BRAF(V600E) Is Correlated with Recurrence of Papillary Thyroid Microcarcinoma: A Systematic Review, Multi-Institutional Primary Data Analysis, and Meta-Analysis

BACKGROUND

Given the increasing incidence of papillary thyroid carcinoma despite stable disease-specific mortality rates, the potential for the disease to reoccur is a key outcome to predict. The BRAF(V600E) mutation has been associated with recurrent disease in larger tumors. However, its correlation in papillary thyroid microcarcinoma (PTMC) is not clear in individual series.

METHODS

The MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for studies including patients with PTMC undergoing initial surgical treatment. Studies with at least two years of follow-up, BRAF genotyping (the comparator), and recurrence as an outcome were included, as were unpublished primary data on 485 patients from two institutions. The metameter analyzed was odds ratio (OR) for recurrence between patients with BRAF(V600E) versus BRAF wild type (BRAFwt).

RESULTS

The initial search identified 431 references. After screening of the abstracts for inclusion, 44 manuscripts were reviewed in full by two independent reviewers. Four published studies and primary data from two institutional cohorts were included in the final analysis. A meta-analysis of 2247 PTMC patients revealed that patients with a BRAF(V600E) mutation had a higher likelihood for recurrence (odds ratio 2.09 [confidence interval 1.31-3.33], p = 0.002).

CONCLUSIONS

This meta-analysis shows that BRAF mutational status correlates with recurrence of PTMCs, highlighting the potential utility of genotyping in preoperative and postoperative planning. BRAF mutation may be helpful in risk-stratifying patients with PTMC for surgical management versus observation.

Outcomes after resection of cortisol-secreting adrenocortical carcinoma

BACKGROUND

We sought to define the impact of cortisol-secreting status on outcomes after surgical resection of adrenocortical carcinoma (ACC).

METHODS

The U.S ACC group database was queried to identify patients who underwent ACC resection between 1993 and 2014. The short-term and long-term outcomes were assessed.

RESULTS

The incidence of all functional and cortisol-secreting tumors was 40.6% and 22.6%, respectively. On multivariable analysis, cortisol secretion remained associated with an increased risk of postoperative complications (odds ratio = 2.25, 95 % confidence interval = 1.04 to 4.88; P = .04). At a median follow-up of 17.6 months, 118 patients (50.4%) had developed a recurrence. On multivariable analysis, after adjusting for patient and disease-related factors cortisol secretion independently predicted shorter recurrence-free survival (Hazard ratio = 2.05, 95% confidence interval = 1.16 to 3.60; P = .01).

CONCLUSIONS

Cortisol secretion was associated with an increased risk of postoperative morbidity. Recurrence remains high among patients with ACC after surgery; cortisol secretion was independently associated with a shorter recurrence-free survival. Tailoring postoperative surveillance of ACC patients based on their cortisol secreting status may be important.

Minimally Invasive Adrenalectomy

Minimally invasive adrenalectomy has become the gold standard for removal of benign adrenal tumors. The imaging characteristics, biochemical evaluation, and patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic approaches are discussed with details of surgical technique for both procedures.

Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy after adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol

BACKGROUND

Secondary adrenal insufficiency (AI) can occur after unilateral adrenalectomy for adrenal-dependent hypercortisolism. Postoperative glucocorticoid replacement (GR), although given routinely, may not be necessary. We sought to identify factors that, in combination with postoperative day 1 cosyntropin stimulation testing (POD1-CST), would predict the need for GR.

METHODS

We reviewed 31 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism (study patients) or hyperaldosteronism (control patients). A standard POD1-CST protocol was used. Hydrocortisone was started for clinical evidence of AI, basal plasma cortisol ≤ 5 (μg/dL), or a stimulated plasma cortisol <18.

RESULTS

A normal POD1-CST was found in all nine control patients and 11 of 22 patients (50%) with Cushing's syndrome; the other 11 study patients (50%) received GR based on the POD1-CST. These patients were younger (51 vs 62 years; P = .017), had a higher body mass index (BMI; 31 vs 29 kg/m(2)), and smaller adrenal neoplasms (16.9 vs 33.0 g; P = .009) than non-GR study patients.

CONCLUSION

After unilateral adrenalectomy for hypercortisolism, only 50% of patients received GR. No preoperative biochemical characteristics were associated with postoperative AI, although patients who received GR were younger, and tended to have a higher BMI and smaller adrenal nodules. Use of this novel protocol for postoperative dynamic adrenal function testing prevented unnecessary GR in 50% of patients and allowed for individualized patient care.

A meta-analysis of bevacizumab combined with chemotherapy in the treatment of ovarian cancer

INTRODUCTION

Angiogenesis plays an important role in the biology of ovarian cancer. The clinical efficacy and side effects of bevacizumab, the vascular endothelial growth factor inhibitor, on survival and toxicity in women with this ovarian cancer, was not conclusive. We performed this systematic review and meta-analysis in order to clarify the efficacy of bevacizumab combined with chemotherapy in the treatment of ovarian cancer.

MATERIALS AND METHODS

We searched the electronic database of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CNKI for clinical controlled trials of comparing bevacizumab combined with chemotherapy and chemotherapy alone in the treatment of ovarian cancer. The primary outcomes of eligible studies included median progression-free survival (PFS), overall survival (OS), and toxicities such as enterobrosis, hypertension, albuminuria, congestive heart failure (CHF), neutrophils, thrombosis, and bleeding. The Hazard ratio (HR) and relative risk were used for the meta-analysis and were expressed with 95% confidence intervals (CIs). All the statistical analyses were carried out by  Stata 11.0 software (http://www.stata.com; Stata Corporation, College Station, TX, USA).

RESULTS

We included 5 studies with 1798 cases in the bevacizumab combined with the chemotherapy group and 1810 subjects in the chemotherapy alone group. The pooled results showed that bevacizumab + chemotherapy compared with chemotherapy alone can significant prolong the median PFS (HR, 0.64; 95% CI, 0.46-0.82; P < 0.05) but not the OS (HR, 0.84; 95% CI, 0.59-10.9; P > 0.05); the toxicity analysis showed that the enterobrosis, hypertension, albuminuria, neutrophils, thrombosis, and bleeding were significantly increased in the bevacizumab + chemotherapy group compared with chemotherapy alone (Pall < 0.05). But the CHF risk between the two groups was not statistical different (P > 0.05).

CONCLUSION

Bevacizumab combined with chemotherapy prolonged the median PFS in patients with ovarian cancer but also increase the risk of developing enterobrosis, hypertension, albuminuria, neutrophils, thrombosis, and bleeding.

Adrenocortical Carcinoma: Impact of Surgical Margin Status on Long-Term Outcomes

BACKGROUND

The influence of surgical margin status on long-term outcomes of patients undergoing adrenal resection for ACC remains not well defined. We studied the impact of surgical tumor margin status on recurrence-free survival (RFS) and overall survival (OS) of patients undergoing resection for ACC.

METHODS

A total of 165 patients who underwent adrenal resection for ACC and met inclusion criteria were identified form a multi-institutional database. Clinicopathological data, pathologic margin status, and long-term outcomes were assessed. Patients were stratified into two groups based on margin status: R0 (margin >1 mm) versus R1.

RESULTS

R0 resection was achieved in 126 patients (76.4 %), whereas 39 patients (23.6 %) had an R1 resection. Median and 5-year OS for patients undergoing R0 resection were 96.3 months and 64.8 % versus 25.1 months and 33.8 % for patients undergoing an R1 resection (both p < 0.001). On multivariable analysis, surgical margin status was an independent predictor of worse OS (hazard ratio [HR] 2.22, 95 % confidence interval [CI] 1.03-4.77; p = 0.04). The incidence of recurrence also differed between the two groups; 5-year RFS was 30.3 % among patients with an R0 resection versus 13.8 % among patients who had an R1 resection (p = 0.03). Lymph node metastasis (N1) was an independent predictor of RFS (HR 2.70, 95 % CI 1.04-6.99; p = 0.04).

CONCLUSIONS

A positive margin after ACC resection was associated with worse long-term survival. Patient selection and an emphasis on surgical technique to achieve R0 margins are pivotal to optimizing the best chance for long-term outcome among patients with ACC.

Curative Resection of Adrenocortical Carcinoma: Rates and Patterns of Postoperative Recurrence

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare malignancy. The aim of this study was to determine the incidence and patterns of recurrence after curative-intent surgery for ACC.

METHODS

Patients who underwent curative-intent resection for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the United States ACC study group. Patients with metastasis or an R2 margin were excluded. Patterns and rates of recurrence were determined and classified as locoregional and distant recurrence.

RESULTS

A total of 180 patients with a median age of 52 years (interquartile range 43-61) were identified. Most patients underwent open surgery (n = 111, 64.5 %) and had an R0 resection margin (n = 117, 75.0 %). At last follow-up, 116 patients (64.4 %) had experienced recurrence (locoregional only, n = 41, 36.3 %; distant only, n = 51, 45.1 %; locoregional and distant, n = 21, 18.6 %). Median time to recurrence was 18.8 months. Several factors were associated with locoregional recurrence, including left-sided ACC location (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.06-6.89) and T3/T4 disease (reference T1/T2, OR 3.04, 95 % CI 1.19-7.80) (both p < 0.05). Distant recurrence was associated with larger tumor size (OR 1.11, 95 % CI 1.01-1.24) and T3/T4 disease (reference T1/T2, OR 5.23, 95 % CI 1.70-16.10) (both p < 0.05). Patients with combined locoregional and distant recurrence had worse survival (3- and 5-year survival: 39.5, 19.7 %) versus patients with distant-only (3- and 5-year survival 55.1, 43.3 %) or locoregional-only recurrence (3- and 5-year survival 81.4, 64.1 %) (p = 0.01).

CONCLUSIONS

Nearly two-thirds of patients experienced disease recurrence after resection of ACC. Although a subset of patients experienced recurrence with locoregional disease only, many patients experienced recurrence with distant disease as a component of recurrence and had a poor prognosis.

Neutrophil-lymphocyte and platelet-lymphocyte ratio as predictors of disease specific survival after resection of adrenocortical carcinoma

BACKGROUND

The systemic inflammatory response may be associated with tumor progression. We sought to analyze the impact of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) on recurrence-free survival (RFS) and disease-specific survival (DSS) among patients who underwent surgery for adrenocortical carcinoma (ACC).

METHODS

Patients undergoing surgery for ACC were identified from a multi-center database. Cut-off values of 5 and 190 were defined as elevated NLR and PLR, respectively, and long-term outcome was assessed.

RESULTS

Among 84 patients with ACC, 29 (34.%) had NLR > 5 while 32 (40.5%) had PLR > 190. NLR and PLR were associated with larger tumors (NLR > 5: ≤ 5 cm, 0% vs. >5 cm, 39.7%; PLR > 190: ≤ 5cm, 0% vs. >5 cm, 45.7%), as well as need to resect of other organs (NLR > 5: other organ resected 48.8% vs. not resected 20.9%; PLR > 190: other organ resected 25.0% vs. not resected 56.4%)(all P < 0.05). Five-year RFS was associated with an elevated NLR (NLR ≤ 5, 14.2% vs. NLR> 5, 10.5%) and PLR (PLR ≤ 190: 19.4% vs. PLR > 190: 5.2%) (both P < 0.05). On multivariate survival analyses, PLR remained a predictor of RFS (HR 1.72), while NLR was associated with both DSS (HR 2.21) and RFS (HR 1.99) (both P < 0.05).

CONCLUSIONS

Immune markers such as NLR and PLR may be useful to stratify patients with regards to prognosis following surgery for ACC.

The Effect of Thyroiditis on the Yield of Central Compartment Lymph Nodes in Patients with Papillary Thyroid Cancer

BACKGROUND

In patients who have undergone thyroidectomy and central compartment neck dissection (CCND) for papillary thyroid cancer (PTC), visualization of enlarged lymph nodes may lead to more extensive CCND. This study sought to determine the effect of patient age and the presence of thyroiditis on the number of malignant and total lymph nodes resected in patients who underwent CCND for PTC.

METHODS

This retrospective review examined a prospective database of patients who underwent total thyroidectomy and CCND for PTC between April 2009 and June 2013 and had thyroiditis on the final pathology. The patients were categorized into age groups by decade (18-29, 30-39, 40-49, 50-59, and ≥60 years) and compared with a control group of patients matched by age, gender, and tumor size.

RESULTS

Of 74 patients with thyroiditis, 64 (87 %) were women. The median age of the patients was 47.5 years (range 18.2-72.0 years). The patients with thyroiditis had more lymph nodes resected than those without thyroiditis (median 11 vs 7; p < 0.01). However, these patients had fewer malignant lymph nodes (median 0 vs 1.5; p = 0.06), resulting in a lower lymph node ratio (0 vs 0.18; p = 0.02) for the entire cohort, but particularly for the youngest (18-29 years) and oldest (≥60 years) age groups.

CONCLUSIONS

Patients with thyroiditis and PTC who underwent CCND had more lymph nodes resected but a had lower proportion of metastatic lymph nodes than those without thyroiditis. Given the relatively low yield of malignant cervical lymphadenopathy, a more judicious approach to CCND might be considered, particularly for the youngest and oldest patients with PTC and thyroiditis.

Comparative effectiveness in thyroid cancer: key questions and how to answer them

Controversies in treatment of thyroid cancer remain despite numerous published studies. Robust comparative effectiveness studies examining: (1) the role of prophylactic central compartment neck dissection (pCCND) in patients with papillary thyroid cancer (PTC); (2) the use of post-operative radioactive iodine (RAI) ablation therapy following total thyroidectomy; (3) use of low versus high doses of I-131 in RAI therapy; (4) thyroid hormone withdrawal (THW) versus recombinant thyroid stimulating hormone (rhTSH) prior to RAI; and (5) the role of routine measurement of serum calcitonin levels are needed to help strengthen existing treatment recommendations. Reasons for the controversies and suggestions for quality comparative effectiveness studies are discussed.

A novel staging system for adrenocortical carcinoma better predicts survival in patients with stage I/II disease

BACKGROUND

Current American Joint Committee on Cancer/International Union against Cancer (AJCC/UICC) and European Network for the Study of Adrenal Tumors staging for adrenocortical carcinoma (ACC) have not shown a survival difference between patients with stage I/II disease. This study evaluates current staging systems for survival prediction using a larger cohort and assesses whether incorporating age into ACC staging improves survival predictions.

METHODS

Patients in the National Cancer Data Base (1985-2006) with a diagnosis of ACC were identified and staged using a novel TNM-A staging system: Stage I (T1/T2N0M0, age ≤ 55), stage II (T1/T2N0M0, age >55), stage III (T1/T2N1M0 or T3/T4N0-N1M0, any age), or stage IV (any T any NM1, any age). Differences in overall survival (OS) by stage were compared using a Cox proportional hazards model.

RESULTS

Staging was derived for 1,579 of 3,262 patients. Median age was 54 years; mean tumor size was 11.6 cm. Using current staging, differences in 5-year OS was observed only between patients with stages II/III and III/IV ACC. With TNM-A staging, differences in 5-year OS between all stages was significant (I/II [P < .003], II/III [P < .0001], III/IV [P < .0001]).

CONCLUSION

A staging system that incorporates patient age better predicts 5-year OS among patients with stages I/II ACC. Consideration should be given to including age in staging for ACC, because it may better inform providers about treatment and prognosis.

Central compartment lymph node dissection for differentiated thyroid cancer: review of the literature

Central lymph node dissection (CLND) remains an important component of the surgical treatment of differentiated thyroid cancer. The indication for CLND is the presence of image-positive metastases in level VI lymph nodes; the elective dissection of radiographically normal central compartment lymph nodes in patients with differentiated thyroid cancer remains controversial. The different types of CLND will be discussed herein, and some of the surrounding controversies will be highlighted.

Factors that influence parathyroid hormone half-life: determining if new intraoperative criteria are needed

IMPORTANCE

Minimally invasive parathyroidectomy using intraoperative parathyroid hormone monitoring remains the standard approach to the majority of patients with primary hyperparathyroidism. This study demonstrates that individual patient characteristics do not affect existing criteria for intraoperative parathyroid hormone monitoring.

OBJECTIVE

To identify patient characteristics, such as age, sex, race, body mass index (BMI), and renal function, that may affect existing criteria for intraoperative parathyroid hormone (IOPTH) levels during minimally invasive parathyroidectomy.

DESIGN

Retrospective review of a prospectively collected parathyroid database populated from August 2005 to April 2011.

SETTING

Academic medical center.

PARTICIPANTS

Three hundred six patients with sporadic primary hyperparathyroidism who underwent initial parathyroidectomy between August 2005 and April 2011.

INTERVENTIONS

All patients underwent minimally invasive parathyroidectomy with complete IOPTH information.

MAIN OUTCOME AND MEASURES

Individual IOPTH kinetic profiles were fitted with an exponential decay curve and individual IOPTH half-lives were determined. Univariate and multivariate analyses were performed to determine the association between patient demographics or laboratory data and IOPTH half-life.

RESULTS

Mean age of the cohort was 60 years, 78.4% were female, 90.2% were white, and median BMI was 28.3. Overall, median IOPTH half-life was 3 minutes, 9 seconds. On univariate analysis, there was no association between IOPTH half-life and patient age, renal function, or preoperative serum calcium or parathyroid hormone levels. Age, BMI, and an age × BMI interaction were included in the final multivariate median regression analysis; race, sex, and glomerular filtration rate were not predictors of IOPTH half-life. The IOPTH half-life increased with increasing BMI, an effect that diminished with increasing age and was negligible after age 55 years (P = .001).

CONCLUSIONS AND RELEVANCE

Body mass index, especially in younger patients, may have a role in the IOPTH half-life of patients undergoing parathyroidectomy. However, the differences in half-life are relatively small and the clinical implications are likely not significant. Current IOPTH criteria can continue to be applied to all patients undergoing parathyroidectomy for sporadic primary hyperparathyroidism.

A meta-analysis of the effect of prophylactic central compartment neck dissection on locoregional recurrence rates in patients with papillary thyroid cancer

BACKGROUND

It is not known whether prophylactic central compartment neck dissection (pCCND) in conjunction with total thyroidectomy decreases rates of locoregional recurrence in patients with papillary thyroid cancer (PTC).

METHODS

A meta-analysis was performed of reported recurrence rates of clinically node-negative PTC in patients treated with total thyroidectomy (TT) alone, or TT and pCCND. The primary outcome was locoregional recurrence of PTC.

RESULTS

Eleven studies capturing 2,318 patients met the inclusion criteria. Overall, the recurrence rate for patients undergoing TT/pCCND was 3.8 % [95 % confidence interval (CI) 2.3-5.8]. In the six comparative studies, which included 1,740 patients, 995 patients undergoing TT and 745 patients undergoing TT/pCCND, the overall recurrence rate was 7.6:7.9 % in the TT group and 4.7 % in the TT/pCCND group. The relative risk of recurrence was 0.59 (95 % CI 0.33-1.07), favoring a lower recurrence rate in the TT/pCCND arm. The number of patients that would need to be treated (NNT) in order to prevent a single recurrence is 31. The relative risk for permanent hypocalcemia was 1.82 (95 % CI 0.51-6.5) and for permanent recurrent laryngeal nerve injury was 1.14 (95 % CI 0.46-2.83).

CONCLUSIONS

There was no difference in recurrence or long-term complication rates between patients undergoing TT or TT/pCCND. There was a trend toward lower recurrence rates in TT/pCCND patients, with a NNT of 31 patients. On the basis of these data, routine pCCND might be considered in the hands of high-volume surgeons treating patients with clinically node-negative PTC.

Focused parathyroidectomy with intraoperative parathyroid hormone monitoring in patients with lithium-associated primary hyperparathyroidism

BACKGROUND

Lithium-associated hyperparathyroidism has been attributed to multigland hyperplasia requiring bilateral exploration and subtotal parathyroidectomy. Recent studies suggest that some patients may have single gland disease and be eligible for minimally invasive parathyroidectomy.

METHODS

We performed a retrospective review of a prospective, single institution parathyroid database of 1,010 patients who underwent parathyroidectomy between December 1999 and October 2010.

RESULTS

Nineteen patients with a history of lithium therapy and sporadic hyperparathyroidism were identified. Median age was 50 years (16-68); median duration of therapy was 19 years (1-37); 11 (58%) were on active therapy with lithium for multiple reasons. Preoperative median serum calcium was 10.9 mg/dL (10.0-12.3), median parathyroid hormone was 111 pg/mL (60-186). A total of 18 patients underwent preoperative imaging. Of 12 patients with single-site localization, 6 (50%) underwent a minimally invasive parathyroidectomy, 2 (17%) underwent unilateral explorations, 1 (8%) underwent bilateral exploration, and 3 (25%) had concomitant thyroidectomies. Six patients did not localize and underwent bilateral exploration for multigland disease. One patient without preoperative imaging had single-gland disease. In all operations surgeons used intraoperative parathyroid hormone (IOPTH) monitoring and met intraoperative criteria. Median IOPTH decrease was 74% (54-86) in single-gland disease and 85% (76-95) in multigland disease. Median abnormal gland weight was 590 mg (134-6,750) in single-gland disease and 296 mg (145-2,170) in multigland disease. All patients were normocalcemic at a median follow-up of 19 months (2-118).

CONCLUSION

Of 19 patients with lithium exposure, 6 (32%) had multigland disease. However, of the 13 (68%) patients with single gland disease, all 12 who had preoperative imaging had single-site localization. If localization suggests single gland disease, minimally invasive parathyroidectomy with IOPTH monitoring can be successfully performed.