With the Risk of Recurrence in Patients With Stage T1 Papillary Thyroid Cancer

The incidence of lymph node metastasis in papillary thyroid carcinoma (PTC) is common and a significant risk factor for local recurrence; however, its impact on recurrence patterns among low-risk patients remains uncertain. We aimed to elucidate the effect of metastatic lymph node on recurrence type. The medical records of 1209 patients with stage T1 PTC who underwent unilateral thyroidectomy with ipsilateral central lymph node dissection were retrospectively analyzed. The study first identified risk factors for different types of recurrence and then categorized patients as high or low risk based on their lymph node positive ratio (LNPR). The diagnostic accuracy of LNPR in predicting recurrence was compared using receiver operating characteristic (ROC) curve analysis, while differences in recurrence-free survival were assessed using the Kaplan-Meier method. During follow-up, a total of 502 (41.5%) patients had central lymph node metastasis and 52 (4.3%) patients experienced recurrence. Notably, LNPR was significantly higher in relapsed patients compared to nonrelapsed patients, with mean values of 0.45 and 0.23, respectively (P < .001). The recurrence rate of residual thyroid did not differ significantly across different T stages (P = .679), N stages (P = .415), or LNPR risk groups (P = .175). However, the recurrence rate of lymph nodes showed a significant correlation with LNPR (P < .001). The area under the ROC curves for LNPR risk stratification at 5 and 10 years were approximately 0.691 and 0.634, respectively, both of which outperformed N stage. The findings underscore the significance of LNPR's reliability as a prognostic indicator for local lymph node recurrence in patients diagnosed with T1 stage PTC.

Homogentisic acid metabolism inhibits papillary thyroid carcinoma proliferation through ROS and p21-induced cell cycle arrest

Thyroid cancer is one of the most common primary endocrine malignancies worldwide, and papillary thyroid carcinoma (PTC) is the predominant histological type observed therein. Although PTC has been studied extensively, our understanding of the altered metabolism and metabolic profile of PTC tumors is limited. We identified that the content of metabolite homogentisic acid (HGA) in PTC tissues was lower than that in adjacent non-cancerous tissues. We evaluated the potential of HGA as a novel molecular marker in the diagnosis of PTC tumors, as well as its ability to indicate the degree of malignancy. Studies have further shown that HGA contributes to reactive oxygen species (ROS) associated oxidative stress, leading to toxicity and inhibition of proliferation. In addition, HGA caused an increase in p21 expression levels in PTC cells and induced G1 arrest. Moreover, we found that the low HGA content in PTC tumors was due to the low expression levels of tyrosine aminotransferase (TAT) and p-hydroxyphenylpyruvate hydroxylase (HPD), which catalyze the conversion of tyrosine to HGA. The low expression levels of TAT and HPD are strongly associated with a higher probability of PTC tumor invasion and metastasis. Our study demonstrates that HGA could be used to diagnose PTC and provides mechanisms linking altered HGA levels to the biological behavior of PTC tumors.

Evolution in the management of thyroid surgery over a period of 15 years in a Belgian center

BACKGROUND

Guidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease the overdiagnosis of low-risk thyroid cancer. Our goal was to analyze the change made in operative thyroid management and the impact on thyroid cancer diagnosis.

BACKGROUND

Guidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease overdiagnosis of low risk thyroid cancer. Our goal was to study the evolution, over a long period, of pre- and postoperative management and the influence on histological cancer diagnosis and, more particularly, microcancer.

METHODS

In this retrospective cohort study, we included 891 consecutive patients who underwent thyroid surgery between 2007 and 2020.

RESULTS

Respectively 305, 290 and 266 patients underwent surgery over the 3 periods of 2007-2010, 2011-2015 and 2016-2020. In all three periods, women represented approximately 70% of the population, and the mean age was 54 years old (range: 67). Most surgeries (90%) involved total thyroidectomies. Over the study period, the proportion of preoperative fine needle aspiration (FNA) increased from 13 to 55%, p < 0,01. Cancer was found in a total of 116 patients: 35 (11%) patients between 2007 and 2010, 50 (17%) between 2011 and 2015 and 32 (12%) between 2016 and 2020 (p = 0.08). For all 3 periods, papillary thyroid cancer (PTC) was the most prevalent, at approximately 80%. The proportion of thyroid cancer > T1a increased significantly from 37% (2011-2015 period) to 81% (2016-2020 period), p = 0.001. Patients treated with radioiodine remained relatively stable (approximately 60%) but were more frequently treated with a low dose of radioiodine (p < 0.01) and recombinant human TSH (p < 0.01). Operative thyroid weight decreased over time in all but the low-risk T1a PTC cases.

CONCLUSIONS

Over a period of 15 years and according to the evolution of recommendations, the care of patients who underwent thyroid surgery changed with the increased use of preoperative FNA. This change came with a decrease in low-risk T1a PTC.

Comparative analysis through propensity score matching in thyroid cancer: unveiling the impact of multiple malignancies

Background

The incidence of thyroid cancer is on the rise worldwide, with childhood exposure to radiation being the sole acknowledged catalyst for its emergence. Nonetheless, numerous other factors that may pose risks are awaiting thorough examination and validation. This retrospective study aims to explore the malignancies linked to thyroid cancer and contrast the survival rates of those afflicted with a solitary tumor versus those with multiple primary neoplasms (MPN).

Methods

This retrospective study examined data from King Hussein Cancer Center (KHCC), Jordan. Among 563 patients diagnosed with thyroid cancer, 30 patients had thyroid malignancy as part of MPN. For a 1:3 propensity score-matched analysis, 90 patients with only a primary thyroid malignancy were also enrolled.

Results

Hematologic and breast malignancies were among the most frequent observed cancers alongside thyroid neoplasm. Patients who had MPN were diagnosed at older age, had higher body mass index and presented with higher thyroglobulin antibody levels (p < 0.05 for each). Additionally, MPN patient displayed a stronger family history for cancers (p= 0.002). A median follow-up duration of 135 months unveiled that MPN patients faced a worse 5-year survival compared to their counterparts with a singular neoplasm (87% vs 100% respectively; p < 0.01). However, no distinction emerged in the 5-year event-free survival between these two groups.

Conclusion

MPN correlates with a significantly altered survival outcome of thyroid cancer patients. The diagnosis of thyroid carcinoma at an older age, accompanied by elevated initial thyroglobulin antibody levels and a notable familial predisposition, may raise concerns about the potential occurrence of synchronous or metachronous tumors.

Genetic trio of BRAF and TERT alterations and rs2853669TT in papillary thyroid cancer aggressiveness

BACKGROUND

BRAF V600E and TERT promoter alterations are core components in current genetics-based risk assessment for precision management of papillary thyroid cancer. It remains unknown whether this approach could achieve even better precision through a widely recognized prognostic single-nucleotide variation (SNV, formerly SNP), rs2853669T>C, in the TERT promoter.

METHODS

The genetic status of alterations and SNV were examined by sequencing genomic DNA from papillary thyroid cancer in 608 patients (427 women and 181 men) aged 47 years (interquartile range = 37-57), with a median follow-up time of 75 months (interquartile range = 36-123), and their relationship with clinical outcomes was analyzed. A luciferase reporter assay was performed to examine TERT promoter activities.

RESULTS

TERT promoter alterations showed a strong association with papillary thyroid cancer recurrence in the presence of genotype TT of rs2853669 (adjusted hazard ratio [HR] = 2.12, 95% confidence interval [CI] = 1.10 to 4.12) but not TC/CC (adjusted HR = 1.17, 95% CI = 0.56 to 2.41). TERT and BRAF alterations commonly coexisted and synergistically promoted papillary thyroid cancer recurrence. With this genetic duet, TT of rs2853669 showed a robustly higher disease recurrence than TC/CC (adjusted HR = 14.26, 95% CI = 2.86 to 71.25). Patients with the genetic trio of BRAF V600E, TERT alteration, and TT of rs2853669 had a recurrence of 76.5% vs recurrence of 8.4% with neither variation and with TC/CC (HR = 13.48, 95% CI = 6.44 to 28.21). T allele of rs2853669 strongly increased TERT promoter activities, particularly the variant promoters.

CONCLUSIONS

The SNV rs2853669T>C dramatically refines the prognostic power of BRAF V600E and TERT promoter alterations to a higher precision, suggesting the need for including this SNV in the current genetics-based risk prognostication of papillary thyroid cancer.

TERT RNAscope analysis of sub-centimetric papillary thyroid carcinomas and synchronous lymph node metastases

BACKGROUND

Sub-centrimetric papillary thyroid carcinomas usually have a good prognosis with a cancer specific survival of > 99%, however in up to 65% of patients, lymph node metastases can be observed. Molecular alterations in BRAF, TERT and TP53 are associated with worse clinicopathological outcome in patients with papillary thyroid carcinoma.

MATERIAL AND METHODS

Twenty-two cases of papillary thyroid carcinomas measuring ≤ 1 cm with synchronous lymph node metastases were examined regarding morphological patterns and immunohistochemical status of p53, Ki-67, and BRAF V600E status. TERT RNA expression in lymph node metastases were evaluated by RNAScope®.

RESULTS

Morphological patterns were heterogeneous in both primary tumors and lymph node metastases. Proliferation indices measured by Ki-67 were low. Both primary and lymph node metastases were wild type for p53 by immunohistochemical analysis. No lymph node metastasis showed TERT expression by RNAScope®.

CONCLUSIONS

Our data indicate that TERT expression is not involved in the development early lymph node metastasis in patients with sub-centimetric PTC.

tRF-1:30-Gly-CCC-3 inhibits thyroid cancer via binding to PC and modulating metabolic reprogramming

tRFs and tiRNAs (tRNA-derived fragments) are an emerging class of small noncoding RNAs produced by the precise shearing of tRNAs in response to specific stimuli. They have been reported to regulate the pathological processes of numerous human cancers. However, the biofunction of tRFs and tiRNAs in the development and progression of papillary thyroid cancer (PTC) has not been reported yet. In this study, we aimed to explore the biological roles of tRFs and tiRNAs in PTC and discovered that a novel 5'tRNA-derived fragment called tRF-1:30-Gly-CCC-3 (tRF-30) was markedly down-regulated in PTC tissues and cell lines. Functionally, tRF-30 inhibited the proliferation and invasion of PTC cells. Mechanistically, tRF-30 directly bound to the biotin-dependent enzyme pyruvate carboxylase (PC), downregulated its protein level, interfered with the TCA cycle intermediate anaplerosis, and thus affected metabolic reprogramming and PTC progression. These findings revealed a novel regulatory mechanism for tRFs and a potential therapeutic target for PTC.

Tumor keratin 15 expression links with less extent of invasion and better prognosis in papillary thyroid cancer patients receiving tumor resection

OBJECTIVE

Keratin 15 (KRT15) is identified as a useful biomarker in several solid tumors, while its clinical role in papillary thyroid cancer (PTC) remains unknown. Herein, this study is intended to explore the correlation of tumor KRT15 with clinical features and survival in PTC patients who received tumor resection.

METHODS

This study retrospectively screened 350 PTC patients who received tumor resection and 50 thyroid benign lesions (TBL) patients. KRT15 in formalin-fixed paraffin-embedded lesion specimens of all subjects was detected by immunohistochemistry (IHC).

RESULTS

KRT15 was reduced in PTC patients compared to TBL patients (P < 0.001). Furthermore, KRT15 was negatively associated with tumor size (P = 0.017), extrathyroidal invasion (P = 0.007), pathological tumor (pT) stage (P < 0.001), and postoperative radioiodine application (P = 0.008) in PTC patients. Regarding prognostic value, high KRT15 (cut-off by an IHC value of 3) is linked with prolonged accumulating disease-free survival (DFS) (P = 0.008) and overall survival (OS) (P = 0.008) in PTC patients. Also, the multivariate Cox regression model showed that high KRT15 (vs. low) was an independent factor for longer DFS (hazard ratio = 0.433, P = 0.049), but not for OS (P > 0.050) in PTC patients. Subgroup analyses revealed that KRT15 possessed a better prognostic value in PTC patients with age ≥ 55 years, tumor size > 4 cm, pathological node stage 1, or pathological tumor-node-metastasis stage ≤ 2 (all P < 0.050).

CONCLUSION

Increased tumor KRT15 associates with a lower invasive degree, prolonged DFS, and OS, revealing its prognostic utility in PTC patients undergoing tumor resection.

RUNX1 methylation as a cancer biomarker in differentiating papillary thyroid cancer from benign thyroid nodules

Aim: It remains a challenge to accurately identify malignancy of thyroid nodules when biopsy is indeterminate. The authors aimed to investigate the abnormal DNA methylation signatures in papillary thyroid cancer (PTC) compared with benign thyroid nodules (BTNs). Methods: The authors performed genome profiling by 850K array and RNA sequencing in early-stage PTC and BTN tissue samples. The identified gene was validated in two independent case-control studies using mass spectrometry. Results: Hypomethylation of RUNX1 in PTC was identified and verified (all odds ratios: ≥1.50). RUNX1 methylation achieved good accuracy in differentiating early-stage PTC from BTNs, especially for younger women. Conclusion: The authors disclosed a significant association between RUNX1 hypomethylation and PTC, suggesting RUNX1 methylation as a potential biomarker for companion diagnosis of malignant thyroid nodules.

Integration of metabolomics and transcriptomics reveals metformin suppresses thyroid cancer progression via inhibiting glycolysis and restraining DNA replication

The anti-tumoral effects of metformin have been widely studied in several types of cancer, including thyroid cancer; however, the underlying molecular mechanisms remain poorly understood. As an oral hypoglycemic drug, metformin facilitates glucose catabolism and disrupts metabolic homeostasis. Metabolic reprogramming, particularly cellular glucose metabolism, is an important characteristic of malignant tumors. This study aimed to explore the therapeutic effects of metformin in thyroid cancer and the underlying metabolic mechanism. In the present study, it was shown that metformin reduced cell viability, invasion, migration, and EMT, and induced apoptosis and cell cycle G1 phase arrest in thyroid cancer. Transcriptome analysis demonstrated that the differentially expressed genes induced by metformin were involved in several signaling pathways including apoptosis singling pathways, TGF-β signaling, and cell cycle regulation in human thyroid cancer cell lines. In addition, the helicase activity of the CDC45-MCM2-7-GINS complex and DNA replication related genes such as RPA2, RAD51, and PCNA were downregulated in metformin-treated thyroid cancer cells. Moreover, metabolomics analysis showed that metformin-induced significant alterations in metabolic pathways such as glutathione metabolism and polyamine synthesis. Integrative analysis of transcriptomes and metabolomics revealed that metformin suppressed glycolysis by downregulating the key glycolytic enzymes LDHA and PKM2 and upregulating IDH1 expression in thyroid cancer. Furthermore, the anti-tumor role of metformin in thyroid cancer in vivo was shown. Together these results show that metformin plays an anti-tumor role by inhibiting glycolysis and restraining DNA replication in thyroid cancer.

Cancer-associated fibroblasts in papillary thyroid carcinoma

Papillary thyroid carcinoma (PTC) has a relatively good prognosis, yet there are some invasive PTC cases with worse clinicopathological features and poor outcome. Cancer-associated fibroblasts (CAFs) play an important role in cancer invasion and metastasis. This study aimed to investigate the expression of marker proteins of CAFs in PTC and their correlations with clinicopathological features through immunohistochemistry. The medical records of 125 PTC patients were reviewed in this study, whose specimens were retrieved for immunohistochemistry. Four CAFs marker proteins, FAP fibroblast activated protein (FAP), α-smooth muscle actin (α-SMA), Vimentin and platelet-derived growth factor receptor-α(PDGFR-α), were stained and scored. Then, statistical analyses were performed. The immunoreactivity scores of FAP and α-SMA correlated with tumor size, BRAF mutation, extrathyroidal, invasion, pathological subtype, lymph node metastasis and ATA risk stratification. Moreover, binary logistic regression analysis and receiver operating characteristic curves showed that high FAP and α-SMA immunoreactivity scores were risk factors for extrathyroidal invasion, BRAF mutation, multi-focality and lymph node metastasis (especially N1b) with good sensitivity and accuracy in prediction. A better performance was found in FAP than α-SMA. Strong expressions of CAFs were risk factors for worse thyroid cancer clinicopathological features. FAP was the better CAFs marker for PTC.

Performance of multigene testing in cytologically indeterminate thyroid nodules and molecular risk stratification

Objective

Thyroid cancer is the third most prevalent cancer among females. Genetic testing based on next-generation sequencing may provide an auxiliary diagnosis to reduce cytologically diagnostic uncertainty. However, commercial multigene tests are not widely available and are not well-tested in the Chinese population.

Methods

In this study, we designed a multigene testing panel and evaluated its performance in 529 cytologically indeterminate thyroid nodules (Bethesda III, IV and V). The molecular data of the DNA mutations and RNA fusions of fine needle aspiration samples were reviewed in conjunction with a clinical diagnosis, pathological reports, and definitive surgery for retrospective analysis. Then, the molecular risk stratification was investigated for its accuracy in malignant risk prediction.

Results

The overall combined consistency revealed substantial agreement (Kappa = 0.726) with the sensitivity, specificity, positive predictive value, and negative predictive values of 97.80%, 82.14%, 98.99%, and 67.65%, respectively. The most common aberration was BRAFV600E (82.59%), followed by NRAS mutants (4.07%), RET fusions (3.70%), and KRAS mutants (3.15%). Two cases (0.44%) were categorized into a high-risk group, 426 cases (94.67%) were categorized into a BRAF-like group with totally histopathologic papillary patterned tumors, and 22 cases (4.89%) were categorized into a RAS-like group with 14 papillary and eight follicular patterned tumors when the cohort concurrent aberrations were excluded. Potentially aggressive features may be related to concurrent molecular alterations of BRAFV600E with TERTQ302R, and AKT1L52R, NRASG12C, NRASQ61R, and CCDC6-RET fusions.

Conclusions

This study provided a multigene panel for identifying benign nodules from cytologically indeterminate thyroid nodules to avoid unnecessary surgery. We provide further evidence for using molecular risk stratification as a promising predictor of disease outcomes. The results of this study may be limited by the extremely high prevalence of cancer in the cohort for clinical reference.

Impact of BRAFV600E Mutation on Event-Free Survival in Patients with Papillary Thyroid Carcinoma: A Retrospective Study in a Romanian Population

We aimed to evaluate the prognostic value of BRAFV600E mutation in a series of 127 papillary thyroid carcinoma (PTC) cases as a single factor, and in synergic interaction with other standard risk factors. BRAFV600E mutation was assessed by real-time PCR. Event-free survival (EFS) was calculated between the date of the first evaluation and the date of occurrence of an adverse event or the date of the last known status. The prevalence of BRAFV600E mutation was 57.2%. The Kaplan-Meier analysis showed a significant reduction of EFS among cases harboring BRAFV600E mutation compared to non-mutated cases (p = 0.010). In addition, BRAFV600E mutation was found to better predict adverse outcomes when associated with the following risk factors: age ≥ 55 years old (p < 0.001), male gender (p < 0.001), conventional (p = 0.005) and tall cell (p = 0.014) histology, tumor size > 40 mm (p = 0.001), extrathyroidal extension (p = 0.001), multifocality (p = 0.001) and lymph node metastasis (p < 0.001). In univariate analysis, a 3.74-fold increased risk for a reduced EFS (p = 0.018) was found for BRAFV600E-mutated cases, but no increased risk was further confirmed by multivariate analysis. Our results highlight that BRAFV600E mutation cannot be used alone as an independent predictive factor in PTC patients, but is prognostically valuable if integrated in the context of other clinicopathological risk factors.

Association between thyroid stimulating hormone levels and papillary thyroid cancer risk: A meta-analysis

High thyroid stimulating hormone (TSH) levels may stimulate papillary thyroid cancer (PTC) cell proliferation; however, the relationship between TSH levels and PTC risk remains controversial. We aim to ascertain the association through a meta-analysis. Literature searches were conducted in PubMed, Embase, and Web of Science databases. After literature screening, the methodological quality was assessed using the Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality methods. Cochran's Q and I 2 tests were used to evaluate heterogeneity in the meta-analysis. Egger's test was applied to assess publication bias. A total of 12 eligible studies were included in this meta-analysis; all were of moderate and high methodological quality. The pooled results suggested that increased TSH levels were significantly associated with PTC risk; however, the included studies were significantly heterogeneous. Stratification analysis indicated that the heterogeneity might be from the area or type of control. Although significant publication bias existed among the studies, the trim-and-fill method and sensitivity analysis revealed that the combined results were stable and robust. TSH levels are significantly associated with the PTC risk; however, more high-quality studies in large sample sizes are recommended to verify the extrapolation of these findings.

A Comparative Analysis of NOX4 Protein Expression in Malignant and Non-Malignant Thyroid Tumors

The comparative analysis of the expression of the reactive oxygen species-generating NADPH oxidase NOX4 from TCGA data shows that the NOX4 transcript is upregulated in papillary thyroid carcinomas (PTC)-BRAF^V600E tumors compared to PTC-BRAF^wt tumors. However, a comparative analysis of NOX4 at the protein level in malignant and non-malignant tumors is missing. We explored NOX4 protein expression by immunohistochemistry staining in malignant tumors (28 classical forms of PTC (C-PTC), 17 follicular variants of PTC (F-PTC), and three anaplastic thyroid carcinomas (ATCs)) and in non-malignant tumors (six lymphocytic thyroiditis, four Graves' disease, ten goiters, and 20 hyperplasias). We detected the BRAF^V600E mutation by Sanger sequencing and digital droplet PCR. The results show that NOX4 was found to be higher (score ≥ 2) in C-PTC (92.9%) compared to F-PTC (52.9%) and ATC (33.3%) concerning malignant tumors. Interestingly, all C-PTC-BRAF^V600E expressed a high score for NOX4 at the protein level, strengthening the positive correlation between the BRAF^V600E mutation and NOX4 expression. In addition, independent of the mutational status of BRAF, we observed that 90% of C-PTC infiltrating tumors showed high NOX4 expression, suggesting that NOX4 may be considered a complementary biomarker in PTC aggressiveness. Interestingly, NOX4 was highly expressed in non-malignant thyroid diseases with different subcellular localizations.

Updates in Thyroid Cancer Surgery

This Special Issue of Cancers entitled "Updates in thyroid surgery" is a collection of nine articles that covers a wide range of topics, providing a comprehensive picture of the latest developments in thyroid surgery [...].

Expression Levels of MicroRNA-300/BCL2L11 in Papillary Thyroid Cancer and Their Clinical Diagnostic Values

INTRODUCTION

This research aims to explore the expression levels of microRNA (miRNA)-300/BCL-2-like protein 11 (BCL2L11) and their values in the clinical diagnosis of papillary thyroid cancer (PTC).

METHODS

Pathological tissues that were surgically removed for thyroid disease were selected. miR-300 and BCL2L11 expression levels in the samples were measured. Receiver operating characteristic (ROC) curves were plotted to analyze miR-300 and BCL2L11 predictive values for PTC. Upon silencing miR-300 and silencing BCL2L11 in PTC cells, the corresponding miR-300 and BCL2L11 expression levels were tested, followed by examining PTC cell activities. The targeting relationship of miR-300 and BCL2L11 was detected by the bioinformatics website and luciferase activity assay.

RESULTS

miR-300 expression levels were elevated and BCL2L11 expression levels were reduced in PTC tissues. miR-300 and BCL2L11 expression levels in PTC tissues had a correlation with TNM stage and lymph node metastasis. The results of ROC curve revealed that both miR-300 and BCL2L11 had clinical predictive values for PTC. Mechanistically, miR-300 negatively regulated BCL2L11. The functional assays unveiled that silencing miR-300 impeded PTC cell activities, and silencing BCL2L11 induced PTC cell activities. In the rescue experiment, silencing BCL2L11 reversed the impacts of silencing miR-300 on PTC cell development.

CONCLUSION

This study underlines that miR-300 expression is increased and BCL2L11 expression is declined in PTC. miR-300 and BCL2L11 both have clinical predictive values for diagnosing PTC.

The 15-year national trends of endocrine cancers incidence among Iranian men and women; 2005-2020

Cancer is one of the important health problems in Iran, which is considered as the third cause of death. Endocrine cancers are rare but mostly curable. Thyroid cancer, the most common endocrine tumors, includes about one percent of malignant cancer. In this study, we examined the 15-year national trend of endocrine cancer incidence in Iranian men and women. The data in each province were evaluated based on age, gender, and cancer type according to International Classification of Disease Codes version 10 (ICD-10) from 2005 to 2020 in Iran. All data were obtained from the reports of the Statistics Center of Iran (SCI), 6 phases of the step-by-step approach to monitoring the risk factors of chronic diseases over 18 years old (STEPs), and 3 periods of the CASPIAN study (survey of non-communicable diseases in childhood and adolescence). Statistical analyzes and graph generation were done using R statistical software. Poisson regression with mixed effects was used for data modeling and incidence rate estimation. The incidence of thyroid gland malignancy is higher in women than in men. On the other hand, the incidence of adrenal gland cancer is slightly higher in men than in women. The same pattern is observed for other endocrine neoplasms and related structures. The incidence rate of these types of cancers has generally increased from 2005 to 2020 in Iran. This increase is more in women than in men. In addition, in the middle of the country, there is a strong region in terms of the occurrence of these types of cancers. The incidence rate in these provinces is relatively higher for both sexes and all studied periods. We conducted a study to observe the changing trends for various types of endocrine cancers over 15 years in men and women. Considering the increasing trend of thyroid cancers in Iran, therefore, creating essential policies for the management of these types of cancers for prevention, rapid diagnosis, and, timely treatment is particularly important.

US Evaluation of Topical Hemostatic Agents in Post-Thyroidectomy

BACKGROUND

the aim of this study was to describe the ultrasound appearance of topical hemostatics after thyroidectomy.

METHODS

we enrolled 84 patients who were undergoing thyroid surgery and were treated with two types of topical hemostats, 49 with an absorbable hemostat of oxidized regenerated cellulose (Oxitamp^®) and 35 with a fibrin glue-based hemostat (Tisseel^®). All patients were examined using B-mode ultrasound.

RESULTS

In 39 patients of the first group (approximately 80%), a hemostatic residue was detected and in some cases confused with a native gland residue, or with cancer recurrence in oncological patients. No residue was detected in patients in the second group. The main ultrasound characteristics of the tampon were analyzed and arranged according to predefined patterns, and suggestions to recognize it and avoid wrong diagnoses were provided. A part of the group of patients with tampon residue was re-evaluated after 6-12 months, ensuring that the swab remained for months after the maximum resorption time declared by the manufacturer.

CONCLUSIONS

with equal hemostatic effectiveness, the fibrin glue pad is more favorable in the ultrasound follow-up because it creates reduced surgical outcomes. It is also important to know and recognize the ultrasound characteristics of oxidized cellulose-based hemostats in order to reduce the number of diagnostic errors and inappropriate diagnostic investigations.

The Tumor Microenvironment and the Estrogen Loop in Thyroid Cancer

Thyroid cancer (TC) cells employ multiple signaling pathways, such as PI3K/AKT/mTOR and RAS/Raf/MAPK, fostering cell proliferation, survival and metastasis. Through a complex interplay with immune cells, inflammatory mediators and stroma, TC cells support an immunosuppressive, inflamed, pro-carcinogenic TME. Moreover, the participation of estrogens in TC pathogenesis has previously been hypothesized, in view of the higher TC incidence observed among females. In this respect, the interactions between estrogens and the TME in TC could represent a relevant, unexplored area of research. We thereby collectively reviewed the available evidence concerning the potential carcinogenic role of estrogens in TC, specifically focusing on their crosstalk with the TME.

Integrated gene profiling of fine-needle aspiration sample improves lymph node metastasis risk stratification for thyroid cancer

BACKGROUND

Lymph node metastasis risk stratification is crucial for the surgical decision-making of thyroid cancer. This study investigated whether the integrated gene profiling (combining expression, SNV, fusion) of Fine-Needle Aspiration (FNA) samples can improve the prediction of lymph node metastasis in patients with papillary thyroid cancer.

METHODS

In this retrospective cohort study, patients with papillary thyroid cancer who went through thyroidectomy and central lymph node dissection were included. Multi-omics data of FNA samples were assessed by an integrated array. To predict lymph node metastasis, we built models using gene expressions or mutations (SNV and fusion) only and an Integrated Risk Stratification (IRS) model combining genetic and clinical information. Blinded histopathology served as the reference standard. ROC curve and decision curve analysis was applied to evaluate the predictive models.

RESULTS

One hundred and thirty two patients with pathologically confirmed papillary thyroid cancer were included between 2016-2017. The IRS model demonstrated greater performance [AUC = 0.87 (0.80-0.94)] than either expression classifier [AUC = 0.67 (0.61-0.74)], mutation classifier [AUC = 0.61 (0.55-0.67)] or TIRADS score [AUC = 0.68 (0.62-0.74)] with statistical significance (p < 0.001), and the IRS model had similar predictive performance in large nodule [>1 cm, AUC = 0.88 (0.79-0.97)] and small nodule [≤1 cm, AUC = 0.84 (0.74-0.93)] subgroups. The genetic risk factor showed independent predictive value (OR = 10.3, 95% CI:1.1-105.3) of lymph node metastasis in addition to the preoperative clinical information, including TIRADS grade, age, and nodule size.

CONCLUSION

The integrated gene profiling of FNA samples and the IRS model developed by the machine-learning method significantly improve the risk stratification of thyroid cancer, thus helping make wise decisions and reducing unnecessary extensive surgeries.

Insights on the Association between Thyroid Diseases and Colorectal Cancer

Benign and malignant thyroid diseases (TDs) have been associated with the occurrence of extrathyroidal malignancies (EMs), including colorectal cancers (CRCs). Such associations have generated a major interest, as their characterization may provide useful clues regarding diseases’ etiology and/or progression, with the possible identification of shared congenital and environmental elements. On the other hand, elucidation of the underlying molecular mechanism(s) could lead to an improved and tailored clinical management of these patients and stimulate an increased surveillance of TD patients at higher threat of developing EMs. Here, we will examine the epidemiological, clinical, and molecular findings connecting TD and CRC, with the aim to identify possible molecular mechanism(s) responsible for such diseases’ relationship.

m6A Writer METTL3-Mediated lncRNA LINC01125 Prevents the Malignancy of Papillary Thyroid Cancer

BACKGROUND

Long non-coding RNA (lncRNA) LINC01125 is an anti-tumor factor in a variety of tumors, and regulates cancer cell function. However, its function and mechanism of N6-methyladenosine (m6A) modification in papillary thyroid cancer (PTC) tumorigenesis remain unclear.

AIMS

This study aimed to reveal the function and m6A modification of LINC01125 in PTC tumorigenesis.

METHODS

The LINC01125 and methyltransferase-like 3 (METTL3) levels in PTC cells and tissues was assessed by qRT-PCR. The binding relationship among LINC01125 and METTL3 was determined by MeRIP, Pearson, bioinformatics, and RNA stabilization analysis. Transwell assays were performed to confirm the changes of PTC cell migration and invasion. Cell proliferation was revealed by CCK-8 as well as colony formation assays.

RESULTS

Low expression of LINC01125 and METTL3 was identified in PTC. LINC01125 was a downstream target of METTL3-mediated m6A modification and was stably upregulated via METTL3. Cell invasion, migration, viability, and colony formation levels were decreased when LINC01125 or METTL3 was upregulated. Inhibition of LINC01125 had the opposite impact, promoting cell proliferation and metastasis, and reversing METTL3 overexpression-resulted cell malignancy suppression.

CONCLUSIONS

Overall, this study proved that the m6A modification of LINC01125 was mediated by METTL3 and LINC01125 inhibited cell invasion, migration and proliferation, thereby suppressing the development of PTC. This points to the LINC01125-m6A-METTL3 axis as a possible prospective target for future treatment of PTC.

An innovative synthetic support for immunocytochemical assessment of cytologically indeterminate (Bethesda III) thyroid nodules

Background

Fine needle aspiration (FNA) is the procedure of choice in the evaluation of thyroid nodules. Nodules with indeterminate cytological categories, Bethesda III and IV, pose challenges in clinical practice and are frequently submitted to diagnostic surgery. CytoFoam Core (CFCS) uses an absorbent foam device inserted into the needle hub to collect the cytological sample aspirated during FNA. Specimen is formalin-fixed and paraffin-embedded.

Aim of the study

Assessing diagnostic efficacy of CFCS, compared to traditional cytology, in re-evaluating thyroid nodules classified as Bethesda III, using post-surgical histology as reference standard.

Method

Retrospective study on 89 patients with a first indeterminate cytological report who were referred to the Department of Endocrinology of Regina Apostolorum Hospital (Albano L. Rome, Italy) for a second FNA. FNA was performed after at least one month under ultrasound guidance with a 23G needle according to the established procedure. During the second procedure, both traditional cytological (TC) smears and a single-pass CFCS specimen were obtained for each patient. On CFCS samples immunocytochemical staining for Galectin-3, HBME-1, and CK-19 was also performed. 51 patients eventually underwent surgery, and their histological diagnoses were compared to the TC and CFCS reports. Four parameters were evaluated: inadequacy rate, rate of persistent indeterminate (Bethesda III and IV) reports, rate of malignancy in persistently indeterminate nodules, and rate of cancer in lesions cytologically classified as malignant.

Results

Non-diagnostic samples were 6 (11.8%) in TC vs 3 (5.9%) in CFCS (p=0.4). Persistent indeterminate samples were 31 (60.8%) in TC vs 19 (37.2%) in CFCS (p=0.01). Rate of malignancy in persistently indeterminate nodules was 8/19 (42.1%) in CFCS vs 9/31 (29%) in TC group (p=0.3). Nine/51 (17.6%) samples were classified as benign by TC vs 21/51 (41.2%) samples by CFCS (p<0.01). All nodules resulted benign at post-surgical evaluation. Five/51 (9.8%) samples were classified as suspicious for malignancy/malignant in TC group against 8/51 (15.7%) samples in CFCS (p=0.5). Post-surgical evaluation confirmed malignancy in all these cases.

Conclusion

CFCS demonstrated greater diagnostic accuracy than TC in repeat FNA assessment of cytologically indeterminate nodules. CFCS increased the conclusive diagnosis rate and decreased the number of cytologically indeterminate cases.

Preoperative prognostic risk stratification model for papillary thyroid carcinoma based on clinical and ultrasound characteristics

Background

The preoperative risk stratification for patients with papillary thyroid carcinoma (PTC) plays a crucial role in guiding individualized treatment. We aim to construct a predictive model that aids in distinguishing between patients with low-risk and high-risk PTC based on preoperative clinical and ultrasound characteristics.

Materials and methods

Patients who underwent open surgery and were diagnosed with PTC via a postoperative pathological report between January 2020 and December 2020 were retrospectively reviewed. Data including basic information, preoperative ultrasound characteristics, thyroid function, and postoperative pathology characteristics were obtained. Univariate logistic regression analysis and least absolute shrinkage and selection operator regression analysis were performed to screen candidate variables. Finally, the preoperative predictive model for PTC was established based on the results of the multivariate logistic regression analysis.

Results

A total of 1,875 patients with PTC were enrolled. Eight variables (sex, age, number of foci, maximum tumor diameter on ultrasound, calcification, capsule, lymph node status on ultrasound, and thyroid peroxidase (TPO) antibody level) significantly associated with risk stratification were included in the predictive model. A nomogram was constructed for clinical utility. The model showed good discrimination, and the area under the curve was 0.777 [95% confidence interval (CI): 0.752-0.803] and 0.769 (95% CI: 0.729-0.809) in the training set and validation set, respectively. The calibration curve exhibited a rather good consistency with the perfect prediction. Furthermore, decision curve analysis and clinical impact curve showed that the model had good efficacy in predicting the prognostic risk of PTC.

Conclusions

The nomogram model based on preoperative indicators for predicting the prognostic stratification of PTC showed a good predictive value. This could aid surgeons in deciding on individualized precision treatments.

Thyroid and renal cancers: A bidirectional association

There is a deep interrelation between the thyroid gland and the kidney parenchyma, with dysfunction of the first leading to significant changes in renal metabolism and vice versa. Given the recognition of cancer as a systemic disease, the raise of thyroid tumors and the common association of several malignancies, such as breast cancer, prostate cancer, colorectal cancer, and other, with an increased risk of kidney disease, public health alert for these conditions is warranted. A systematic review of the current evidence on the bidirectional relationship between thyroid and renal cancers was conducted including 18 studies, highlighting patient’s characteristics, histology, time for secondary malignancy to develop from the first diagnosis, treatment, and follow-up. A total of 776 patients were identified; median age was 64 years (range: 7–76 years). Obesity and family history were identified as the most common risk factors, and genetic susceptibility was suggested with a potential strong association with Cowden syndrome. Controversy on chemo and radiotherapy effects was found, as not all patients were previously exposed to these treatments. Men were more likely to develop kidney cancer after a primary thyroid malignancy, with 423/776 (54%) experiencing renal disease secondarily. Median time after the first malignancy was 5.2 years (range: 0–20 years). With the advancement of current oncological therapy, the prognosis for thyroid cancer patients has improved, although there has been a corresponding rise in the incidence of multiple secondary malignancy within the same population, particularly concerning the kidney. Surgery can achieve disease-free survival, if surveillance follow-up allows for an early localized form, where radical treatment is recommended.

Weight Gain and Asthenia Following Thyroidectomy: Current Knowledge from Literature Review

BACKGROUND

Thyroidectomy is a common procedure all over the world. Its complication rate is low, but some patients complain of weight gain and/or asthenia. The aim of this review is to investigate the correlation between thyroidectomy and weight change and asthenia.

MATERIALS AND METHODS

Seven papers concerning weight gain and four concerning asthenia were found.

RESULTS

Weight gain would seem to be more related to the change in habits after surgery. Asthenia seems to be more linked to endocrine mechanisms not yet clarified although a deficiency of triiodothyronine and its metabolites could explain some of its aspects.

CONCLUSION

Patients who are candidates for thyroidectomy should be adequately informed of the onset of both possible implications of the surgical act in terms of weight gain and chronic asthenia.

Is Melanoma Progression Affected by Thyroid Diseases?

Clinical and epidemiological evidence indicate a relationship between thyroid diseases and melanoma. In particular, the hypothyroidism condition appears to promote melanoma spread, which suggests a protective role of thyroid hormones against disease progression. In addition, experimental data suggest that, in addition to thyroid hormones, other hormonal players of the hypothalamic–pituitary–thyroid (HPT) axis, namely the thyrotropin releasing hormone and the thyrotropin, are likely to affect melanoma cells behavior. This information warrants further clinical and experimental studies in order to build a precise pattern of action of the HPT hormones on melanoma cells. An improved knowledge of the involved molecular mechanism(s) could lead to a better and possibly personalized clinical management of these patients.

Risk Factors for Cervical Lymph Node Metastasis in Middle Eastern Papillary Thyroid Microcarcinoma

Papillary thyroid microcarcinoma (PTMC) typically has an indolent course and excellent prognosis. Nonetheless, a subset of PTMC carries a risk of lymph node metastasis (LNM) and local recurrence. PTC from the Middle Eastern population is unique with respect to demographic and clinico-pathological characteristics as compared to other ethnicities of the world. The risk factors of LNM in PTMC patients of Middle Eastern ethnicity have not been fully explored. The present study aims to investigate the influencing factors of LNM in Middle Eastern PTMC patients and its predictive impact on patient’s outcome. A total of 226 confirmed PTMC cases were selected in this retrospective study. The correlation between clinico-pathological, as well as molecular, characteristics and LNM was evaluated. Multivariate analysis was performed by logistic regression and Cox proportional hazards models. Among the 226 patients, the rate of LNM was 43.8% (99/226). Bilaterality, multifocality, gross extrathyroidal extension (ETE), and intermediate-to-high American Thyroid Association (ATA) risk tumors were significantly associated with LNM in PTMC. Multivariate logistic regression analysis showed that bilaterality and gross ETE were independent predictive factors for LNM in PTMC. The recurrence-free survival (RFS) was shorter in PTMC with LNM compared to those without LNM (p = 0.0051) and was significant on multivariate analysis. In conclusion, our study showed that bilaterality and gross ETE were independent influencing factors of LNM in Saudi patients with PTMC. LNM was also associated with shorter RFS. The identification of risk factors for LNM in patients of Middle Eastern ethnicity could help the individualization of clinical management for PTMC patients.

Association between hashimoto thyroiditis and differentiated thyroid cancer: A single-center experience

Hashimoto’s thyroiditis is the most common cause of hypothyroidism in the iodine-sufficient areas of the world. Differentiated thyroid cancer is the most common thyroid cancer subtype, accounting for more than 95% of cases, and it is considered a tumor with a good prognosis, although a certain number of patients experience a poor clinical outcome. Hashimoto’s thyroiditis has been found to coexist with differentiated thyroid cancer in surgical specimens, but the relationship between these two entities has not yet been clarified. Our study aims to analyze the relationship between these two diseases, highlighting the incidence of histological diagnosis of Hashimoto thyroiditis in differentiated thyroid cancer patients, and assess how this autoimmune disorder influences the risk of structural disease recurrence and recurrence rate.

Artificial Intelligence for Thyroid Nodule Characterization: Where Are We Standing?

Simple Summary

In the present review, an up-to-date summary of the state of the art of artificial intelligence (AI) implementation for thyroid nodule characterization and cancer is provided. The opinion on the real effectiveness of AI systems remains controversial. Taking into consideration the largest and most scientifically valid studies, it is possible to state that AI provides results that are comparable or inferior to expert ultrasound specialists and radiologists. Promising data approve AI as a support tool and simultaneously highlight the need for a radiologist supervisory framework for AI provided results. Therefore, current solutions might be more suitable for educational purposes.

Abstract

Machine learning (ML) is an interdisciplinary sector in the subset of artificial intelligence (AI) that creates systems to set up logical connections using algorithms, and thus offers predictions for complex data analysis. In the present review, an up-to-date summary of the current state of the art regarding ML and AI implementation for thyroid nodule ultrasound characterization and cancer is provided, highlighting controversies over AI application as well as possible benefits of ML, such as, for example, training purposes. There is evidence that AI increases diagnostic accuracy and significantly limits inter-observer variability by using standardized mathematical algorithms. It could also be of aid in practice settings with limited sub-specialty expertise, offering a second opinion by means of radiomics and computer-assisted diagnosis. The introduction of AI represents a revolutionary event in thyroid nodule evaluation, but key issues for further implementation include integration with radiologist expertise, impact on workflow and efficiency, and performance monitoring.

Advanced Differentiated Thyroid Cancer: A Complex Condition Needing a Tailored Approach

Differentiated thyroid cancers (DTCs) are slow-growing malignant tumours, including papillary and follicular carcinomas. Overall, prognosis is good, although it tends to worsen when local invasion occurs with bulky cervical nodes, or in the case of distant metastases. Surgery represents the main treatment for DTCs. However, radical excision is challenging and significant morbidity and functional loss can follow the treatment of the more advanced forms. Literature on advanced thyroid tumours, both differentiated and undifferentiated, does not provide clear and specific guidelines. This emerges the need for a tailored and multidisciplinary approach. In the present study, we report our single-centre experience of 111 advanced (local, regional, and distant) DTCs, investigating the rate of radical excision, peri-procedural and post-procedural complications, quality of life, persistence, recurrence rates, and survival rates. Results are critically appraised and compared to the existing published evidence review.

Improving the diagnosis of thyroid cancer by machine learning and clinical data

Thyroid cancer is a common endocrine carcinoma that occurs in the thyroid gland. Much effort has been invested in improving its diagnosis, and thyroidectomy remains the primary treatment method. A successful operation without unnecessary side injuries relies on an accurate preoperative diagnosis. Current human assessment of thyroid nodule malignancy is prone to errors and may not guarantee an accurate preoperative diagnosis. This study proposed a machine learning framework to predict thyroid nodule malignancy based on our collected novel clinical dataset. The ten-fold cross-validation, bootstrap analysis, and permutation predictor importance were applied to estimate and interpret the model performance under uncertainty. The comparison between model prediction and expert assessment shows the advantage of our framework over human judgment in predicting thyroid nodule malignancy. Our method is accurate, interpretable, and thus useable as additional evidence in the preoperative diagnosis of thyroid cancer.

Prognostic Impact of Microscopic Extra-Thyroidal Extension (mETE) on Disease Free Survival in Patients with Papillary Thyroid Carcinoma (PTC)

Background: This study assessed the risk of reduced disease-free survival (DFS) and poor clinical outcome in patients with papillary thyroid carcinomas (PTC) with microscopic extra-thyroidal extension (mETE), as compared to PTC patients without mETE. Methods: Retrospective analysis of a prospective database of patients treated by total thyroidectomy and radioactive iodine (RAI) with a five-year follow-up and tumors < 40 mm. In total, 303 patients were analyzed: 30.7% presented tumors with mETE, and 69.3% without. mETE was defined as extra-thyroidal invasion without skeletal muscle involvement. The primary outcome, DFS, was defined as the interval between initial treatment and any subsequent PTC-related treatment. The second outcome was the clinical status at five years. Results: In univariate analyses, the five-year DFS was significantly lower for tumors with mETE (62.4% versus 88.1%, p < 0.001). In multivariate analysis, mETE and massive lymph node involvement (LNI) were independent prognostic factors, associated respectively with a hazard ratio of 2.55 (95% CI 1.48−4.40) and 8.94 (95% CI 4.92−16.26). mETE was significantly associated with a pejorative clinical outcome at five years, i.e., biochemical/indeterminate response and structural persistence (Respectively OR 1.83 (95% CI 0.83; 4.06) and OR 4.92 (95% CI 1.87; 12.97)). Conclusion: Our results suggest that mETE is an independent poor prognosis factor of reduced DFS and predictive of poor clinical outcome.