Lymph Node Metastases Papillary Thyroid Carcinoma and their Importance in Recurrence of Disease

Enhanced stiffness in peri-cancerous tissue: a marker of poor prognosis in papillary thyroid carcinoma with lymph node metastasis

BACKGROUND

The prognostic significance of lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) remains controversial. Notably, there is evidence suggesting an association between tissue stiffness and the aggressiveness of the disease. We therefore aimed to explore the effect of tissue stiffness on LNM-related invasiveness in PTC patients.

METHOD

A total of 2492 PTC patients from 3 hospitals were divided into an LNM group and a non-LNM group based on their pathological results. The effects of interior lesion stiffness (E) and peri-cancerous tissue stiffness (Eshell) on the LNM-related recurrence rate and mortality in each patient with PTC subgroup were analyzed. The activation of cancer-associated fibroblasts (CAFs) and extracellular matrix component type 1 collagen (COL-I) in the lesion were compared and analyzed across different subgroups. The underlying biological basis of differences in each subgroup was identified using RNA sequencing (RNA-seq) data.

RESULTS

The Eshell value and Eshell/E in the LNM group were significantly higher than those in the non-LNM group of patients with PTC (Eshell: 72.72 ± 5.63 vs 66.05 ± 4.46; Eshell/E: 1.20 ± 1.72 vs 1.09 ± 1.10, P < .001). When Eshell/E > 1.412 and LNM were both present, the recurrence rate and mortality were significantly increased compared to those of group of patients with LNM (91.67% and 7.29%, respectively). The CAF activation and COL-I content in the Eshell/E+ group were significantly higher than those in the Eshell/E- group (all P < .001), and the RNA-seq results revealed significant extracellular matrix (ECM) remodeling in the LNM-Eshell/E+ group.

CONCLUSIONS

Stiff peri-cancerous tissue induced CAF activation, COL-I deposition, and ECM remodeling, resulting in a poor prognosis for PTC patients with LNM.

Visualizing thyroid health: a pictorial journey through 2017 ACR TI-RADS and common thyroid pathologies

With the advent of high-resolution ultrasonography (HRUS), more thyroid nodules are being detected than ever before, and they are being identified at an earlier stage. It poses a challenge for radiologists and clinicians in deciding what to do next. Most nodules are benign and require no follow-up and intervention. Even highly suspicious nodules can be followed up, if the size is small. Variations in HRUS interpretation among radiologists are common, with frequent misidentifications between spongiform and solid-cystic lesions, hypoechoic and very hypoechoic nodules, and microcalcification and hyperechoic foci with comet-tail artifacts. Cystic lesions with echogenic contents are often confused with solid nodules, cystic papillary carcinoma thyroid is often confused with colloid cysts. The 2017 ACR TI-RADS (American College of Radiology Thyroid Imaging Reporting and Data System) aims to standardize the interpretation of thyroid nodules and guide further management. Rather than giving specific diagnosis like colloid cyst, adenomatous nodule and papillary carcinoma; ACR TI-RADS classifies nodules from TI-RADS 1 to TI-RADS 5 based on HRUS characteristics and recommends further management. What the authors often read are textual contents that are theoretical, and in practice, the authors get confused while interpreting the characteristics of thyroid nodules. This review offers a detailed visual overview of the 2017 ACR TI-RADS and common thyroid conditions, explaining key features through imaging data and examples for consistent interpretation. Combining textual explanations with visual aids, this article provides practical guidance for interpreting thyroid nodules for radiologists, and clinicians seeking a clear understanding of thyroid imaging and pathology.

Proteomic and Phosphoproteomic analysis of thyroid papillary carcinoma: Identification of potential biomarkers for metastasis

Thyroid cancer has emerged as the most rapidly proliferating solid neoplasm. In this study, we included a cohort of patients who underwent sonographic assessment and surgical intervention at the Sir Run Run Shaw Hospital, associated with the School of Medicine at Zhejiang University, spanning from January 2019 to June 2020. Stratification of cases was based on a combination of preoperative ultrasonographic evaluations and postoperative histopathological diagnoses, resulting in three distinct groups: high-risk papillary thyroid carcinoma (PTC) labeled as C1, low-risk PTC designated as C2, and a control group (N) composed of benign thyroid tissue adjacent to the carcinoma. Proteomic and phosphoproteomic analyses were conducted on PTC specimens. The comparative assessment revealed that proteins up-regulated in the C1/N and C2/N groups were predominantly involved in functions such as amino acid binding, binding of phosphorylated compounds, and serine protease activity. Notably, proteins like NADH dehydrogenase, ATP synthase, oxidoreductases, and iron ion channels were significantly elevated in the C1 versus C2 comparative group. Through meticulous analysis of differential expression multiples, statistical significance, and involvement in metabolic pathways, this study identified eight potential biomarkers pertinent to PTC metastasis diagnostics, encompassing phosphorylated myosin 10, phosphorylated proline-directed protein kinase, leucine tRNA synthetase, 2-oxo-isovalerate dehydrogenase, succinic semialdehyde dehydrogenase, ADP/ATPtranslocase, pyruvate carboxylase, and fibrinogen. Therapeutic assays employing metformin, an AMP-activated protein kinase (AMPK) activator, alongside the phosphorylation-specific inhibitor ML-7 targeting Myosin10, demonstrated attenuated cellular proliferation, migration, and invasion capabilities in thyroid cancer cells, accompanied by a reduction in amino acid pools. Cellular colocalization and interaction studies elucidated that AMPK activation imposes an inhibitory influence on Myosin10 levels. The findings of this research corroborate the utility of proteomic and phosphoproteomic platforms in the identification of metastatic markers for PTC and suggest that modulation of AMPK activity, coupled with the inhibition of Myosin10 phosphorylation, may forge novel therapeutic avenues in the management of thyroid carcinoma. SIGNIFICANCE: The significance of our research lies in its potential to transform the current understanding and management of thyroid papillary carcinoma (PTC), particularly in its metastatic form. By integrating both proteomic and phosphoproteomic analyses, our study not only sheds light on the molecular alterations associated with PTC but also identifies eight novel biomarkers that could serve as indicators of metastatic potential.

Investigating the Involvement of Mediastinal Lymph Nodes in Patients with Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma (PTC) is also the most common endocrine malignancy. In the present study, we aimed to evaluate the metastasis pattern of upper mediastinal lymph node involvement in patients with PTC.

Materials and Methods

This is a descriptive cross-sectional study that was performed in 2020 in Isfahan, Iran, on 73 patients with PTC who were candidates for total thyroidectomy. Demographic data including age and gender were collected. The frequency distribution of upper mediastinal lymph node involvements and their relationships with mass size, gender, and age, location of tumor in the thyroid gland and involvement of lateral lymph nodes in the neck were evaluated.

Results

The mean mass size was 17.27 mm. The most involved thyroid lobe in patients with upper mediastinal lymph node involvement was the right lobe (16.5%). In terms of mediastinal lymph node involvement, there were no significant relationships between the two sexes (P = 0.161), primary mass size (P = 0.151), and thyroid mass location (P = 0.739) with mediastinal lymph node involvement. There was a significant relationship between lateral lymph node involvement of the neck (P = 0.007) and age groups (P = 0.042) with involvement of the upper mediastinal lymph nodes. Based on our results, the upper mediastinal lymph node involvement was more frequent among patients under 40 years of age.

Conclusion

Upper mediastinal lymph node metastasis in PTC was significantly more frequent in cases with younger ages (lower than 40 years) and involvements of lateral lymph nodes in the neck.

Long Non-Coding RNAs as Determinants of Thyroid Cancer Phenotypes: Investigating Differential Gene Expression Patterns and Novel Biomarker Discovery

Thyroid Cancer (TC) is the most common endocrine malignancy, with increasing incidence globally. Papillary thyroid cancer (PTC), a differentiated form of TC, accounts for approximately 90% of TC and occurs predominantly in women of childbearing age. Although responsive to current treatments, recurrence of PTC by middle age is common and is much more refractive to treatment. Undifferentiated TC, particularly anaplastic thyroid cancer (ATC), is the most aggressive TC subtype, characterized by it being resistant and unresponsive to all therapeutic and surgical interventions. Further, ATC is one of the most aggressive and lethal malignancies across all cancer types. Despite the differences in therapeutic needs in differentiated vs. undifferentiated TC subtypes, there is a critical unmet need for the identification of molecular biomarkers that can aid in early diagnosis, prognosis, and actionable therapeutic targets for intervention. Advances in the field of cancer genomics have enabled for the elucidation of differential gene expression patterns between tumors and healthy tissue. A novel category of molecules, known as non-coding RNAs, can themselves be differentially expressed, and extensively contribute to the up- and downregulation of protein coding genes, serving as master orchestrators of regulated and dysregulated gene expression patterns. These non-coding RNAs have been identified for their roles in driving carcinogenic patterns at various stages of tumor development and have become attractive targets for study. The identification of specific genes that are differentially expressed can give insight into mechanisms that drive carcinogenic patterns, filling the gaps of deciphering molecular and cellular processes that modulate TC subtypes, outside of well-known driver mutations.

Feasibility of active surveillance in patients with clinically T1b papillary thyroid carcinoma ≤1.5 cm in preoperative ultrasonography: MASTER study

Objective

Active surveillance (AS) is generally accepted as an alternative to immediate surgery for papillary thyroid carcinoma (PTC) measuring ≤1.0 cm (cT1a) without risk factors. This study investigated the clinicopathologic characteristics of PTCs measuring ≤2.0 cm without cervical lymph node metastasis (cT1N0) by tumor size group to assess the feasibility of AS for PTCs between 1.0 cm and 1.5 cm (cT1b≤1.5).

Design

This study enrolled clinically T1N0 patients with preoperative ultrasonography information (n= 935) from a cohort of 1259 patients who underwent lobectomy and were finally diagnosed with PTC from June 2020 to March 2022.

Results

The cT1b≤1.5 group (n = 171; 18.3 %) exhibited more lymphatic invasion and occult central lymph node (LN) metastasis with a higher metastatic LN ratio than the cT1a group (n = 719; 76.9 %). However, among patients aged 55 years or older, there were no significant differences in occult central LN metastasis and metastatic LN ratio between the cT1a, cT1b≤1.5, and cT1b>1.5 groups. Multivariate regression analyses revealed that occult central LN metastasis was associated with age, sex, tumor size, extrathyroidal extension, and lymphatic invasion in patients under 55, while in those aged 55 or older, it was associated only with age and lymphatic invasion.

Conclusion

For PTC patients aged 55 years or older with cT1b≤1.5, AS could be a viable option due to the absence of a significant relationship between tumor size and occult central LN.

Development and Validation of a Dual-Energy CT-Based Model for Predicting the Number of Central Lymph Node Metastases in Clinically Node-Negative Papillary Thyroid Carcinoma

RATIONALE AND OBJECTIVES

This study aimed to develop and validate a dual-energy CT (DECT)-based model for preoperative prediction of the number of central lymph node metastases (CLNMs) in clinically node-negative (cN0) papillary thyroid carcinoma (PTC) patients.

MATERIALS AND METHODS

Between January 2016 and January 2021, 490 patients who underwent lobectomy or thyroidectomy, CLN dissection, and preoperative DECT examinations were enrolled and randomly allocated into the training (N = 345) and validation cohorts (N = 145). The patients' clinical characteristics and quantitative DECT parameters obtained on primary tumors were collected. Independent predictors of> 5 CLNMs were identified and integrated to construct a DECT-based prediction model, for which the area under the curve (AUC), calibration, and clinical usefulness were assessed. Risk group stratification was performed to distinguish patients with different recurrence risks.

RESULTS

More than 5 CLNMs were found in 75 (15.3%) cN0 PTC patients. Age, tumor size, normalized iodine concentration (NIC), normalized effective atomic number (nZeff) and the slope of the spectral Hounsfield unit curve (λHu) in the arterial phase were independently associated with> 5 CLNMs. The DECT-based nomogram that incorporated predictors demonstrated favorable performance in both cohorts (AUC: 0.842 and 0.848) and significantly outperformed the clinical model (AUC: 0.688 and 0.694). The nomogram showed good calibration and added clinical benefit for predicting> 5 CLNMs. The KaplanMeier curves for recurrence-free survival showed that the high- and low-risk groups stratified by the nomogram were significantly different.

CONCLUSION

The nomogram based on DECT parameters and clinical factors could facilitate preoperative prediction of the number of CLNMs in cN0 PTC patients.

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.

HLA-G Gene Variability Is Associated with Papillary Thyroid Carcinoma Morbidity and the HLA-G Protein Profile

Human leukocyte antigen (HLA)-G is an immune checkpoint molecule that is highly expressed in papillary thyroid carcinoma (PTC). The HLA-G gene presents several functional polymorphisms distributed across the coding and regulatory regions (5'URR: 5' upstream regulatory region and 3'UTR: 3' untranslated region) and some of them may impact HLA-G expression and human malignancy. To understand the contribution of the HLA-G genetic background in PTC, we studied the HLA-G gene variability in PTC patients in association with tumor morbidity, HLA-G tissue expression, and plasma soluble (sHLA-G) levels. We evaluated 185 PTC patients and 154 healthy controls. Polymorphic sites defining coding, regulatory and extended haplotypes were characterized by sequencing analyses. HLA-G tissue expression and plasma soluble HLA-G levels were evaluated by immunohistochemistry and ELISA, respectively. Compared to the controls, the G0104a(5'URR)G*01:04:04(coding)UTR-03(3'UTR) extended haplotype was underrepresented in the PTC patients, while G0104a(5'URR)G*01:04:01(coding)UTR-03(3'UTR) was less frequent in patients with metastatic and multifocal tumors. Decreased HLA-G tissue expression and undetectable plasma sHLA-G were associated with the G010102a(5'URR)G*01:01:02:01(coding)UTR-02(3'UTR) extended haplotype. We concluded that the HLA-G variability was associated with PTC development and morbidity, as well as the magnitude of the encoded protein expression at local and systemic levels.

Development and validation of a dynamic nomogram based on conventional ultrasound and contrast-enhanced ultrasound for stratifying the risk of central lymph node metastasis in papillary thyroid carcinoma preoperatively

Purpose

The aim of this study was to develop and validate a dynamic nomogram by combining conventional ultrasound (US) and contrast-enhanced US (CEUS) to preoperatively evaluate the probability of central lymph node metastases (CLNMs) for patients with papillary thyroid carcinoma (PTC).

Methods

A total of 216 patients with PTC confirmed pathologically were included in this retrospective and prospective study, and they were divided into the training and validation cohorts, respectively. Each cohort was divided into the CLNM (+) and CLNM (-) groups. The least absolute shrinkage and selection operator (LASSO) regression method was applied to select the most useful predictive features for CLNM in the training cohort, and these features were incorporated into a multivariate logistic regression analysis to develop the nomogram. The nomogram's discrimination, calibration, and clinical usefulness were assessed in the training and validation cohorts.

Results

In the training and validation cohorts, the dynamic nomogram (https://clnmpredictionmodel.shinyapps.io/PTCCLNM/) had an area under the receiver operator characteristic curve (AUC) of 0.844 (95% CI, 0.755-0.905) and 0.827 (95% CI, 0.747-0.906), respectively. The Hosmer-Lemeshow test and calibration curve showed that the nomogram had good calibration (p = 0.385, p = 0.285). Decision curve analysis (DCA) showed that the nomogram has more predictive value of CLNM than US or CEUS features alone in a wide range of high-risk threshold. A Nomo-score of 0.428 as the cutoff value had a good performance to stratify high-risk and low-risk groups.

Conclusion

A dynamic nomogram combining US and CEUS features can be applied to risk stratification of CLNM in patients with PTC in clinical practice.

Deep learning to predict cervical lymph node metastasis from intraoperative frozen section of tumour in papillary thyroid carcinoma: a multicentre diagnostic study

Background

Lymph node metastasis (LNM) assessment in patients with papillary thyroid carcinoma (PTC) is of great value. This study aimed to develop a deep learning model applied to intraoperative frozen section for prediction of LNM in PTC patients.

Methods

We established a deep-learning model (ThyNet-LNM) with the multiple-instance learning framework to predict LNM using whole slide images (WSIs) from intraoperative frozen sections of PTC. Data for the development and validation of ThyNet-LNM were retrospectively derived from four hospitals from January 2018 to December 2021. The ThyNet-LNM was trained using 1987 WSIs from 1120 patients obtained at the First Affiliated Hospital of Sun Yat-sen University. The ThyNet-LNM was then validated in the independent internal test set (479 WSIs from 280 patients) as well as three external test sets (1335 WSIs from 692 patients). The performance of ThyNet-LNM was further compared with preoperative ultrasound and computed tomography (CT).

Findings

The area under the receiver operating characteristic curves (AUCs) of ThyNet-LNM were 0.80 (95% CI 0.74-0.84), 0.81 (95% CI 0.77-0.86), 0.76 (95% CI 0.68-0.83), and 0.81 (95% CI 0.75-0.85) in internal test set and three external test sets, respectively. The AUCs of ThyNet-LNM were significantly higher than those of ultrasound and CT or their combination in all four test sets (all P < 0.01). Of 397 clinically node-negative (cN0) patients, the rate of unnecessary lymph node dissection decreased from 56.4% to 14.9% by ThyNet-LNM.

Interpretation

The ThyNet-LNM showed promising efficacy as a potential novel method in evaluating intraoperative LNM status, providing real-time guidance for decision. Furthermore, this led to a reduction of unnecessary lymph node dissection in cN0 patients.

Funding

National Natural Science Foundation of China, Guangzhou Science and Technology Project, and Guangxi Medical High-level Key Talents Training "139" Program.

Cervical lymph node metastasis prediction of postoperative papillary thyroid carcinoma before 131I therapy based on clinical and ultrasound characteristics

BACKGROUND

The status of lymph nodes is crucial to determine the dose of radioiodine-131(¹³¹I) for postoperative papillary thyroid carcinoma (PTC). We aimed to develop a nomogram for predicting residual and recurrent cervical lymph node metastasis (CLNM) in postoperative PTC before ¹³¹I therapy.

METHOD

Data from 612 postoperative PTC patients who underwent ¹³¹I therapy from May 2019 to December 2020 were retrospectively analyzed. Clinical and ultrasound features were collected. Univariate and multivariate logistic regression analyses were performed to determine the risk factors of CLNM. Receiver operating characteristic (ROC) analysis was used to weigh the discrimination of prediction models. To generate nomograms, models with high area under the curves (AUC) were selected. Bootstrap internal validation, calibration curves and decision curves were used to assess the prediction model's discrimination, calibration, and clinical usefulness.

RESULTS

A total of 18.79% (115/612) of postoperative PTC patients had CLNM. Univariate logistic regression analysis found serum thyroglobulin (Tg), serum thyroglobulin antibodies (TgAb), overall ultrasound diagnosis and seven ultrasound features (aspect transverse ratio, cystic change, microcalcification, mass hyperecho, echogenicity, lymphatic hilum structure and vascularity) were significantly associated with CLNM. Multivariate analysis revealed higher Tg, higher TgAb, positive overall ultrasound and ultrasound features such as aspect transverse ratio ≥ 2, microcalcification, heterogeneous echogenicity, absence of lymphatic hilum structure and abundant vascularity were independent risk factors for CLNM. ROC analysis showed the use of Tg and TgAb combined with ultrasound (AUC = 0.903 for "Tg+TgAb+Overall ultrasound" model, AUC = 0.921 for "Tg+TgAb+Seven ultrasound features" model) was superior to any single variant. Nomograms constructed for the above two models were validated internally and the C-index were 0.899 and 0.914, respectively. Calibration curves showed satisfied discrimination and calibration of the two nomograms. DCA also proved that the two nomograms were clinically useful.

CONCLUSION

Through the two accurate and easy-to-use nomograms, the possibility of CLNM can be objectively quantified before ¹³¹I therapy. Clinicians can use the nomograms to evaluate the status of lymph nodes in postoperative PTC patients and consider a higher dose of ¹³¹I for those with high scores.

Identification and Validation of Prognostic Related Hallmark ATP-Binding Cassette Transporters Associated With Immune Cell Infiltration Patterns in Thyroid Carcinoma

ATP-binding cassette (ABC) transporters are a large superfamily of membrane proteins that facilitate the translocation of heterogeneous substrates. Studies indicate that ABC transporters may play important roles in various carcinomas. However, the correlation between ABC transporters and immunomodulation in thyroid carcinoma (TC), as well as the prognoses for this disease, is poorly understood.TC data from The Cancer Genome Atlas (TCGA) database were used to identify prognostic hallmark ABC transporters associated with immune cell infiltration patterns via multiple bioinformatic analyses. Thereafter, quantitative real-time polymerase chain reaction (qRT-PCR) was performed to validate the expression of these selected hallmark ABC transporters in both TC and para-cancerous thyroid tissues. Of a total of 49 ABC transporters, five (ABCA8, ABCA12, ABCB6, ABCB8, and ABCC10) were identified as hallmark ABC transporters. All five were differentially expressed in TC and associated with the relapse-free survival rates of patients with TC. Immunoregulation by these five hallmark ABC transporters involved the modulation of various aspects of immune cell infiltration, such as hot or cold tumor subsets and the abundances of infiltrating immune cells, as well as specific immunomodulators and chemokines. Besides the diverse significantly correlated factors, the five hallmark ABC transporters and correlated genes were most highly enriched in plasma membrane, transporter activity, and transmembrane transport of small molecules. In addition, many chemicals, namely bisphenol A and vincristine, affected the expression of these five transporters. The qRT-PCR results of collected TC and para-cancerous thyroid tissues were consistent with those of TCGA. The findings in this study may reveal the role played by these five hallmark ABC transporters in regulating immune cell infiltration patterns in TC as well as the molecular mechanisms underlying their functions, leading to a better understanding of their potential prognostic and immunotherapeutic values.

Clinical and prognosis value of the number of metastatic lymph nodes in patients with papillary thyroid carcinoma

Objective

It has been reported that papillary thyroid carcinoma (PTC) patients with lymph node metastasis (LNM) are largely associated with adverse outcomes. The present study aimed to assess the correlation between the number of metastatic lymph nodes (NMLNs) and clinical prognosis in patients with PTC.

Methods

We retrospectively reviewed the medical records of patients with PTC who underwent initial thyroid cancer surgery in Renmin Hospital of Wuhan University between 2017 and 2019. A total of 694 patients with PTC and cervical lymph node dissection as well as a total checked number of lymph nodes ≥ 5 were involved in this study. The clinicopathological characteristics of patients were compared according to NMLNs, the number of central cervical lymph nodes (CLNs) and the number of lateral lymph nodes (LLNs).

Results

NMLNs > 5, CLNs > 5 and LLNs > 5 were 222 (32.0%), 159 (24.3%) and 70 (10.1%) seen in the analyzed samples, respectively. Young patients, patients with larger tumor diameter, bilaterality, multifocality and gross extrathyroidal extension (ETE) were more inclined to NMLNs > 5, CLNs > 5 and LLNs > 5 (P < 0.05). It was found that the recurrence-free survival among pN1 patients was significantly discrepant between different groups (NMLNs ≤ 5/5: P = 0.001; LLNs ≤ 5/5: P < 0.001). In multivariate logistic regression analysis, patients aged < 55 years (OR = 1.917), primary tumor size > 10 mm (OR = 2.131), bilaterality (OR = 1.889) and tumor gross ETE (OR = 2.759) were independent predictors for high prevalence of total NMLNs > 5 (P < 0.05). Specially, patients aged < 55 years (OR = 2.864), primary tumor size > 10 mm (OR = 2.006), and tumor gross ETE (OR = 2.520) were independent predictors for high prevalence of CLNs > 5 (P < 0.01); Bilaterality (OR = 2.119), CLNs > 5 (OR = 6.733) and tumor gross ETE (OR = 4.737) were independent predictors for high prevalence of LLNs > 5 (P < 0.05).

Conclusions

In conclusion, it is evident that NMLNs is related to the invasive clinicopathological features and adverse outcome of patients with PTC which should be correctly evaluated to provide an appropriate guidance for reasonable treatment and careful follow-up.

Risk factors for metastasis in indeterminate lymph nodes in preoperative patients with thyroid cancer

OBJECTIVES

To investigate the relevance of clinical and sonographic features as indicators of metastasis in indeterminate lymph node (LN), to determine possible indications for fine-needle aspiration (FNA).

METHODS

Consecutive patients who underwent US-guided FNA for sonographic indeterminate LNs from differentiated thyroid carcinoma between January 2014 and December 2018 were retrospectively reviewed. Indeterminate LNs were defined as LNs which had neither an echogenic hilum nor hilar vascularity in the absence of any suspicious finding in accordance with the Korean Society of Thyroid Radiology (KSThR) guidelines. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors related to malignancy of indeterminate LNs.

RESULTS

Of the 236 LNs in 212 patients enrolled in this study, 67 LNs (28.3%) were metastatic. The multivariate logistic regression analysis showed that the long diameter of LNs has a negative association with metastasis in indeterminate LNs and the sonographic features of extrathyroidal extension (ETE) and nonparallel orientation of the primary tumor are associated with metastasis in indeterminate LNs. The sensitivity and positive predictive value were increased when FNA was performed for LNs with primary tumors showing ETE or nonparallel orientation than when FNA was performed for LNs larger than 5 mm (59.7% and 40.4% vs. 11.94% and 15.69%).

CONCLUSIONS

The size of LNs has a negative association with metastasis in indeterminate LNs. Performing FNA for indeterminate LNs in patients whose primary tumor shows ETE or a nonparallel orientation can improve the diagnostic performance and decrease the rate of unnecessary FNA.

KEY POINTS

• The size of lymph nodes was negatively related to the risk of metastasis in indeterminate lymph nodes. • Extrathyroidal extension and a nonparallel orientation of the primary tumor were suggested as sonographic features predicting metastasis in indeterminate lymph nodes. • The routine practice of FNA for large indeterminate lymph nodes detected during preoperative evaluation of thyroid cancer should be discouraged.

Population-level Outcomes of Early Thyroid Cancers: A Need to Revisit Current Practice

BACKGROUND

Early thyroid cancers have excellent long-term outcomes, yet the word "cancer" draws unnecessary apprehension. This study aimed to define when the recommendations for observation and surveillance may be extended to early thyroid cancers at the population level.

METHODS

Non-metastasized thyroid cancers ≤40 mm diameter were identified from the 1975-2016 Surveillance, Epidemiology and End Results (SEER) database. Causes of death were compared across demographic data. Disease-specific outcomes were compared to the age-adjusted healthy United States (US) population. Survival estimates were computed using Kaplan-Meier and compared using the Cox proportional hazard model. Dynamic benchmarks impacting disease-specific overall survival were determined by decision tree modeling and tested by the Cox model.

RESULTS

Of the 28,728 thyroid cancers included in this study, 98.4% underwent some form of thyroid-specific treatment and were followed for a maximum of 10.9 years. This group had a 4.3% mortality rate at the end of follow-up (10.9 years maximum), with 13 times more deaths attributed to competing risks rather than thyroid cancer (stage T1a versus stage T1b, P=1.000; T1 versus T2, P<0.001). Among the untreated T1a or T1b tumors, the risk of disease-specific death was 21 times lower than death due to other causes. There was no significant difference between T1a and T1b tumors nor across sex. The age-adjusted risk of death for the healthy US population was higher than for the population with thyroid cancer. Dynamic categorization demonstrated worsening outcomes up to 73 years, uninfluenced by sex or tumor size. For patients over 73 years of age, only tumors >26 mm impacted outcomes.

CONCLUSION

Based on the current data, T1a and T1b nodules have similar survival outcomes and are not significantly impacted even when left untreated. Multi-institutional prospective studies are needed to confirm these findings so that current observation and surveillance recommendations can be extended to certain T1 thyroid nodules.

Histopathological Types of Papillary Thyroid Carcinoma: Clinicopathologic Study

BACKGROUND: Papillary thyroid carcinoma (PTC) is the most common type of thyroid carcinoma that represents a set of characteristic of nuclear features in which the diagnosis is depend. AIM: The study aimed to review different variants of PTC which has different malignant potential in correlation with many prognostic and clinical factors in Iraq. PATIENTS AND METHODS: Paraffin blocks of 227 cases of PTC were selected, subtyped, and grouped according to the malignant potential. The prognostic and clinical factors were studied. RESULTS: The mean age was (39.29 ± 12.17) years, with female predominance (86.3%), where (55.5%) of them below 40 years, conventional variant was most common (40.1%), followed by papillary microcarcinoma variant, 197 cases (86.8%) were classified as low to intermediate malignant potential, and 30 cases (13.2%) were classified as high malignant potential. On comparison, among the tumor stages, tumor focality, native capsular invasion, lymph nodes involvement, presence or absence of vascular invasion, extrathyroid extension, and distant metastasis, there is no significant correlation between them, whereas with the tumor size, there is significant correlation between them (p =< 0.05). CONCLUSION: Conventional type followed by micropapillary type is most common. The mean age in Iraqi patients is lower than other countries for PTC. There is no significant association regarding prognostic factors between low to intermediate malignant potential variants and high malignant potential variants with exception of tumor diameter.

Identification and validation of an immune-related prognostic signature and key gene in papillary thyroid carcinoma

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most common pathological type of thyroid cancer. The effect of traditional anti-tumor therapy is not ideal for the patients with recurrence, metastasis and radioiodine resistance. The abnormal expression of immune-related genes (IRGs) has critical roles in the etiology of PTC. However, the effect of IRGs on PTC prognosis remains unclear.

METHODS

Based on The Cancer Genome Atlas (TCGA) and ImmPort databases, we integrated IRG expression profiles and progression-free intervals (PFIs) of PTC patients. First, we identified the differentially expressed IRGs and transcription factors (TFs) in PTC. Subsequently, an IRG model that can predict the PFI was constructed by using univariate Cox regression, least absolute shrinkage and selection operator (LASSO) regression and multivariate Cox regression analyses of the differentially expressed IRGs in the TCGA. Additionally, a protein-protein interaction (PPI) network showed the interactions between the differentially expressed genes (DEGs), and the top 30 genes with the highest degree were extracted from the network. Then, the key IRG was identified by the intersection analysis of the PPI network and univariate Cox regression, which was verified the differential expression of by western blotting and immunohistochemistry (IHC). ssGSEA was performed to understand the correlation between the key IRG expression level and immune activity.

RESULTS

A total of 355 differentially expressed IRGs and 43 differentially expressed TFs were identified in PTC patients. Then, eight IRGs were finally utilized to construct an IRG model. The respective areas under the curve (AUCs) of the IRG model reached 0.948, 0.820, and 0.831 at 1, 3 and 5 years in the training set. In addition, lactotransferrin (LTF) was determined as the key IRG related to prognosis. The expression level of LTF in tumor tissues was significantly lower than that in normal tissues. And the results of ssGSEA showed the expression level of LTF is closely related to immune activity.

CONCLUSIONS

These findings show that the prognostic model and key IRG may become promising molecular markers for the prognosis of PTC patients.

Oncosuppressor-Mutated Cell-Based Diagnostic Platform for Liquid Biopsy Diagnoses Benign Head and Neck Masses and Predicts Malignancy in Thyroid Nodules: Results from a Consecutive Cohort of Patients

BACKGROUND

We reported that a novel oncosuppressor-mutated cell (OMC)-based platform has the potential for early cancer detection in healthy individuals and for identification of cancer patients at risk of developing metachronous metastases.

OBJECTIVE

Herein, we sought to determine the diagnostic accuracy of this novel OMC-based platform in a consecutive cohort of patients operated for suspicious head and neck masses.

METHODS

OMCs (BRCA1-deficient fibroblasts) were exposed to blood serum from patients with head and neck nodules before surgical removal. These cells were analyzed for their proliferation and survival. Treated OMCs were inoculated subcutaneously in NOD/SCID mice, and tumor growth was monitored over time.

RESULTS

OMCs exposed to serum from patients with malignant lesions displayed increased proliferation compared to those exposed to serum from patients with benign lesions. Only OMCs exposed to serum from patients diagnosed with malignant thyroid neoplasia generated a cancerous mass. The sensitivity of the test was 92%, with only 1 false negative out of 34 patients. Immunohistochemical staining showed that the cancerous masses were poorly differentiated adenocarcinomas with high proliferative index.

CONCLUSIONS

These data show that liquid biopsy combined with an OMC-based in vivo platform has the potential to diagnose benign head and neck masses and predict whether a thyroid nodule is malignant. These results strengthen the concept that OMCs can be used to detect circulating malignant factors in cancer patients.

[A Meta-analysis of risk factors related to the lymph nodes posterior to the right recurrent laryngeal nerve in thyroid micropapillary carcinoma]

Objective:To evaluate the risk factors for metastasis of the lymph nodes posterior to the right recurrent laryngeal nerve in thyroid micropapillary carcinoma（PTMC） by Meta-analysis. Methods:We searched domestic and foreign databases for relevant studies published up to June, 2020. Two independent reⅥewers performed literature screening and data extraction according to the inclusion and exclusion criteria. Then, Meta-analysis was performed using Revman 5.3 software. Results:A total of 5 articles were included, with a total of 1884 subjects.The results of the study showed that the rate of lymph node metastasis in PTMC Ⅵb area was 10.8% （203/1884）. The risk factors for metastasis included patients' age <45 years old, male, right lobe tumor Diameter ≥0.5 cm, invading the envelope, Ⅵa lymph node metastasis. Conclusion:Ⅵb lymph node dissection is recommended when there exists age<45 years, male sex, right lobe tumor≥0.5 cm, capsular invasion or Ⅵa lymph node metastasis.

Deltex3 inhibits Epithelial Mesenchymal Transition in Papillary Thyroid Carcinoma via promoting ubiquitination of XRCC5 to regulate the AKT signal pathway

Background: Papillary thyroid carcinoma (PTC) is one of the most common endocrine malignant tumors. Poor prognoses such as high recurrence rate always appear in PTC patients with cervical lymph node metastasis. The process of ubiquitination plays important roles in PTC. As ubiquitin E3 ligases, Deltex (DTX) family proteins were reported to associate with multiple cancers. However, functions and mechanisms of DTX3 in PTC are currently unknown.

Methods: In this study, DTX3 expressions were examined in 114 PTC and paired paracancerous normal tissues through quantitative real-time polymerase chain reaction and western blot. The clinical significances of DTX3 expressions in PTC patients were also investigated. After stable transfection with either short hairpin RNA to knock down DTX3 expression or full-length complementary DNA to upregulate DTX3 expression, changes of malignant phenotypes in two PTC cell lines K1 and TPC-1 were observed using cell viability, flow cytometry, wound healing and transwell assays. Afterwards, altered expressions of epithelial-mesenchymal transition (EMT) and AKT signal pathway related proteins were measured by western blot. Immunoprecipitation and mass spectrometry (IP-MS), immunofluorescence and Co-IP were utilized to identify the possible DTX3 interacting proteins.

Results: Both mRNA and protein expressions of DTX3 were lower in PTC tissues and correlated with the presence of cervical lymph node metastasis (P<0.05). DTX3 overexpression inhibited migration and invasion of PTC cells, decreased Vimentin and phosphorylated AKT expressions, but promoted E-cadherin expression (P<0.05). Moreover, knockdown of DTX3 led to opposite changes (P<0.05). Total 46 probable DTX3 interacting proteins were identified by IP-MS. Among them, X-ray repair cross-complementing protein 5 (XRCC5) and NADH: Ubiquinone Oxidoreductase Complex Assembly Factor 5 (NDUFAF5) were verified to be associated with DTX3. Moreover, DTX3 was proved to be co-localized with XRCC5 in nucleus and promote ubiquitination of XRCC5.

Conclusions: DTX3 suppresses EMT by partially facilitating ubiquitination of XRCC5 to inhibit AKT signal pathway in PTC.

Using ultrasound features and radiomics analysis to predict lymph node metastasis in patients with thyroid cancer

Background

Lymph node metastasis (LNM) is an important factor for thyroid cancer patients’ treatment and prognosis. The aim of this study was to explore the clinical value of ultrasound features and radiomics analysis in predicting LNM in thyroid cancer patients before surgery.

Methods

The characteristics of ultrasound images of 150 thyroid nodules were retrospectively analysed. All nodules were confirmed as thyroid cancer. Among the assessed patients, only one hundred and twenty-six patients underwent lymph node dissection. All patients underwent an ultrasound examination before surgery. In the radiomic analysis, the area of interest was identified from selected ultrasound images by using ITK-SNAP software. The radiomic features were extracted by using Ultrosomics software. Then, the data were classified into a training set and a validation set. Hypothetical tests and bagging were used to build the model. The diagnostic performance of different ultrasound features was assessed, a radiomic analysis was conducted, and a receiver operating characteristic (ROC) curve analysis was performed to explore the diagnostic accuracy.

Results

Regarding the prediction of LNM, the ROC curves showed that the area under the curve (AUC) values of an irregular shape and microcalcification were 0.591 (P = 0.059) and 0.629 (P = 0.007), respectively. In the radiomics analysis, in the training set, the AUC value of LNM was 0.759, with a sensitivity of 0.90 and a specificity of 0.860. In the verification set, the AUC was 0.803, with a sensitivity of 0.727 and a specificity of 0.800.

Conclusions

Microcalcification and an irregular shape are predictors of LNM in thyroid carcinoma patients. In addition, radiomics analysis has promising value in screening meaningful ultrasound features in thyroid cancer patients with LNM. Therefore, the prediction of LNM based on ultrasound features and radiomic features is useful for making appropriate decisions regarding surgery and interventions before thyroid carcinoma surgery.

LIMD2 Regulates Key Steps of Metastasis Cascade in Papillary Thyroid Cancer Cells via MAPK Crosstalk

Although papillary thyroid carcinoma (PTC) has a good prognosis, 20–90% of patients show metastasis to regional lymph nodes and 10–15% of patients show metastasis to distant sites. Metastatic disease represents the main clinical challenge that impacts survival rate. We previously showed that LIMD2 was a novel metastasis-associated gene. In this study, to interrogate the role of LIMD2 in cancer invasion and metastasis, we used CRISPR-mediated knockout (KO) of LIMD2 in PTC cells (BCPAP and TPC1). Western blot and high-content screening (HCS) analysis confirmed functional KO of LIMD2. LIMD2 KO reduced in vitro invasion and migration. Ultrastructural analyses showed that cell polarity and mitochondria function and morphology were restored in LIMD2 KO cells. To unveil the signals supervising these phenotypic changes, we employed phospho-protein array. Several members of the MAPK superfamily showed robust reduction in phosphorylation. A Venn diagram displayed the overlap of kinases with reduced phosphorylation in both cell lines and showed that they were able to initiate or sustain the epithelial-mesenchymal transition (EMT) and DNA damage checkpoint. Flow cytometry and HCS validation analyses further corroborated the phospho-protein array data. Collectively, our findings show that LIMD2 enhances phosphorylation of kinases associated with EMT and invasion. Through cooperation with different kinases, it contributes to the increased genomic instability that ultimately promotes PTC progression.

LncRNA HOTAIR Influences the Growth, Migration, and Invasion of Papillary Thyroid Carcinoma via Affection on the miR-488-5p/NUP205 Axis

Objective:

The study was aim to investigate the effect of HOX transcript antisense RNA (HOTAIR) on the growth, migration, and invasion of papillary thyroid carcinoma (PTC) and its underlying mechanisms.

Methods:

Cell growth, invasion, and migration was respectively investigated using the MTT assay, trans-well assay, and wound healing assay. The expression of genes and proteins was respectively determined by Western blot analysis and RT-PCR experiments.

Results:

It was demonstrated that high expression of HOTAIR in PTC cells (BCPAP) and tissues resulted in fast tumor growth and poor survival time of the PTC-bearing mice models. Moreover, overexpression of HOTAIR leaded to markedly enhanced proliferation, migration, and invasion of BCPAP cells. Increase the levels of HOTAIR in BCPAP cells signally down-regulated the miR-488-5p levels which was able of inhibiting the growth rate, increasing the apoptosis rate, and decreasing the invasion/migration ability of BCPAP cells. Further studies indicated that HOTAIR promoted BCPAP cell growth, invasion, and migration mainly through regulating the miR-488-5p/NUP205 axis and the levels of Bcl-2 as well.

Conclusion:

HOTAIR promoted the growth, migration, and invasion of papillary thyroid carcinoma mainly through regulating the miR-488-5p/NUP205 axis.

Value of Ultrasound Combined with Immunohistochemistry Evaluation of Central Lymph Node Metastasis for the Prognosis of Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma (PTC) is often accompanied by cervical lymph node metastasis (LNM). The accuracy of the preoperative ultrasound diagnosis of central LNM (CLNM) is limited. LNM is a high-risk factor for local recurrence and may affect the prognosis. Factors not directly related to tumor proliferation are used for risk assessment in the tumor-node-metastasis (TNM) staging system for thyroid cancer. The present study aimed to investigate the value of ultrasound and immunohistochemistry in predicting the presence of CLNM and the prognosis of PTC.

Patients and Methods

The ultrasound and immunohistochemistry features of 303 patients with first-ever PTC and who underwent surgery between 01/2014 to 12/2016 were analyzed, as well as the prognosis of the patients. Univariable and multivariable analyses were carried out to determine the risk factors of CLNM and recurrence.

Results

Among 303 patients, 125 (41.3%) were pathologically confirmed with CLNM. Multivariable analysis showed that multifocality, taller-than-wide shape, grade III–IV blood flow, capsular invasion, Ki-67 >10%, p53 ≥5%, T2 or T3 stages were independent risk factors for CLNM. The median follow-up was 56 months. Cox regression analysis showed that age ≥55 years, maximum tumor diameter >20 mm, multifocality, capsular invasion, Ki-67 5–10%, Ki-67 >10%, p53 ≥5%, T3 stage and N1a stage were independent risk factors for PTC recurrence. The Kaplan–Meier showed that recurrence-free survival (RFS) was different according to age (P=0.017), tumor size multifocality, capsular invasion, Ki-67, p53, T stage and N stage (all P<0.001).

Conclusion

For PTC with rich blood flow, taller-than-wide shape, multifocality, capsular invasion, p53 ≥5%, Ki-67 >10%, T2 or T3 stages prophylactic CLNM dissection might be indicated. Age≥55 years, maximum tumor diameter >20 mm, multifocality, capsular invasion, high Ki-67, p53 ≥5%, T3 and N1a stages affected the clinical outcome.

Competing-Risks Model for Predicting the Postoperative Prognosis of Patients with Papillary Thyroid Adenocarcinoma Based on The Surveillance, Epidemiology, and End Results (SEER) Database

Background

The aim of this study was to identify accurate prognostic factors for postoperative papillary thyroid adenocarcinoma (PTAC) using a competing-risks model based on data from the Surveillance, Epidemiology, and End Results (SEER) database.

Material/Methods

Data on patients with PTAC who had received surgery between 2010 and 2015 in the SEER database were extracted. A univariate analysis was performed while considering competing risks using the cumulative incidence function, with Nelson-Aalen cumulative risk curves of the incidence function for PTAC-specific death were calculated and then compared between 2 groups using Gray’s test. To identify the factors that affect the cumulative incidence of PTAC-specific death, a multivariate analysis using the Fine-Gray model was performed.

Results

The 8324 eligible surgical PTAC patients included 101 patients who died from PTAC and 129 patients who died from other causes. The univariate Gray’s test revealed that the cumulative incidence rate for events of interest was significantly affected (P<0.05) by age, sex, marital status, metastasis, differentiation grade, American Joint Committee on Cancer (AJCC) stage, radiation status, chemotherapy status, regional lymph nodes removal, and tumor size. Multivariate competing-risks analyses showed that age, sex, metastasis, differentiation grade, radiation status, chemotherapy status, and tumor size were independent risk factors for the postoperative prognosis of PTAC patients (P<0.05). The results of multivariate Cox regression were different, with marital status also appearing as an independent risk factor.

Conclusions

This study established a competing-risks analysis model to evaluate the risk factors of surgical PTAC patients. Our findings may be useful for improving patient prognoses and decision-making when providing individualized treatments.

Ultrasound validation of predictive model for central cervical lymph node metastasis in papillary thyroid cancer on BRAF

Aim: To compare the value of predictive power of the models for central cervical lymph node metastasis (CLNM) in papillary thyroid carcinomas (PTCs). Patients & methods: 220 PTCs were prospectively enrolled into the study with pathological examination. We established a new risk model with univariate and multivariate analyses and receiver-operating characteristic curves were plotted. Z-test was performed to compare the area under two curves and validated the predictive model for central CLNM in PTCs. The comparison of previous and new predictive model was analyzed. Results: Microcalcification, capsule contact or involvement, internal flow and BRAF^V600E mutation were four independent risk factors for PTCs with central CLNMs. The area under the curves for the new and the previous model were 0.948 and 0.934 (p = 0.572), respectively. Conclusion: Two predictive models showed strong consistency in predicting central CLNM in PTCs. The predictive model may be helpful in selecting appropriate treatment method in PTCs.

[Analysis of the factors for the lymph node metastasis in rⅥb region of thyroid micropapillary carcinoma and the application value of intraoperative nano-carbon]

Objective:To investigate the relationship between lymph node metastasis in rⅥb region and pathological features of papillary thyroid microcarcinoma, and the application value of carbon nanoparticles in the operation for lymph node dissection in rⅥb region. Method:One hundred and seventy-five patients were divided into carbon nanoparticles group and the control group depending on whether carbon nanoparticles were used in the operation. The operation time, the number of central lymph node, the number of rⅥb region lymph node, hypocalcaemia symptom complex and hoarseness after the operaion were compared between the two groups. The lymph node metastasis in the rⅥb region and the pathological features of papillary thyroid microcarcinoma were statistically analyzed. Result:The amount of lymph nodes in Central District and rⅥb region was increased and the probability of parathyroid gland injury was decreased by using nano-carbon. The positive rate of lymph nodes in rⅥb region was not related to age, sex, aspect ratio of nodules and microcalcification, but was related to the tumor size, multifoci and the invasion of the capsule. The evaluation model of lymph node metastasis in rⅥb region was established based on the above three correlative features of color doppler ultrasound. The ROC curve analysis showed that the model had high application value . Conclusion:The tumor size, multiple foci and capsule invasion are risk factors for lymph node metastasis in rⅥb region of thyroid micropapillary carcinoma.

Positive central lymph-nodes are underdiagnosed in patients with Bethesda V cytology in an endemic goiter region

Background

Fine needle aspiration (FNA) is a significant diagnostic procedure for detecting malignancy in patients with nodular thyroid disease. A high proportion of patients with cytological diagnosed follicular neoplasia (Bethesda IV and V) ultimately have thyroid cancer. The aim of this study was to evaluate the incidence of preoperatively undiagnosed central lymph node metastasis in patients with multinodular goiter (MNG).

Methods

Patients who underwent FNA and were classified as Bethesda IV/V were included. Applying a radical approach, all patients underwent (hemi)thyroidectomy and prophylactic unilateral central neck dissection.

Results

During our study period 2009-2013, 60 patients (19.7%) were classified as Bethesda IV and 21 (6.9%) Bethesda V. Final histopathological results revealed malignancy in 35 (43.2%) of 81 Bethesda IV/V nodules. Of the nodules classified as Bethesda IV, 20 (33.3%) showed malignancy in the final histology. Ten patients (16.7%) had papillary micro-carcinoma (mPTC, <10 mm), 4 (6.6%) PTC and 6 (10%) follicular thyroid cancer. Fifteen of 21 (71.4%) Bethesda V nodules were revealed as PTC of whom seven (33.3%) patients also had lymph-node metastases.

Conclusions

While 33.3% of the patients with PTC, preoperatively classified as Bethesda V, had previously undetected positive lymph-nodes, only one patient with Bethesda IV had lymph-node metastasis.

Theranostic approaches in nuclear medicine: current status and future prospects

Introduction: Theranostics is an emerging field in which diagnosis and specific targeted therapy are combined to achieve a personalized treatment approach to the patient. In nuclear medicine clinical practice, theranostics is often performed utilizing the same molecule labeled with two different radionuclides, one radionuclide for imaging and another for therapy.Areas covered: The authors review the clinical applications of different radiopharmaceuticals in the field of interest, including the well-established use of radioactive iodine in differentiated thyroid cancer, radiolabeled metaiodobenzylguanidine (MIBG) in neuroblastoma and the clinical impact of peptide radionuclide receptorial therapy (PRRT) in the management of neuroendocrine tumors. Furthermore, the more cutting-edge and recently introduced theranostic approaches will be reviewed, such as the radioligand therapy with ¹⁷⁷Lu-prostate specific membrane antigen (PSMA) and targeted alpha therapy in castration-resistant prostate cancer. Finally, the main applications of PET for the imaging of biomarkers suitable for the non-radionuclide targeted therapy will be covered.Expert opinion: Theranostics is envisaging a revolutionary clinical approach which is deeply connected with the concept of personalized medicine and ruled by a 'patient-centered' vision. In this perspective, the theranostic applications will need well-trained specialists, capable to manage not only the technological aspects of the discipline, but also to deal with the more innovative oncological therapies in a multidisciplinary setting.

Pre-sternal thyroid swellings: a case of rare aberrant site recurrence and review of literature

Background

Thyroid swellings enlarge caudally into the mediastinum behind the sternum. Pre-sternal swelling of thyroid origin is very rare. We present our case of pre-sternal thyroid swelling which was albeit a surprisingly rare site of papillary thyroid carcinoma recurrence and review of pre-sternal thyroid swellings reported till date.

Case summary

A 60 year old female presented with a painless, progressive swelling on the anterior part of the chest for the past 2 years. A 15 cm × 8 cm vertically aligned, non tender, well defined swelling was present on the pre-sternal region, with consistency ranging from soft to firm. The swelling was fixed to the underlying tissues and a fixed level IV lymph node was palpable on the right side. Ultrasonography revealed a large mass of 15 × 7 cm with multiple cystic areas. Fine needle aspiration cytology was inconclusive twice. Patient had undergone a total thyroidectomy for papillary carcinoma 10 years back. Computed tomography findings revealed a large 15 × 6.6 × 7 cm lobulated, pre-sternal, soft tissue lesion with solid & cystic components. The mass was infiltrating the right sided strap muscles and sternocleidomastoid. FNAC was inconclusive and thyroid scan could not pick up any activity in the mass. Henceforth a PET scan was done that showed increased FDG uptake by the lesion and the level IV lymph node. The patient underwent wide excision of the mass with right functional neck dissection, along with removal with both sternal head of sternocleido-mastoid, the strap muscles and the surrounding fascia. Histopathology confirmed papillary thyroid carcinoma. Patient received post-operative radioactive iodine ablation and is healthy with no recurrence up to 30 months of follow up.

Discussion

The mechanisms for pre-sternal thyroid swelling are not understood due to paucity of cases. The mechanisms proposed are invasion of strap muscles and cervical linea alba and tumor cells spread anterior to sternum, truly ectopic thyroid tissue, de novo carcinogenesis in the embryonal remnants like the thyro-thymic residues, sequestered thyroid tissue which grows later or migration of thyroid cells, incomplete clearance at the time of primary surgery or intraoperative seeding.

Conclusion

Pre-sternal region masses of thyroid origin are very rare. A proper work up, suspicion for thyroid mass and array of tests will be required to come to a provisional diagnosis. Since the masses reported in literature were primarily malignant, any such mass may be treated on lines of malignancy with radical surgery.

Pre-operative serum TSH levels: A risk factor for advanced metastatic differentiated thyroid carcinoma

Background and Objective:

As the thyroid cancer incidence is increasing, the search for its risk factor is becoming more important. Serum thyroid stimulating hormone (TSH) levels being a growth factor for normal thyroid tissue, is also considered as growth promotor of cancer cells. In our study we aimed for pre-operative serum TSH levels of Differentiated thyroid cancers (DTC) done before their first surgery and determined its association with advanced disease in terms of stage, multifocal disease, lymph node involvement and distant metastasis.

Methods:

We have conducted a retrospective review of thyroid cancers from 1^st January 2008 to 31^st December 2017. Out of 281, 142 cases were included according to inclusion criteria. We noted the demographic details of participants, their histopathological diagnosis and serum TSH levels done before first surgery from the medical records. We calculated the stage of tumor through modified American Joint Committee (AJCC) staging system.

Results:

Out of 147 participants, 89.4% had papillary carcinoma or its variants whereas 10.6% reported follicular carcinoma. The mean pre-op TSH level of the patients included was 2.04 ± 1.79. In addition to the descriptive analysis, the univariate regression analysis revealed that the association of serum TSH levels was found to be statistically insignificant with advanced stage of thyroid cancer, multifocal disease, lymph node metastasis and distant metastasis respectively.

Conclusion:

The serum TSH levels before surgery was not associated with poor prognosis of differentiated thyroid cancer with respect to higher staging, multifocal disease, lymphatic or distant metastasis.