Patterns in the Reporting of Aggressive Histologic Subtypes in Papillary Thyroid Cancer

INTRODUCTION

The tall cell, columnar, and diffuse sclerosing subtypes are aggressive histologic subtypes of papillary thyroid cancer (PTC) with increasing incidence, yet there is a wide variation in reporting. We aimed to identify and compare factors associated with the reporting of these aggressive subtypes (aPTC) to classic PTC (cPTC) and secondarily identify differences in outcomes.

METHODS

The National Cancer Database was utilized to identify cPTC and aPTC from 2004 to 2017. Patient and facility demographics and clinicopathologic variables were analyzed. Independent predictors of aPTC reporting were identified and a survival analysis was performed.

RESULTS

The majority of aPTC (67%) were reported by academic facilities. Compared to academic facilities, all other facility types were 1.4-2.0 times less likely to report aPTC (P < 0.05). Regional variation in reporting was noted, with more cases reported in the Middle Atlantic, despite there being more total facilities in the South Atlantic and East North Central regions. Compared to the Middle Atlantic, all other regions were 1.4-5 times less likely to report aPTC (P < 0.001). Patient characteristics including race and income were not associated with aPTC reporting. Compared to cPTC, aPTC had higher rates of aggressive features and worse 5-y overall survival (90.5% versus 94.5%, log rank P < 0.001).

CONCLUSIONS

Aggressive subtypes of PTC are associated with worse outcomes. Academic and other facilities in the Middle Atlantic were more likely to report aPTC. This suggests the need for further evaluation of environmental or geographic factors versus a need for increased awareness and more accurate diagnosis of these subtypes.

Low Mitotic Activity in Papillary Thyroid Cancer: A Marker for Aggressive Features and Recurrence

CONTEXT

The significance of low mitotic activity in papillary thyroid cancer (PTC) is largely undefined.

OBJECTIVE

We aimed to determine the behavioral landscape of PTC with low mitotic activity compared to that of no- and high-mitotic activity.

METHODS

A single-institution consecutive series of PTC patients from 2018-2022 was reviewed. Mitotic activity was defined as no mitoses, low (1-2 mitoses/2 mm2) or high (≥3 mitoses/2 mm2) per the World Health Organization. The 2015 American Thyroid Association risk stratification was applied to the cohort, and clinicopathologic features were compared between groups. For patients with ≥6 months follow-up, Cox regression analyses for recurrence were performed.

RESULTS

640 PTCs were included - 515 (80.5%) no mitotic activity, 110 (17.2%) low mitotic activity, and 15 (2.3%) high mitotic activity. Overall, low mitotic activity exhibited rates of clinicopathologic features including vascular invasion, gross extrathyroidal extension, and lymph node metastases in between those of no- and high-mitotic activity. PTCs with low mitotic activity had higher rates of intermediate- and high-risk ATA risk stratification compared to those with no mitotic activity (p < 0.001). Low mitotic activity PTCs also had higher recurrence rates (15.5% vs. 4.5%, p < 0.001). Low mitotic activity was associated with recurrence, independent of the ATA risk stratification (HR 2.96; 95% CI 1.28-6.87, p = 0.01).

CONCLUSIONS

Low mitotic activity is relatively common in PTC and its behavior lies within a spectrum between no- and high-mitotic activity. Given its association with aggressive clinicopathologic features and recurrence, low mitotic activity should be considered when risk stratifying PTC patients for recurrence.

Clinical utility of a microRNA classifier in cytologically indeterminate thyroid nodules with RAS mutations: A multi-institutional study

BACKGROUND

Molecular testing guides the management of cytologically indeterminate thyroid nodules. We evaluated the real-world clinical benefit of a commercially available thyroid mutation panel plus microRNA risk classifier in classifying RAS-mutated nodules.

METHODS

We performed a subgroup analysis of the results of molecular testing of Bethesda III/IV nodules using the ThyGenX/ThyGeNEXT-ThyraMIR platform at 3 tertiary-care centers between 2017 and 2021, defining a positive result as 10% or greater risk of malignancy.

RESULTS

We identified 387 nodules from 375 patients (70.7% female, median age 59.3 years) who underwent testing. Positive nodules (32.3%) were associated with increased surgical intervention (74.4% vs 14.9%, P < .0001) and carcinoma on surgical pathology (46.4% vs 3.4%, P < .0001) compared to negative modules. RAS mutations were the most common mutations, identified in 71 of 380 (18.7%) nodules, and were classified as ThyraMIR- (28 of 71; 39.4%) or ThyraMIR+ (43 of 71; 60.6%). Among RAS-mutated nodules, there was no significant difference in operative rate (P = .2212) or carcinoma diagnosis (P = .6277) between the ThyraMIR+ and ThyraMIR- groups, and the sensitivity, specificity, negative predictive value, and positive predictive value of ThyraMIR were 64.7%, 34.8%, 40.0%, and 59.5%, respectively.

CONCLUSION

Although testing positive is associated with malignancy in surgical pathology, the ThyraMIR classifier failed to differentiate between benign and malignant RAS-mutated nodules. Diagnostic lobectomy should be considered for RAS-mutated nodules, regardless of microRNA expression status.

Radioactive iodine administration is not associated with improved disease-specific survival in classic papillary thyroid carcinoma greater than 4 cm confined to the thyroid

BACKGROUND

We aimed to evaluate the impact of radioactive iodine on disease-specific survival in intrathyroidal (N0M0) papillary thyroid carcinoma >4 cm, given conflicting data in the American Thyroid Association guidelines regarding their management.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for N0M0 classic papillary thyroid carcinoma >4 cm. Kaplan-Meier estimates were performed to compare disease-specific survival between radioactive iodine-treated and untreated groups. A multivariable Cox regression was performed to identify predictors of disease-specific survival.

RESULTS

There were more patients aged ≥55 (41.7% vs 32.3%, P = .001) and fewer multifocal tumors (25.3% vs 30.6%, P = .006) in the no radioactive iodine group. Ten-year disease-specific survival was similar between the radioactive iodine treated and untreated groups (97.2% vs 95.6%, P = .34). Radioactive iodine was not associated with a significant disease-specific survival benefit (adjusted hazard ratio = 0.78, confidence interval [0.39-1.58], P = .49). Age ≥55 (adjusted hazard ratio = 3.50, confidence interval [1.69-7.26], P = .001) and larger tumor size (adjusted hazard ratio = 1.04, confidence interval [1.02-1.06], P < .001) were associated with an increased risk of disease-specific death. Subgroup analyses did not demonstrate improved disease-specific survival with radioactive iodine in patients ≥55 and in tumors >5 cm.

CONCLUSION

Adjuvant radioactive iodine administration in classic papillary thyroid carcinoma >4 cm confined to the thyroid did not significantly impact disease-specific survival. Thus, these patients may not require routine treatment with adjuvant radioactive iodine.

Antithrombotic Agent Use in Elderly Patients Sustaining Low-Level Falls

BACKGROUND

Elderly patients who are injured from a low-level fall comprise an increasing percentage of trauma admissions. We sought to evaluate the prevalence of antithrombotic (anticoagulant or antiplatelet) agent use, injury patterns, and outcomes in this population, focusing on intracranial hemorrhage (ICH).

METHODS

We retrospectively reviewed the trauma registry at an American College of Surgeons-verified Level I trauma center for all patients aged 65 y or older admitted between 2007 and 2016 following a low-level fall. Medical records of patients on antithrombotic agents were examined in detail. Patients were divided into four groups based on the presence/absence of ICH and presence/absence of preadmission antithrombotic medication use.

RESULTS

There were 4074 elderly patients admitted after a low-level fall, of which 1153 (28.3%) had a traumatic ICH, and 1238 (30.4%) were on antithrombotic agents. Notably, 35.9% of patients on antithrombotics had an ICH, as compared to 25.0% of 2836 patients not on antithrombotics other than aspirin (P < 0.001). The overall distribution of antithrombotic agent use differed significantly between the ICH and non-ICH groups; the ICH group had more coumadin usage. The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 14.2% (P < 0.001). Excluding the 27.8% of patients who were transferred into our hospital demonstrated that significantly more admissions on antithrombotics had ICH (22.4%) versus ICH admissions not on antithrombotics (14.7%, P < 0.001). The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 12.0% (P < 0.001). On multivariable analysis, anticoagulants, antiplatelets, and aspirin were all significantly associated with ICH; but only anticoagulants were significantly associated with mortality.

CONCLUSIONS

Antithrombotic agent use was common in admitted elderly patients sustaining a low-level fall and is associated with an elevated rate of ICH. Anticoagulants were also associated with increased mortality.

Intestinal Aspergillosis: Systematic Review on Patterns of Clinical Presentation and Management

Background: Intestinal aspergillosis (IA) is a rare entity primarily discovered in immunocompromised patients. Because of its low incidence, IA is not considered routinely in the differential of abdominal pain, distension, and diarrhea. A systematic characterization of demographics, comorbidities, clinical presentations, and outcomes can help surgeons recognize and manage IA in critically ill patients. Methods: Two independent authors carried out the literature search using PubMed, MEDLINE, and Scopus databases. The Mesh terms utilized were: 'intestinal' and 'aspergillosis' combined with the Boolean operator 'AND' (synonyms were combined with the Boolean operator 'OR'). Intestinal aspergillosis was defined as inflammation of the gastrointestinal tract (duodenum to rectum) caused by Aspergillus spp. All articles reporting IA were included. Articles describing aspergillosis of the esophagus or stomach were excluded. Statistical analysis was performed using SPSS software (version 18; SPSS Inc., Chicago, IL). Results: Forty-two articles reporting 56 cases were included in the study. Mean age was 44.9 ± 20.5 years. Male to female ratio was 29:27. The most common condition in patients who developed IA was transplantation (19 patients; 34%). The most common clinical presentations of IA were abdominal pain (21 patients; 38%) and diarrhea 12 patients; 21%). Sixty-six percent of patients had primary IA whereas 34% developed IA secondarily to systemic infection. Diagnostic modalities included exploratory laparotomy (35 patients; 63%) and endoscopy (7 patients; 13%). Mean time to diagnosis was 8.6 ± 11.3 days. Intestinal aspergillosis was limited to the small bowel in 61% of patients. In 43 (77%) patients, bowel resection is the definitive treatment, whereas 13 (23%) patients underwent antifungal therapy alone. Mortality rate was 39%. Sixty-three percent of patients treated with surgery survived, compared with 46% treated with antifungal therapy alone (p = 0.34). Conclusion: Intestinal aspergillosis is a life-threatening condition with a mortality rate of 39%. Extrapulmonary IA is seen in patients with neutropenia, sepsis, inflammatory conditions, and immunosuppression. Patients who undergo surgery are more likely to survive this infection.

Evaluating the utility of fasting lipid panel in addition to random lipid panel in determining lipid-lowering therapy in acute ischemic stroke or TIA patients

BACKGROUND

Hyperlipidemia is one of the major risk factors for cerebrovascular disease and it is common practice to obtain fasting lipid profile prior to starting lipid lowering therapy (LLT). Recent AHA Guidelines published in 2018 allow for a non-fasting value to be used.

OBJECTIVE

To determine if obtaining fasting lipid levels in addition to random lipid levels prompts changes in hyperlipidemia management of acute stroke patients.

METHODS

206 patients met the study criteria which included a diagnosis of acute ischemic stroke or transient ischemic attack on admission and availability of both random and fasting LDL levels collected within 72 h of each other. Patients were divided into three groups based on random LDL at admission: Group A: LDL < 70, Group B: LDL 70-99, and Group C: LDL ≥ 100 mg/dL. The dataset was analyzed to conform to the 2018 AHA/ACC guidelines using an LDL cutoff of 70 mg/dL.

RESULTS

In 206 patients, statin management would change based on the fasting LDL level in 12 patients, 11 of whom were in Group B. Our data suggests that lipid management is more likely to change if the initial random LDL falls between 70-99 mg/dL as compared to a value outside of this range (P < 0.001). We present a decision algorithm to guide lipid management in acute stroke patients.

CONCLUSIONS

Foregoing a fasting lipid panel to guide LLT in patients with ischemic stroke is appropriate in most cases but for select patients with random LDL levels between 70 and 99, fasting lipid profile should be obtained prior to deciding upon LLT.