Preoperative prediction of Ki-67 expression in medullary thyroid carcinoma based on ultrasonographic features: a 10-year retrospective study

PURPOSE

To identify ultrasonographic features that help distinguish Ki-67 expression levels in patients with medullary thyroid carcinoma (MTC).

MATERIALS AND METHODS

A total of 210 patients (245 nodules) with pathological diagnosis of MTC were included in this retrospective study between January 2013 and April 2024. Based on preoperative clinical and ultrasonographic features, univariate analysis and multivariate logistic regression analysis were performed to determine the risk factors associated with Ki-67 ≥ 5 %. A prediction model was subsequently established to evaluate the differential diagnostic performance of Ki-67 by the area under the curve (AUC).

RESULTS

Among the 210 MTC patients (245 nodules), 35 patients (41 nodules) exhibited high Ki-67 expression (Ki-67 ≥ 5 %), while 175 patients (204 nodules) had low Ki-67 expression (Ki-67 < 5 %). There were no significant differences in age, sex, body mass index (BMI), preoperative calcitonin and preoperative CEA levels between the two groups (P > 0.05). Multivariate analysis of the nodules in the two groups revealed that the ultrasound features, including location in the upper or middle region, tumor size > 2.15 cm, and markedly hypoechoic were independent risk factors for high Ki-67 expression. A prediction model was established with the AUC of 0.812 (95 % CI 0.743-0.882).

CONCLUSIONS

Compared to the low Ki-67 expression group, Ki-67 ≥ 5 % group were more likely to exhibit the ultrasound characteristics of location in the upper or middle region, tumor size > 2.15 cm, and markedly hypoechoic. The prediction model demonstrated preferable diagnostic value.

Diagnostic yield of thyroid CT in differentiated thyroid carcinoma according to treatment response

OBJECTIVES

To evaluate the diagnostic yield of thyroid CT in patients with post-treatment differentiated thyroid carcinoma (DTC) stratified by treatment response.

MATERIALS AND METHODS

This retrospective study included DTC patients who underwent total thyroidectomy and radioactive iodine ablation, followed by thyroid CT. Patients were categorized into response assessment groups according to the American Thyroid Association guidelines: excellent response (ER), biochemical incomplete response (BIR), indeterminate response (IR), and structural incomplete response (SIR). Diagnostic yield was defined as the proportion of patients with recurrent tumors among all patients. The yields of ER, BIR, and IR were compared. For IR, subgroup analyses were performed based on the presence of indeterminate lesions on ultrasound (US). Chi-squared tests with Bonferroni correction were used to compare the diagnostic yields between groups.

RESULTS

A total of 450 patients (mean age, 44.9 ± 13.4 years; 164 men) were included. The overall diagnostic yield of thyroid CT was 15.3% (69/450; 95% confidence interval [CI]: 12.3-19%). Yields for the ER, BIR, and IR groups were 2% (4/201; 95% CI: 0.6-5.2%), 23.1% (12/52; 95% CI: 13.6-36.3%), and 26.9% (53/197; 95% CI: 21.2-33.5%), respectively. Among IR patients, the yield was significantly lower in US-negative patients (7.5%, 7/93; 95% CI: 3.5-15%) compared to those with indeterminate US lesions (44.2%, 46/104; 95% CI: 35.1-53.8%) (p < 0.001).

CONCLUSION

The diagnostic yield of thyroid CT varies according to the treatment response; it was low in ER and US-negative IR but higher in BIR and IR with indeterminate US lesions.

KEY POINTS

Question Guidelines recommend considering CT for follow-up in DTC based on treatment response, but the diagnostic yield of CT remains underexplored. Findings The diagnostic yield of CT was low in an ER and US-negative IR but higher in BIR and US-positive IR. Clinical relevance The diagnostic yield of thyroid CT varies according to treatment response. Utilizing CT based on treatment response may enhance the detection of recurrent tumors or clarify unclear findings on US.

5G remote robotic-assisted transcervical thyroidectomy: the first case report in the world

BACKGROUND

The incidence of thyroid malignancies is increasing due to the development of detection techniques. The demand for aesthetics and precision has led surgeons to innovate in surgery, and with the development of 5G technology, telesurgery has become a reality.

CASE PRESENTATION

We present the case of a 37-year-old woman with a physical examination that revealed a nodule of about 0.5*0.5 cm in size in the left lobe of the thyroid gland, with preoperative puncture pathology suggestive of papillary carcinoma. A 5G remote robotic thyroidectomy was performed from Shanghai to Shenzhen.

CONCLUSIONS

We believe this paper reports the world's first 5G tele-robotic-assisted transthoracic breast approach thyroidectomy.

Analysis of risk factors for distant metastasis of column cell subtypes of thyroid papillary carcinoma

OBJECTIVE

To analyze independent risk factors for distant metastasis of columnar cell subtype of papillary thyroid carcinoma (CCS-PTC) and to construct and validate a nomogram to help clinicians make more individualized clinical decisions.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patient data were downloaded from the SEER database. Chi-square test and Logistic regression analysis were used to determine independent risk factors for distant metastasis of CCS-PTC. A nomogram based on significant independent risk factors was established using the rms package of R software (version 4.3.3). The performance of the nomograms was evaluated using subject work characteristic curves (ROC), calibration curves, and decision curve analysis (DCA).

RESULTS

A total of 1712 patients with CCS-PTC were included, of which 79 patients developed distant metastasis, accounting for 4.61% of the entire cohort. The results of chi-square test showed that age, gender, race, tumor size, and lymph node metastasis were significantly associated with distant metastasis of CCS-PTC. Multifactorial logistic regression analysis showed that age, race, tumor size, and lymph node metastasis were independent risk factors for distant metastasis of CCS-PTC, and this was used to draw the nomogram. the results of ROC, calibration curves, and DCA showed that the predictive performance of the nomogram was good.

CONCLUSION

We successfully constructed and validated a nomogram for CCS-PTC distant metastases, which is important for clinicians to identify patients at high risk of distant metastases in a timely manner and make more individualized clinical decisions.

Establish a Nomogram Based on Ultrasound Novel Vascularity Characteristics to Differentiate Follicular Thyroid Carcinoma From Follicular Benign Neoplasms

PURPOSE

This study aimed to construct a nomogram based on novel ultrasound vascularity features to differentiate follicular thyroid carcinoma (FTC) from follicular benign neoplasms (FBN).

METHODS

A total of 153 patients were included. We evaluated various sonographic features of all nodules and analyzed the diagnostic efficiency of different vascularity patterns for FTC. Furthermore, independent predictors for FTC were screened using multivariable logistic regression. A nomogram was established to predict FTC, and various methods were used to evaluate the performance of the nomogram.

RESULTS

The firework-like pattern and central-grasp pattern were more likely to appear in the FTC (p < 0.001, p = 0.007), while the ring-like pattern was more likely to appear in the FBN (p < 0.001). The firework-like pattern showed the best performance in accuracy (71.2%) and NPV (73.4%) among other vascularity patterns. Besides, thick hypo-halo, ring-like pattern, central-grasp pattern, and firework-like pattern were four predictors used to construct the nomogram. The bootstrap AUC was 0.814 (95% CI: 0.743-0.884) which revealed the nomogram had accurate prediction accuracy.

CONCLUSION

The firework-like pattern and central-grasp pattern were vascularity characteristics for FTC, while the ring-like pattern was for FBN. Besides, our nomogram based on novel vascularity characteristics can help distinguish FTC and FBN before operation.

Thyroid cancer

In recent decades, the diagnosis of thyroid cancer, especially the papillary type, has increased significantly due to the use of imaging techniques such as ultrasound. For this reason, it is essential to rationalize diagnosis and treatment, since the behavior of thyroid cancer varies from slow-progressing tumors to highly aggressive ones. The application of risk assessment systems for ultrasound images and the optimization of cytology incorporating molecular studies allows cases to be stratified in order to select therapy on an individual basis. Currently, attempts are being made to avoid overtreatment in low-risk tumors, with active surveillance or minimally invasive techniques. The administration of radioiodine is indicated according to risk, with lower doses, and in advanced cases, oncospecific systemic treatments are being incorporated. The management of thyroid cancer requires a multidisciplinary team and population studies and quality clinical trials are necessary to update treatment guidelines.

Micronucleus and Nuclear Budding Help to Identify Malignancy in Thyroid Fine Needle Aspiration Cytology

OBJECTIVE

Micronucleus (MN) and Nuclear Budding (NB) Have Been Used as an Important Stimulus for Nuclear Atypia in Revealing Chromosomal Damage and Cancer Risk. This Study Aims to Assess MN and NB as Nuclear Parameters and Explore Their Role in Differential Diagnosis of Thyroid FNA and "Bethesda System for Reporting Thyroid Cytology" (BSRTC).

METHODS

The Study Included 350 Thyroid FNA Samples Categorised According to BSRTC. NB And MN Were Evaluated in 1000 Thyrocytes on FNA Slides. The Thyroidectomy Sections Were Divided Into Three Categories as 'Malignant', 'Low-Risk' and 'Benign'.

RESULTS

A Total of 350 Cases Were Classified as follows: 55 (15.71%) Benign, 159 (45.43%) Atypia of Undetermined Significance (AUS), 20 (5.71%) Follicular Neoplasm (FN), 48 (13.71%) Suspicious for Malignancy (SFM) and 68 (19.43%) Malignant. In comparison to all other cytopathologic diagnostic groups, the benign group had significantly lower levels of MN and NB (p < 0.001). The AUS group's MN and NB counts were significantly lower than those of the FN, SFM and malignant groups (MN for AUS-FN/SFM/M p < 0.001, NB for AUS-FN p = 0.01, NB for AUS-SFM/M p < 0.001, respectively). MN and NB counts were greater in the AUS group for cases with a malignant histopathologic diagnosis than for those with a benign histopathologic diagnosis (p < 0.001). MN and NB cut-off values > 5.50 and > 14.50, respectively, suggest high sensitivity and specificity of malignancy.

CONCLUSIONS

Increased Frequency of MN and NB closely associated with an increased risk of malignancy in thyroid FNA. Assessing MN and NB in thyroid FNA may help better stratify the risk in the AUS category.

Protocol and Progress of a Thyroid Study in the Epidemiological Study of Health Effects in Fukushima Emergency Workers

OBJECTIVE

To describe the protocol and progress of a thyroid study using thyroid ultrasonography in emergency workers who responded to the Fukushima nuclear accident.

METHODS

Thyroid ultrasonography was performed on Fukushima emergency workers at over 60 health examination institutions. The accuracy of ultrasonography is controlled by standard procedural protocols, examiner training, and a central review system. Thyroid findings are classified into 4 categories: Category A1 (no nodule or cyst), Category A2 (nodules ≤ 5.0 mm and/or cysts ≤ 20.0 mm), Category B (nodules ≥ 5.1 mm and/or cysts ≥ 20.1 mm), and Category C (requires immediate further examination). Participants classified as Categories B or C are recommended for secondary examination.

RESULTS

Among 3398 participants with available ultrasound images obtained at the first health examination between January 2016 and October 2023, 45.2 % were classified as Category A1, 39.2 % as Category A2, 15.5 % as Category B, and 0 % as Category C. Of the 207 participants for whom secondary examination results were available, seven were diagnosed with cancer or suspected cancer.

CONCLUSIONS

An accuracy control system of thyroid ultrasonography has been established which will continue to carefully investigate the thyroids of Fukushima emergency workers.

Anlotinib inhibits c-MET and ITGA2 in the treatment of anaplastic thyroid carcinoma

OBJECTIVE

This study explored the therapeutic effects of anlotinib in anaplastic thyroid carcinoma (ATC) models and the underlying molecular mechanisms.

METHODS

Human C643 and CAL-62 anaplastic thyroid carcinoma cell lines were cultured in vitro and treated with anlotinib. The effects of anlotinib on the proliferation, apoptosis, cell cycle progression, migration, and invasion of C643 and CAL-62 cells were observed. The tumour volumes and body weights of BALB/c-nu mice bearing subcutaneous tumours were recorded within 14 days of anlotinib treatment. HE staining and immunohistochemical staining for Ki67 and CD31 were performed on the tumour tissues from the mice. We collected anlotinib-treated and untreated C643 cell samples for subsequent transcriptome sequencing and analysis. Western blotting was conducted to measure the protein expression of c-MET, p-MET, LAMC2, COL5A1, and ITGA2 in mouse tumour tissues and C643 cell samples.

RESULTS

Anlotinib inhibited the growth of C643 and CAL-62 cells in a dose-dependent manner. Anlotinib also induced apoptosis and caused cell cycle arrest at the G2/M phase in C643 and CAL-62 cells (p < 0.05). Anlotinib significantly reduced the migration and invasion of C643 and CAL-62 cells (p < 0.001). Moreover, anlotinib effectively suppressed the growth of subcutaneously transplanted tumours in mice (p < 0.05). Immunohistochemical staining for Ki67 and CD31 demonstrated that anlotinib significantly inhibited tumour cell proliferation and angiogenesis. Furthermore, anlotinib downregulated the protein expression of p-MET, LAMC2, COL5A1, and ITGA2 in mouse tumour tissues and C643 cells (p < 0.05).

CONCLUSION

This study confirmed the therapeutic effect of anlotinib on ATC via in vivo and in vitro experiments. In addition, preliminary studies suggest that the mechanism of anlotinib in treating ATC may be to alter the high invasiveness of ATC cells by inhibiting c-MET signaling pathway.

ENDOCAN-TUTHYREF network consensus recommendations. Refractory medullary thyroid cancer

Medullary thyroid carcinoma (MTC) accounts for 2-4% of thyroid cancers. It has the particularity of being a neuroendocrine tumor associated with a proto-oncogene germline RET mutation: germline in 20-25% of cases, somatic in 70-80% of metastatic sporadic cases. Locally advanced and metastatic MTCs are called "refractory". Individual prognosis is difficult, since the clinical behavior of the disease varies greatly from one patient to another. However, histological factors, such as high-grade forms, associated with greater risk of tumor progression and death, have been recently identified, and biological factors, such as the doubling time of plasma calcitonin, may help assess prognosis. Treatment of refractory medullary thyroid carcinoma has progressed considerably over recent years, with the advent of targeted therapies such as multi-kinase inhibitors and selective RET inhibitors. Management requires multidisciplinary expertise, and is tailored to the individual clinical situation patient, the molecular characteristics of the tumor, and the progression of the disease. These advances have led the ENDOCAN-TUTHYREF rare-cancer network of the French National Institute for Cancer (INCa), dedicated to refractory thyroid cancer, to draw up a set of consensus recommendations. This article focuses on refractory medullary thyroid cancer.

Cancer-Associated Retinopathy Presenting as Panuveitis Secondary to Minimally Invasive Follicular Thyroid Carcinoma

Purpose: To describe a case of cancer-associated retinopathy (CAR) secondary to follicular thyroid carcinoma. Methods: A single retrospective case was evaluated. Results: A 68-year-old woman presented with floaters and decreased vision in the right eye and was found to have panuveitis. The left eye subsequently developed panuveitis 6 months later, ultimately resulting in retinal atrophy. Extensive investigations, including vitreous biopsies, imaging, and positron emission tomography, led to a diagnosis of CAR secondary to minimally invasive follicular thyroid carcinoma with serology positive for anti-enolase, anti-HSP60, and anti-glyceraldehyde-3-phosphate dehydrogenase. Conclusions: Cases of CAR secondary to minimally invasive follicular thyroid carcinoma are rare. Ensuring an early diagnosis and promptly initiating treatment, with a goal of preserving sight, are imperative.

Malignancy Risk, Molecular Mutations, and Surgical Outcomes of Thyroid Nodules Classified as Atypia of Undetermined Significance in the Bethesda System: A Comprehensive Analysis

OBJECTIVES

Thyroid nodules classified as atypia of undetermined significance (AUS) within the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) present a diagnostic challenge, with a risk of malignancy (ROM) of 5% to 50%. In 2017, TBSRTC introduced AUS subcategories to enhance ROM assessment. This study explores the correlation between AUS subclassification, molecular mutations, and surgical outcomes.

METHODS

Retrospective analysis was performed of 114 AUS cases with molecular profiling by ThyroSeqV3 and surgical follow-up. AUS subcategories as defined by TBSRTC included: AUS-Architectural, AUS-Nuclear, AUS-Nuclear and Architectural, and AUS-Hürthle cell. Pathology diagnoses were categorised as benign, malignant, or borderline, including noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).

RESULTS

Of the 114 nodules, 32.5% were AUS-Architectural, 28.9% AUS-Nuclear and Architectural, 18.4% AUS-Nuclear, 19.3% AUS-Hürthle cell, and 0.9% AUS-Not Otherwise Specified. Papillary carcinoma, predominantly follicular variant, was the most common diagnosis (47.4%), followed by benign lesions (34.2%) and NIFTP (9.6%). RAS family mutations were the most prevalent molecular alteration (34.2%) followed by DICER1, EIF1AX, EXH1 mutations, CNA and GEP (29.8%). THADA fusions, PTEN, TSHR and BRAFK601E mutations were identified in 10.5% of cases, while high-risk mutations such as BRAF V600E, TERT, and TP53 were found in 8.8% of cases. AUS subcategories demonstrated distinct molecular profiles and were linked to varying surgical outcomes.

CONCLUSIONS

AUS subcategorization is associated with specific molecular profiles and surgical outcomes, supporting the subclassification of AUS cases per TBSRTC guidelines for improved risk stratification and clinical management. Further prospective studies with larger cohorts are necessary for validation.

Urinary iodine levels and thyroid disorder prevalence in the adult population of China: a large-scale population-based cross-sectional study

In the past decade, the incidence of thyroid disorders has been steadily increasing, emerging as a prominent public health concern. Consequently, there is a growing interest in understanding the association between iodine nutritional status and thyroid disorders. We selected 13,487 adults (aged 18-69 years) from the baseline population of Zhejiang Environmental Health Cohort (ZEHC) research. Serum thyroid function indicators, urinary iodine concentration (UIC), and urinary creatinine were measured and an ultrasonography of the thyroid were systematically assessed. Urinary iodine/creatinine ratio (UI/Cr) was calculated to mitigate hydration bias. The median of UIC and UI/Cr were 158.2 (IQR: 97.0-250.5) µg/L and 113.4 (IQR: 69.5-178.4) µg/g, respectively. Excessive iodine intake (UIC ≥ 300 µg/L) increased the risk of subclinical hypothyroidism (adjusted OR 1.451, 95% CI 1.252-1.681), while insufficient iodine intake (UIC < 100 µg/L) reduced this risk (adjusted OR 0.831, 95% CI 0.716-0.965). Conversely, insufficient iodine intake (UIC < 100 µg/L) was associated with elevated thyroid nodule incidence (adjusted OR 1.196, 95% CI 1.099-1.301). After creatinine adjustment, the risk of subclinical hypothyroidism was higher in high (quartile 4) UI/Cr level (adjusted OR 1.520, 95% CI 1.334-1.732), and participants with low (quartile 1) UI/Cr level exhibit a lower risk of subclinical hypothyroidism (adjusted OR 0.624, 95% CI 0.523-0.744). Participants with low (quartile 1) UI/Cr level had a significant increase in the incidence of thyroid nodule (adjusted OR 1.315, 95% CI 1.203-1.437). This large-scale population-based study found that higher iodine level was associated with an increased risk of subclinical hypothyroidism, while lower iodine level was associated with an increased incidence of thyroid nodules.

The additive value of real-time elastography to thyroid ultrasound in detecting papillary carcinoma in nodules over 20 mm in diameter

PURPOSE

Ultrasonography (US) is the most accurate and cost-effective imaging method for identifying thyroid nodules. The difficulty in determining which nodules to sample for fine-needle aspiration (FNA) cytology has prompted the introduction of the Thyroid Imaging Reporting and Data Systems (TIRADS), which assesses the malignancy risk associated with thyroid nodules. Real-time elastography (RTE), coupled with strain ratio (SR) measurements, offers a means to evaluate the nodule stiffness and potentially discern their likelihood of being malignant. The present study aimed to investigate the efficacy of RTE and SR, combined with the TIRADS grading systems, in distinguishing between benign and malignant thyroid nodules.

METHODS

From 1094 patients with thyroid nodules referred for thyroid ultrasound at a University Hospital, those with thyroid nodules ≥20 mm in diameter were enrolled. Each nodule was categorized according to European (EU)- and American College of Radiology (ACR)-TIRADS systems, ranging from 2-5. Nodules' SRs were evaluated together with RTE. The thyroid nodule diagnosis was documented by post-thyroidectomy histopathological examination and/or US-guided FNA according to the Bethesda classification of the examined smears.

RESULTS

The study involved 267 patients (mean age 60.3 ± 14.3 years; 46 males and 221 females) with 308 nodules categorized into EU-TIRADS categories 3, 4, and 5. Of these nodules, 22 proved malignant, and 286 benign. The elastography ratio exhibited high predictive performance in diagnosing thyroid malignancy (p < 0.001) at a threshold value of >0.84 (sensitivity 90.9%, specificity 73.4%). In the 168 nodules with EU-TIRADS 3, this threshold had 100% sensitivity and 75.1% specificity in discriminating malignant thyroid nodules.

CONCLUSION

Combining TIRADS with data derived from RTE reduces unnecessary FNAs and surgeries in patients with thyroid nodular disease.

Can Aggressive Papillary Thyroid Carcinoma Variants With Oncocytıc Morphology (Tall Cell and Hobnail Variants) be Detected Cytologically? Is the Differentiation as Straightforward as Reported?

OBJECTIVE

Identifying aggressive variants of throid papillary carcinoma correctly is paramount, as their diagnosis requires more extensive surgical interventions. Numerous cytologic scoring systems have been proposed to distinguish non-aggressive from aggressive variants. Oncocytic morphology is characterised by cells with abundant granular cytoplasm resulting from mitochondrial accumulation. This feature is particularly prominent in specific PTC variants. Tall cell and hobnail variants are aggressive variants with oncocytic morphology. The present study aims to evaluate the cytomorphological features of 51 histologically confirmed papillary thyroid carcinoma (PTC) cases with oncocytic morphology and to identify cytological features that could facilitate the distinction between aggressive (tall cell and hobnail) and non-aggressive (oncocytic and Warthin-like) variants during the FNA stage, thereby enabling early detection of aggressive variants.

METHODS

We retrospectively examined the cytological features of cases diagnosed with histologically confirmed aggressive variants with poor prognosis (tall cell and hobnail) and non-aggressive variants with good prognosis (oncocytic and Warthin-like), obtained from the pathology department of our hospital between 2014 and 2020.

RESULTS

39 cases (76.5%) classified into the good prognosis group, which included oncocytic variant (O-PTC) (33 cases) and Warthin-like variant (WL-PTC) (6 cases). The poor prognosis group included 12 cases (23.5%), comprising hobnail variant (HN-PTC) (2 cases) and tall cell variant (TC-PTC) (10 cases). The swirl pattern was significantly more frequent in the poor prognosis group (83.3% vs. 43.6%, p = 0.022), with a sensitivity of 83.3% and specificity of 56.4%. The presence of nuclear grooves was observed in all cases of the poor prognosis group (100%) while in 61.5% of the good prognosis group (p = 0.011). This feature exhibited 100% sensitivity and 38.4% specificity. Concerning cytoplasmic volume, scant-medium amount cytoplasmic volume was significantly more common in the poor prognosis group (66.7% vs. 20.5%, p = 0.005), showing 66.7% sensitivity and 79.4% specificity, and yielding the highest accuracy rate (76.4%) among all characteristics.

CONCLUSIONS

Oncocytic morphology-based approaches may help identify poor prognosis variants and guide clinical decisions. In our study, cellular swirls, grooves and scant-medium cytoplasmic volume were the most significant cytological indicators for identifying poor prognosis variants. Despite previous emphasis on cell width/height ratio and foamy INCIs for TC-PTC diagnosis, no significant differences were found between the two groups in our study.

Selective parathyroid autotransplantation prevent permanent hypoparathyroidism after total thyroidectomy with central neck dissection

Background

The impact of parathyroid gland autotransplantation on permanent hypoparathyroidism remains incompletely understood. This study aimed to ascertain how selective autotransplantation of parathyroid glands affects the occurrence of permanent hypoparathyroidism after total thyroidectomy with central neck dissection (CND).

Method

A retrospective cohort study encompassed consecutive patients with papillary thyroid carcinoma who underwent primary total thyroidectomy plus CND from January 2008 to December 2010 and January 2012 to December 2019. Patients were categorized into two groups (0 and ≥1 parathyroid glands autotransplanted, respectively).

Result

The autotransplantation group comprised 501 patients, while the non-autotransplantation group comprised 652 patients. The autotransplantation group showed significantly lower permanent hypoparathyroidism than the non-autotransplantation group [1.2% (6 of 501) vs. 4.4% (29 of 652), P = 0.001]. Out of the total 1,153 patients, 652 (56.5%) had no autotransplanted glands, and 358 (31.0%), 136 (11.8%), and 7 (0.6%) had 1, 2, and 3 glands autotransplanted, respectively. As the number of autotransplanted glands increased (from 0 to 3), the prevalence of permanent hypoparathyroidism was 4.4% (29 of 652), 1.4% (5 of 358), 0.7% (1 of 136), and 0.0% (0 of 7), respectively (P = 0.016). Multivariate logistic analysis revealed that parathyroid autotransplantation independently prevented postoperative permanent hypoparathyroidism.

Conclusion

Selective parathyroid autotransplantation is associated with a lower risk of permanent postoperative hypoparathyroidism. Autotransplantation is recommended for parathyroid glands that are devascularized or challenging to preserve in their original location.

Analysis of risk factors and construction of a predictive model for contralateral occult carcinoma in patients with unilateral papillary thyroid carcinoma

Objective

This study aims to investigate the risk factors associated with contralateral occult carcinoma in patients with unilateral papillary thyroid carcinoma and to develop a corresponding prediction model to enhance early detection and clinical management of occult carcinoma.

Methods

The clinical data of 430 patients who underwent total thyroidectomy for unilateral papillary thyroid carcinoma at Xiangyang Central Hospital between January 2021 and December 2022 were collected. Univariate and multivariate logistic regression analyses were performed to identify risk factors for contralateral occult cancer in patients with unilateral thyroid carcinoma. A prediction model was established, and the diagnostic value of the model was assessed using calibration curves and decision curve analysis.

Results

The results of univariate logistic regression analysis indicated that tumor diameter, tumor location, multifocality, presence of contralateral benign nodules, and lateral neck lymph node metastasis were risk factors for contralateral occult carcinoma in patients with unilateral thyroid cancer (P < 0.05). Multivariate logistic regression analysis further showed that a tumor diameter >1 cm, proximity of the tumor to the isthmus, multifocality, presence of contralateral benign nodules, and lateral neck lymph node metastasis were independent risk factors for contralateral occult carcinoma in unilateral thyroid cancer (P < 0.01). A risk nomogram model was developed based on these five risk factors, with areas under the curve (AUC) of 0.921 and 0.96 for the training and validation sets, respectively. The calibration curve demonstrated good consistency, and decision curve analysis indicated that the model had a high level of net benefit.

Conclusion

A tumor diameter >1 cm, proximity of the tumor to the isthmus, lateral neck lymph node metastasis, presence of contralateral benign nodules, and multifocality are independent risk factors for contralateral occult carcinoma in patients with unilateral papillary thyroid carcinoma. The predictive model developed in this study demonstrates strong predictive ability for the occurrence of contralateral occult carcinoma in patients with unilateral papillary thyroid carcinoma.

Malignant risk of thyroid nodules with isolated macrocalcifications - A study based on surgery results

OBJECTIVE

To determine the malignancy risk of thyroid nodules with Isolated Macrocalcifications (IMC) based on surgical results and evaluate the postoperative risk of malignant nodules with IMC.

METHODS

A total of 46 thyroid nodules with IMC were enrolled from 3680 consecutive patients who underwent thyroidectomy between August 2018 and September 2023. The malignancy risk of IMC nodules, postoperative risk of malignant nodules, and whether the ultrasonic features of IMC (smooth, lobulated, or focal disruption of the anterior margin) were associated with malignancy were investigated. The nodules were further divided into three groups (group A, maximum diameter < 10 mm; group B, maximum diameter of 10‒14 mm and group C, maximum diameter ≥ 15 mm). Differences in malignancy and Lymph Node Metastasis (LNM) risks were also evaluated among the three groups.

RESULTS

The malignancy risk of the IMC nodules was 30.43% (14/46). Four patients developed LNM. Eight nodules were staged as T1aN0M0 and low-risk, whereas six nodules were staged as T1bN1aM0 and intermediate-risk. Focal disruption of the anterior margin of IMC was significantly associated with malignancy. Malignant and LNM risk showed no differences among nodules with different sizes.

CONCLUSIONS

IMC nodules with different sizes had a lower intermediate risk of malignancy and exhibited the same aggressive behavior. The cutoff value of these nodules for further Fine Needle Aspiration (FNA) warranted further investigation. Interruption of IMC was more often seen in malignant nodules, and more attention should be paid to these nodules.

Quality of life in thyroid cancer survivors with and without permanent hypoparathyroidism

PURPOSE

Hypoparathyroidism (HypoPT) is one of the most common complications of surgical treatment for thyroid cancer and afflicated patients often report symptoms or impairments in quality of life (QoL). We aimed to investigate differences in various QoL domains between thyroid cancer survivors with and without permanent hypoparathyroidism.

METHODS

Thyroid cancer survivors with a minimum of 1.5 years post-diagnosis completed the EORTC core questionnaire (EORTC QLQ-C30) and the EORTC thyroid module (QLQ-THY34). Sociodemographic and clinical information were obtained from the patients themselves and their medical charts. Analysis of covariance was used to compare QoL between survivors with and without hypoparathyroidism (adjusting for age, gender, time since diagnosis, and comorbidity).

RESULTS

Of the 126 participants, 21 (17%) were diagnosed with permanent HypoPT. There was no evidence of differences regarding any QoL domain between survivors due to hypoparathyroidism. The symptoms with the highest burden for both groups were fatigue (hypoPT: 24.9; non-hypoPT: 32.8; p = 0.151) and insomnia (hypoPT: 22.2; non-hypoPT: 30.8; p = 0.213). Thyroid cancer specific impairments were observed for joint pain (hypoPT: 28.6; non-hypoPT: 34.0; p = 0.480), worry about important others (hypoPT: 25.8; non-hypoPT: 27.9; p = 0.765), exhaustion (hypoPT: 23.8; non-hypoPT: 27.9; p = 0.482), and lacking social support (hypoPT: 36.5; no-hypoPT: 23.0; p = 0.070).

CONCLUSION

The present study appears to show that QoL in thyroid cancer survivors may be unrelated to hypoparathyroidism, further suggesting a more complex relationship between these two aspects.

FNA-Tg improves the diagnostic efficacy of FNAC for PTC lateral cervical LN metastasis

The detection of thyroglobulin in lymph node (LN) fine needle aspirates (FNA-Tg) is an effective supplement to ultrasound and fine needle aspiration cytology (FNAC) in diagnosis of cervical LN metastases for patients with papillary thyroid carcinoma (PTC). However, there is no unique cutoff value of FNA-Tg in practice. We aimed to determine the optimal cutoff of FNA-Tg and evaluate the interfering factors of FNA-Tg. A serial of 405 lateral cervical LN samples from 317 patients with PTC were analyzed retrospectively. Receiver operating characteristic (ROC) curve was used to determine the optimal cutoff of FNA-Tg. The factors that impact FNA-Tg were evaluated. Serum Tg, serum thyroglobulin antibody (TgAb) and serum thyroid stimulating hormone (TSH) level, and thyroid status did not differ between the malignant and benign LN groups. The median FNA-Tg was 3.81 ng/mL (0.16-33.40 ng/mL) in LNs without metastasis and 310.32 ng/mL (124.41-500.00 ng/mL) in LNs with metastasis, and the differences reached statistical significance (P < 0.01). The optimal cutoff of FNA-Tg was 36.22 ng/mL, and the values of area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was 0.88, 0.89, 0.75, 0.91 and 0.71, respectively. The diagnostic accuracy of FNA-Tg cutoff of 36.22ng/mL was 85%. When FNAC and the present FNA-Tg cutoff of 36.22 ng/mL were combined together, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy was 0.96, 0.75, 0.92, 0.87 and 91%, respectively. FNA-Tg improves the diagnostic efficacy of FNAC for PTC lateral cervical LN metastasis, and the optimal cutoff value of FNA-Tg was 36.22 ng/mL. FNA-Tg was affected by LN status but was not associated with serum Tg, serum TgAb, serum TSH and thyroid status.

Thyroid Diseases in Patients With Pituitary Neuroendocrine Tumours

BACKGROUND

Due to the hypothalamic-pituitary-thyroid axis, thyroid disease is often associated with pituitary neuroendocrine tumours (PitNETs). However, the associations across different PitNETs subtypes remain underexplored. This study investigates the characteristics of thyroid disease in patients with different PitNETs subtypes and evaluates the impact of PitNETs treatment on thyroid disease.

METHODS

A retrospective analysis was conducted on 168 patients with PitNETs who were categorised into 3 groups: GH (n = 53), PRL (n = 65) and NF (n = 50). All patients underwent thyroid ultrasonography, pituitary tests and thyroid function tests before treatment and 1 year after treatment.

RESULTS

Thyroid volume was significantly larger in the GH group (30.78 ± 7.87 mL, p < 0.01). The incidence of thyroid goitre and nodules was markedly higher in the GH group (73.58%, p < 0.01; 54.17%, p < 0.01), with a significantly higher proportion of multiple thyroid nodules in the GH group (79.31%, p < 0.01). Autoimmune thyroiditis was more common in PRL group (18.46%, p = 0.04), associated with elevated TPOAb (169.63 ± 325.28 IU/mL, p = 0.02) and TGAb antibody levels (236.23 ± 379.91 IU/mL, p = 0.02). One-year postoperative follow-up, the postoperative thyroid volume decreased from 23.45 ± 8.99 mL to 20.42 ± 6.48 mL (p < 0.01). The incidence of thyroid goiter decreased from 36.90% to 13.10% (p < 0.01). In patients with autoimmune thyroiditis, TPOAb and TGAb levels decreased significantly after treatment (p = 0.01, p < 0.01, respectively).

CONCLUSION

Increased thyroid volume, goiter and multiple nodules are prevalent in GH-PitNETs patients, while autoimmune thyroiditis predominates in PRL-PitNETs. Treatment of PitNETs alleviates these thyroid manifestations. Routine thyroid ultrasound monitoring is recommended for PitNETs patients.

Preoperative Vitamin D Supplementation to Reduce Hypocalcemia Following Total Thyroidectomy: Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

This study aims to determine whether preoperative supplementation of vitamin D reduces the incidence of hypocalcemia following total thyroidectomy.

METHODS

Conducted in conformity with the PRISMA statement, a systematic review and meta-analysis of randomized clinical trials (RCT) was performed assessing postoperative hypocalcemia and postoperative symptomatic hypocalcemia.

RESULTS

The search strategy yielded 3808 potentially relevant publications, with eight RCTs ultimately included. These eight trials included a total of 902 patients (22.73% male, n = 205/902), with a median age of 48.9 years (95% CI, 43.5-53.5). Four trials administered only vitamin D in the interventional arm, three trials administered both calcium and vitamin D in the interventional arm, and one trial administered vitamin D in the interventional arm and calcium in both arms. Pooled results from the eight included trials showed a reduced risk of postoperative hypocalcemia in the intervention arm (RR, 0.77; 95% CI, 0.62-0.96; p = 0.02). When excluding the studies that administered calcium supplements in addition to vitamin D, the pooled results showed a similar reduced risk of postoperative hypocalcemia (RR, 0.74; 95% CI, 0.57-0.96; p = 0.03). Analysis of six trials reporting the incidence of postoperative symptomatic hypocalcemia (n = 564) showed a reduced risk in the vitamin D arm, with or without calcium, compared to the control arm (RR, 0.56; 95% CI, 0.34-0.93; p = 0.023).

CONCLUSIONS

Our findings suggest that preoperative vitamin D administration, with or without calcium carbonate, significantly reduces the risk of postoperative hypocalcemia and symptomatic hypocalcemia in patients undergoing total thyroidectomy.

LEVEL OF EVIDENCE: 1

Effect of Psychosomatic Symptom Intervention on Psychosomatic Symptoms During Initial Treatment in Patients With Differentiated Thyroid Cancer: A Single-blind Randomized Controlled Trial

BACKGROUND

There is increasing evidence suggesting that patients with thyroid cancer may experience prolonged anxiety and depression postsurgery, which could potentially impact their treatment outcomes adversely.

OBJECTIVES

To investigate the impact of a psychosomatic symptom intervention program on the psychological and physical health of patients with differentiated thyroid cancer (DTC).

METHODS

Eighty-four patients with DTC were recruited from one cancer hospital and were randomly assigned to either the experimental (n = 42) or control group (n = 42). The intervention group received a 12-week psychosomatic symptom intervention. Anxiety and depression, thyroid-stimulating hormone attainment rate, self-management efficacy, and shoulder joint function were evaluated before intervention, after intervention, and during follow-up.

RESULTS

The generalized estimating equation showed that the intervention group had significantly lower levels of anxiety and depression at T1 and T2 compared with the control group (P < .001). The time, group, and interaction effects were significant (P < .001). The thyroid-stimulating hormone target rate in the intervention group (59.5%) was higher than that in the control group (26.2%) (P = .008). There were significant differences in self-management efficacy and shoulder joint function between the 2 groups (P < .001).

CONCLUSIONS

These findings hold significant implications for the psychological and physical symptoms of DTC patients. It suggests that early interventions can expedite patient recovery during the initial treatment phase.

IMPLICATION FOR PRACTICE

During the initial treatment phase, nurses can implement interventions targeting psychological and physical symptoms in DTC patients, aimed at facilitating postoperative self-care and promoting expeditious recovery of overall health.

Impact of Reclassification of Oncocytic and Follicular Thyroid Carcinoma by the 2022 WHO Classification

BACKGROUND

The 2022 WHO Classification categorizes oncocytic (OTC) and follicular thyroid carcinoma (FTC), based on the degree of capsular and vascular invasion, into minimally invasive (MI), encapsulated angio-invasive (EA), and widely invasive tumors (WI). While associations with clinical outcomes have been studied extensively in FTC, robust clinical data are lacking for OTC. We aimed to investigate the impact of the reclassification of OTC and FTC by the 2022 WHO Classification on clinical outcomes.

METHODS

All adult OTC and FTC patients treated at the Erasmus MC (the Netherlands) between 2000 and 2016 were retrospectively included. All tumors were extensively revised by 2 independent pathologists, facilitated by Palga: Dutch Pathology Databank. Kaplan-Meier curves were used to study the association of the 2004 and 2022 WHO Classification with overall survival, disease-specific survival (DSS), recurrence-free survival, and radioactive iodine (RAI)-refractory disease.

RESULTS

Among 52 OTC and 89 FTC patients, 15 (28.8%) OTC and 34 (38.2%) FTC tumors were reclassified as EAOTC or EAFTC. The 2022 WHO Classification substantially improved risk stratification in both subtypes for DSS, compared to the 2004 edition. Ten-year DSS rates were 100% for MIOTC, 92.9% for EAOTC, and 56.5% for WIOTC, compared to 100% (MIOTC) and 64.2% (WIOTC) following the 2004 WHO Classification. For FTC and RAI-refractory disease, similar trends were observed.

CONCLUSION

Classification of OTC and FTC into 3 subcategories as defined by the 2022 WHO Classification substantially improves discrimination between low-, intermediate-, and high-risk patients, especially for DSS and RAI-refractory disease.

Association of Free Thyroxine With Progression-Free Survival in Intermediate and High-Risk Differentiated Thyroid Cancer

CONTEXT

Supraphysiologic T4 doses are used in intermediate- and high-risk patients with differentiated thyroid cancer (IR/HR-DTC) to suppress tumor progression by TSH. However, preclinical data suggest that T4 can also act as a growth stimulus for cancer, but there is no clinical evidence supporting this claim.

OBJECTIVE

We analyzed the association between free T4 (FT4) and progression-free survival (PFS) in patients with IR/HR-DTC.

METHODS

This longitudinal cohort study, approved by multi-institutional review board, included patients with IR/HR-DTC treated uniformly with total thyroidectomy, radioiodine, and TSH suppression therapy, with at least 3 TSH and FT4 values available. Association between FT4 and PFS at landmarks 6, 12, and 18 months was assessed by Kaplan-Meier survival curves, whereas competing risks were assessed through Cox proportional hazards model.

RESULTS

From 739 screened patients, 382 met the inclusion criteria and were characterized by a median age of 46 (34-59) years, 64.1% women, and treated with a median radioiodine dosage of 159 (110-410) mCi. During follow up of 7.1 (3.4-12.7) years, 34.6% experienced disease progression. Elevated FT4, observed in 29.3% of patients, was not associated with worse PFS (hazard ratio [HR], 0.9; CI, 0.54-1.5; P = .69), whereas age (HR, 1.02; CI, 1.004-1.04; P = .01), tumor size (HR, 1.15; CI, 1.04-1.28; P = .01) and metastases to the lateral neck lymph nodes (HR, 2.9; CI, 1.7-4.74; P < .001), bones (HR, 4.87; CI, 1.79-13.3; P = .002), and brain (HR, 5.56; CI; 2.54-12.2; P < .001) were associated with shorter PFS.

CONCLUSION

Contrary to preclinical evidence, elevated FT4 levels do not affect PFS in patients with IR/HR-DTC.

Stimulated Raman Scattering Microscopy Facilitates the Discovery of Diacylglycerol O-Acyltransferase 2 as a Target to Enhance Iodine Uptake in Papillary Thyroid Carcinoma

Radioactive 131I therapy is a primary treatment for papillary thyroid carcinoma (PTC), with approximately 30% of patients developing iodine-refractory disease. There is an urgent clinical need to improve iodine uptake in PTC. Previous research suggested a connection between triglyceride (TG) accumulation and decreased iodine uptake in benign thyroid cells. Notably, TG accumulation has been found to be a marker of aggressive human PTC. Therefore, it is crucial to elucidate whether TG accumulation affects iodine uptake in PTC, which may lead to a new way for enhancement of iodine uptake. Here, by combining stimulated Raman scattering (SRS) microscopy and deuterated Raman tags, we first quantitatively analyzed the level of TG and its source in the K1 cell with low iodine uptake and the TPC-1 cell with high iodine uptake. It was found that K1 cells had significantly greater TG accumulation than TPC-1 cells, primarily due to an increased exogenous uptake of fatty acids. Further RNA-seq transcriptome experiments revealed that the underlying mechanism could be upregulation of lipid biosynthesis, uptake, and transport-related genes, along with down-regulation of fatty acid β-oxidation and lipolysis-related genes in K1 cells. Among the upregulated lipid biosynthesis genes, diacylglycerol O-acyltransferase 2 (DGAT2) is of great importance as the rate-limiting enzyme in TG biosynthesis. Notably, the inhibition of DGAT2 led to a significant increase in the expression of iodine uptake-related proteins, namely, sodium iodide symporter (NIS) and thyroglobulin (Tg), in K1 cells. Further Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses unraveled that DGAT2 inhibition could enhance thyroid hormone synthesis, for which iodine is an essential raw material, by alleviating endoplasmic reticulum stress and upregulating the pathways related to protein glycosylation and transmembrane transport. In summary, our study has shown that SRS microscopy facilitates the discovery of DGAT2 as a potential target to enhance iodine uptake in PTC, which holds promise for improving treatment outcome of iodine-refractory PTC.

Occupational radiation exposure during blood sample collection post I-131 therapeutic administration in thyroid cancer patients

The blood sampling required for the verification of dose delivered during radioactive iodine (131I) therapy is a source of radiation exposure for healthcare staff. This study aims to estimate staff exposures, using Monte Carlo modelling, as well as experimental measurements. The study further aimed to validate the models with staff exposure measurements and examine the impact of protective measures on the procedure. The clinical set-up of blood sampling post131I patient administration, within a dedicated131I ablation therapy suite, was modelled using EGSnrc Monte Carlo simulations (MCSs). The dose scoring regions representing deep dose (Hp(10)) and skin dose (Hp(0.07)) were estimated and validated with an experimental approach and clinical monitoring of staff members using electronic personal dosimeters. MCSs and experimental values did not show significant differences between the two approaches (p> 0.05), with simulated values having lower uncertainties. It is demonstrated that the model is capable of being tailored to clinical scenarios at any centre. The simulations were corroborated with dosimetry data of blood sampling from 14 patients post administering 3.7 GBq131I, amounting to a total of 54 measurements from 14 staff members. With the employed protective shielding, none of the staff were exposed to a dose rate approaching the annual dose constraint of 0.3 mSv.yr-1. The experimental and MCS data show good agreement with the clinical data, demonstrating the advantages of MCS approaches for providing useful information for planning and carrying out risk assessments before implementing a new dosimetry practice.

High Prevalence of Hypercalcitoninemia in a Large Cohort of Adult and Pediatric Patients With PTH Resistance Syndromes

CONTEXT

Pseudohypoparathyroidism (PHP) refers to a group of rare hereditary disorders associated with resistance to parathyroid hormone (PTH) and other hormones now termed inactivating PTH/PTHrP disorders (iPPSD). Hypercalcitoninemia has been seldom reported in small series.

OBJECTIVE

Our aim was to investigate the characteristics of hypercalcitoninemia in pediatric and adult patients with PHP/iPPSD.

METHODS

We retrospectively collected data from 2 cohorts from 2 European endocrinology tertiary centers: the pediatric cohort comprised 88 children with available calcitonin (CT) measurements; the adult cohort included 43 individuals with simultaneous CT and PTH measurements.

RESULTS

In the pediatric cohort, 65.9% had hypercalcitoninemia (median CT 15 ng/L); in the adult cohort 53.5% (mean CT 21.6 ng/L). There was no difference between CT in pediatric and adult population; we observed stable CT levels over a median follow-up of 134.5 months in adults. Notably, no correlations were detected between CT and PTH levels. Other etiologies of hypercalcitoninemia were excluded; adult patients underwent regular thyroid ultrasound to screen for medullary thyroid cancer (MTC). We performed 20 calcium stimulation tests in adult patients. While there was a significant difference in basal and peak CT between our patients, healthy subjects, and subjects with MTC, there was no difference with patients with C-cell hyperplasia.

CONCLUSION

This study underscores the common occurrence of hypercalcitoninemia in both pediatric and adult patients with PHP/iPPSD, in particular with subtypes iPPSD2 and iPPSD3. Furthermore, these patients show hyperresponsiveness to calcium stimulation tests falling between healthy subjects and patients with MTC. These findings contribute to the understanding of CT dynamics in the context of PHP/iPPSD.

Natural History of Cytologically Low-Risk Indeterminate Thyroid Nodules

CONTEXT

Thyroid nodules classified cytologically as low-risk indeterminate lesions (TIR3A) on fine-needle aspiration biopsy (FNAB) present a clinical challenge due to their uncertain malignancy risk.

OBJECTIVE

This single-center study aimed to evaluate the natural history of TIR3A nodules.

METHODS

FNABs performed between July 2017 and December 2019 were retrospectively retrieved and patients, with TIR3A nodules were evaluated at baseline and throughout a follow-up based on ultrasound (US) parameters and clinical data.

RESULTS

The final study group encompassed 371 patients with an initial TIR3A cytological result. Among them, 102 were directed to surgery after the first endocrinological evaluation, and 269 were directed to conservative follow-up. Repeat FNAB was performed in 120 out of 269 and 13 further patients underwent surgery following FNAB repetition. The malignancy rate among TIR3A nodules was 16.5%, with most interventions being performed for reasons unrelated to the TIR3A result. Repeat FNAB provided a more definitive diagnosis in 40% of cases, with a 5% increase in malignancy risk. The remaining patients were monitored with clinical and US follow-up. Among all patients with TIR3A cytology managed conservatively (149 without FNAB repetition and 66 with at least one FNAB repetition), no significant changes in nodule size and/or US pattern were observed during a median follow-up of 3.3 years.

CONCLUSION

These findings suggest that active surveillance is a safe option for managing TIR3A nodules, particularly when no additional risk factors are present. The study highlights the role of repeat FNAB in reducing unnecessary surgeries and underscores the generally indolent nature of TIR3A nodules.

Regulation of PEST-containing nuclear proteins in cancer cells: implications for cancer biology and therapy

The PEST-containing nuclear protein (PCNP) is a nuclear protein involved in the regulation of cell cycle progression, protein degradation, and tumorigenesis. PCNP contains a PEST sequence, a polypeptide structural motif rich in proline (P), glutamic acid (E), serine (S), and threonine (T), which serves as a proteolytic recognition signal. The degradation of specific proteins via the PEST sequence plays a crucial role in modulating signaling pathways that control cell growth, differentiation, apoptosis, and stress responses. PCNP is primarily degraded through the ubiquitin-proteasome system (UPS) and the calpain pathway, with phosphorylation of threonine and serine residues further accelerating its degradation. The ubiquitination of PCNP by the ring finger protein NIRF in an E3 ligase-dependent manner is well documented, along with its involvement in the MAPK and PI3K/AKT/mTOR signaling pathways. Additionally, PCNP is implicated in p53-mediated cell cycle arrest and apoptosis, which are essential for inhibiting tumor growth. To explore the role of PCNP in cancer, this review examines its effects on cell growth, differentiation, proliferation, and apoptosis in lung adenocarcinoma, thyroid cancer, ovarian cancer, and other malignancies derived from glandular epithelial cells. By focusing on PCNP and its regulatory mechanisms, this study provides a scientific basis for further research on the biological functions of the PEST sequence in tumor development and cancer progression.

Data-driven Thyroglobulin Cutoffs for Low- and Intermediate-risk Thyroid Cancer Follow-up: ITCO Real-world Analysis

CONTEXT

The utility of thyroglobulin (Tg) in the follow-up of patients with differentiated thyroid cancer has been well-documented. Although third-generation immunoassays have improved accuracy, limitations persist (interfering anti-Tg antibodies and measurement variability). Evolving treatment strategies require a reevaluation of Tg thresholds for optimal patient management.

OBJECTIVE

To assess the performance of serum Tg testing in 2 populations: patients receiving total thyroidectomy and radioiodine remnant ablation (RRA) or treated with thyroidectomy alone.

DESIGN

Prospective observational study.

SETTING

Centers contributing to the Italian Thyroid Cancer Observatory database.

PATIENTS

We included 540 patients with 5 years of follow-up and negative anti-Tg antibodies.

INTERVENTIONS

Serum Tg levels assessed at 1-year follow-up visit.

MAIN OUTCOME MEASURE

Detection of structural disease within 5 years of follow-up.

RESULTS

After excluding 26 patients with structural disease detected at any time point, the median Tg did not differ between patients treated with or without radioiodine. Data-driven Tg thresholds were established based on the 97th percentile of Tg levels in disease-free individuals: 1.97 ng/mL for patients undergoing thyroidectomy alone (lower than proposed by the Memorial Sloan Kettering Cancer Center protocol and ESMO Guidelines, yet demonstrating good predictive ability, with a negative predictive value of 98% and 0.84 ng/mL for patients receiving postsurgical RRA. High sensitivity and negative predictive value supported the potential of these thresholds in excluding structural disease.

CONCLUSION

This real-world study provides evidence for the continued reliability of 1-year serum Tg levels. The data-driven Tg thresholds proposed offer valuable insights for clinical decision-making in patients undergoing total thyroidectomy with or without RRA.

A Phase I/II Trial of Sapanisertib in Advanced Anaplastic and Radioiodine Refractory Differentiated Thyroid Carcinoma

BACKGROUND

There are limited therapeutic options for patients with recurrent/metastatic anaplastic thyroid carcinoma (ATC) and radioiodine refractory (RAIR) differentiated thyroid carcinoma (DTC) refractory to multikinase inhibitors. This multicenter trial evaluated sapanisertib, a next-generation oral kinase inhibitor of mTOR complexes 1/2, in ATC and RAIR DTC.

METHODS

A safety run-in phase I was followed by nonrandomized phase II trial in ATC, with an exploratory cohort in RAIR DTC. The primary endpoint was the proportion of patients with ATC who were without disease progression at 4 months. Safety and survival outcomes were key secondary endpoints.

RESULTS

Forty-six patients (20 ATC, 26 DTC) were enrolled including 40 (18 ATC, 22 DTC) who received recommended phase II dose of 5 mg daily. Eleven percent [2/18, 95% confidence interval (CI): 1.4-34.7%] of patients with ATC were progression-free at 4 months; 22.2% (4/18) had stable disease as best response. Enrollment in the ATC cohort stopped early with 18 patients out of the proposed 23 due to overall futility. One confirmed partial response (4.5%, 1/22) occurred in RAIR DTC, with stable disease in 63.6% (14/22) patients. Median progression-free survival was 1.6 (95% CI: 0.9-2.8) months and 7.8 (2.0-not reached) months in ATC and DTC, respectively. Grade 3 treatment-related adverse events occurred in 30% of patients who received the phase II dose, with the most common being anorexia, nausea, diarrhea, fatigue, skin rash, and hyperglycemia. Genomic alterations in the PI3K/AKT/mTOR pathway were not associated with response or progression-free survival.

CONCLUSION

Sapanisertib monotherapy did not meet the primary endpoint of this trial (proportion progression-free at 4 months) in ATC and did not show clinically meaningful activity. Clinical trials with alternative therapeutic strategies are needed.

Multimodality Ultrasound Utilizing Microvascular Flow Imaging and Shear Wave Elastography to Guide Fine-Needle Aspiration of Thyroid Lesions: A Prospective Study Validating Pattern-Based Microvascular Classification

Background: Most current guidelines recommend fine-needle aspiration (FNA) biopsy of thyroid nodules based on grayscale ultrasound (GUS) features, but the biopsy rate for benign nodules remains high. Our aim was to construct a new pattern-based microvascular classification (PBMC) for thyroid nodules to develop and validate predictive multimodality US models based on GUS, microvascular flow imaging, and shear wave elastography, and compare FNA decision accuracy with the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). Methods: This prospective study included consecutive patients with thyroid nodules who underwent multimodality US examinations from September 2022 to December 2023. Using PBMC, lesions were divided into three categories: malignant signs (convergence sign, piercing sign, and spoke wheel sign), benign signs (ring sign), and other vascular patterns. Univariate and multivariable logistic regression analyses were conducted to determine the odds ratios (ORs) of US features, including vascular signs, and construct predictive models based on multimodality US. Multimodality US models were validated with internal cross-validation and evaluated based on discrimination, calibration, and decision curve analyses. Results: Overall, 793 thyroid nodules confirmed using pathological analysis (248 benign and 545 malignant) in 599 participants (mean age, 43 years ±11 [SD]) were included. In univariate logistic regression analyses, malignant vascular signs showed a positive association with malignant nodules (OR: 10.43, 95% confidence interval [CI]: 5.76, 18.88; p < 0.01), whereas benign vascular signs were inversely associated with malignancy (OR: 0.10, 95% CI: 0.06, 0.16; p < 0.01). Four multivariable models incorporated GUS features, Young's modulus, and PBMC. The highest area under the receiver operating characteristic curve (AUC) was 0.95 (95% CI: 0.82, 0.97) for the multimodality US model, and the lowest AUC was 0.62 (95% CI: 0.57, 0.66) for ACR TI-RADS based on GUS (p < 0.001). At a 71% risk threshold, multimodality US avoided 27% (95% CI: 21, 34) of FNA procedures, compared with 13% (95% CI: 0, 38) with TI-RADS (p < 0.001). Conclusion: Visual assessment of microvascular morphology patterns may improve differentiation of benign and malignant thyroid nodules and potentially reduce the risk of unnecessary biopsy of benign thyroid nodules.

Delayed Tracheal Perforation After Microwave Ablation of Papillary Thyroid Microcarcinoma: A Case Report and Literature Review

Microwave ablation (MWA) is a relatively new, well-tolerated, minimally invasive approach, developed in recent years as an alternative to surgery for low-risk papillary thyroid microcarcinoma (PTMC). We describe an 81-year-old patient with unifocal PTMC who refused active surveillance and underwent percutaneous MWA. Two weeks after the procedure, the patient presented dyspnea and cough, and delayed tracheal perforation was confirmed by computed tomography. Conservative therapy was chosen as the initial treatment, and the tracheal defect was confirmed healing successfully 1 month later. Radiologists should be aware of the possibility of delayed tracheal perforation following MWA even in the absence of unusual intraoperative events.

Efficacy assessment of repeat iodine-131 treatment in patients with papillary thyroid carcinoma assessed as biochemical incomplete response

PURPOSE

Although most patients with Papillary Thyroid Carcinoma (PTC) have a favorable prognosis, some continue to have elevated serum Thyroglobulin (Tg) levels after surgery and ¹³¹I treatment, classified as a Biochemical Incomplete Response (BIR). According to the 2015 American Thyroid Association (ATA) guidelines, 20% of these patients will develop a Structural Incomplete Response (SIR). Doctors often recommend ¹³¹I retreatment without imaging evidence, hoping for benefits. However, the effectiveness of this treatment strategy is still not supported by evidence. The aim of this study is to explore the potential benefits by comparing Tg levels and their changes in patients who were retreated with 131I and combining them with the results of follow-up assessment using Dynamic Risk Stratification (DRS).

METHODS

This retrospective study collected clinical data from patients with PTC who underwent ¹³¹I therapy after surgery at two medical centers. All of them were evaluated for Biochemical Incomplete Response (BIR) after initial treatment. Based on whether they received ¹³¹I retreatment, they were divided into two groups: the retreatment group and the no-retreatment group. Our primary outcome measures included basic clinical data, suppressed Tg, change in Tg levels, and DRS stratification at the last follow-up. The potential benefits of ¹³¹I retreatment were analyzed by comparing the changes in Tg levels and the DRS distribution at the end of follow-up between the two groups.

RESULTS

Patients with PTC assessed for BIR after initial therapy showed a greater reduction in Tg at short-term follow-up after ¹³¹I retreatment compared to the no retreatment group (0.84 ng/mL vs. 0.72 ng/mL). The one-sample Wilcoxon signed-rank test results were T = 6.001, p < 0.001 and T = 1.378, p = 0.168, respectively. At the end of follow-up, this treatment did not alter the DRS strata composition ratio (R = 3.06, p = 0.39). The area under the receiver operating characteristic curve for pre-ablation stimulated thyroglobulin (Ps-Tg) predicting non-remission status was 0.64 (95% CI: 0.55-0.73), with the highest Youden index (0.26) at a Ps-Tg cutoff of 20.5 ng/mL, corresponding to a sensitivity of 62.6% and a specificity of 63.3%. For the first suppressed Tg (sup-Tg) predicting non-remission, the AUC was 0.75 (95% CI: 0.67-0.84). The highest Youden index (0.40) was achieved at a sup-Tg cutoff of 1.85 ng/mL, corresponding to a sensitivity of 68.9% and a specificity of 70.8%.

CONCLUSION

For patients with PTC who received 131I therapy after surgery and are classified as BIR, 131I retreatment may accelerate the decline in Tg levels over time but does not change the DRS distribution. Only few of patients have structural and/or functional lesions detected on the whole-body scan after 131I retreatment. The Ps-Tg and first sup-Tg values after the first ¹³¹I treatment can help predict a non-remission state, with cutoff values of 20.5 ng/mL and 1.85 ng/mL, respectively.

Low-iodine diet: what to eat and avoid before iodine-131 procedures?

OBJECTIVE

The aim of this study was to compile a list of low-iodine foods for use in the Low-Iodine Diet (LID) to optimize the uptake of Iodine-131 by cells, which is used in the diagnosis and treatment of thyroid gland disorders.

METHODS

A bibliographic research was conducted focusing on the most commonly consumed foods in Brazil. Iodine quantification was derived from both national and international food composition tables, with an emphasis on sources indicating the highest concentrations of this microelement. The foods were organized into categories, and their iodine levels were presented in micrograms per 100 grams of food.

RESULTS

The compiled list includes foods classified into categories such as cereals, legumes, vegetables, fruits, flours, oils, fats, meats, dairy products, and beverages. Foods with more than 50 μg of iodine per 100 g were identified and classified separately. Based on the findings, marine-derived foods should be avoided, while dairy products and eggs can be consumed, provided substitutions are made.

CONCLUSION

Identifying and quantifying low-iodine foods is essential for guiding the LID, making it more effective and better suited to the population's needs. Legumes, vegetables, and most fruits can be consumed in larger quantities, forming the core of the diet.

A Deep Learning Survival Model for Evaluating the Survival Prognosis of Papillary Thyroid Cancer: A Population-Based Cohort Study

BACKGROUND

Deep learning can assess the individual survival prognosis in sizeable datasets with intricate underlying processes. However, studies exploring the performance of deep learning survival in papillary thyroid cancer (PTC) are lacking. This study aimed to construct a deep learning model based on clinical risk factors for survival prediction in patients with PTC.

METHODS

A Cox proportional hazards deep neural network (DeepSurv) was developed and validated by using consecutive patients with PTC from 17 US Surveillance, Epidemiology, and End Results Program (SEER) cancer registries (2000-2020). The performance of the DeepSurv model was further validated on two external test datasets from the University of Texas MD Anderson Cancer Center (MDACC) and The Cancer Genome Atlas (TCGA). Using the survival risk scores at 10 years predicted by the DeepSurv model, we classified patients with PTC into low-risk and high-risk groups and explored their overall survival (OS).

RESULTS

The concordance index of the DeepSurv model for predicting OS was 0.798 in the SEER test dataset, 0.893 in the MDACC dataset, and 0.848 in the TCGA dataset. The DeepSurv model was capable of classifying patients with PTC into low-risk and high-risk groups according to the survival risk scores at 10 years. Patients in the high-risk group had significantly worse OS than patients in the low-risk group in all three test datasets (all P < 0.001).

CONCLUSION

The DeepSurv model was capable of classifying patients with PTC into low-risk and high-risk groups, which may provide important prognostic information for personalized treatment in patients with PTC.

The effect of menopausal hormone therapy on thyroid cancer survivors from the National Health Insurance Database in South Korea cohort

OBJECTIVE

There is a lack of research on how menopausal hormone therapy (MHT) affects the prognosis of postmenopausal thyroid cancer (TC) survivors. This study aimed to evaluate the association between MHT and the risk of death in postmenopausal TC survivors.

METHODS

This retrospective cohort study used the data of women with the diagnostic code for TC from the Korean National Health Insurance Database between 2007 and 2021. The postmenopausal women with TC who received radical treatment such as surgery or/and radioactive iodine therapy were divided into two groups - MHT group and non-MHT group - according to whether or not they received MHT after TC treatment. The risk of death in TC survivors was analysed according to the type and duration of the MHT regimen.

RESULTS

Among postmenopausal TC survivors, the risk of death did not differ between the women with MHT duration > 5 years and the non-MHT group, with a hazard ratio (HR) of 0.964 [95 % confidence interval (CI) 0.697-1.334] (p = 0.826). However, MHT duration < 5 years was associated with increased risk of death, with the MHT group having an HR of 1.744 (95 % CI 1.105-2.753) (p = 0.017) compared with the non-MHT group. A trend was observed towards increased risk of death in women with MHT duration ≤ 6 months, with an HR of 1.703 (95 % CI 0.98-2.962) (p = 0.059). The risk of death did not differ between women with MHT duration > 6 months and women in the non-MHT group (HR 1.205, 95 % CI 0.79-1.839) (p = 0.064). In analyses by MHT regimen, no increase in the risk of death was observed for any MHT regimen for any duration.

CONCLUSION

The risk of death in postmenopausal TC survivors who used MHT for > 5 years did not differ from that of their counterparts who did not use MHT. However, postmenopausal TC survivors who used MHT for < 5 years, particularly those who used MHT for < 6 months, had a higher risk of death than their counterparts who did not use MHT.

Comparison of Tumor Diameter and Tumor Volume in Terms of Aggressive Tumor Behavior and Prognosis in Papillary Thyroid Cancer

BACKGROUND

Tumor diameter may not reflect tumor burden accurately in all cancers. In this study, we aimed to investigate the relationship between tumor volume (TV) and aggressive features and prognosis in papillary thyroid cancer (PTC).

METHODS

Patients diagnosed with single foci PTC were recruited for the study. The largest tumor diameter was considered as the primary tumor diameter. TV was calculated using the formula for an ellipsoid shape, considering the three pathologically specified dimensions. Primary tumor diameter and TV were compared in terms of aggressive tumor characteristics and prognosis.

RESULTS

The data of 118 patients were analyzed. There was no significant relationship between primary tumor diameter and lymph node metastasis (LNM), extrathyroidal extension (ETE), and vascular invasion (p > 0.05 for each). In patients with tumor diameter >2 cm, TV was negatively associated with LNM (p = 0.015). One-unit increase in TV was associated with 1.629 times greater likelihood of absence of LNM (95% CI: 1.099-2.415). When the TV was ≤5.26 cm3, the sensitivity and specificity for the presence of LNM were 88.9% and 75.8%, respectively. Again in this group, the sensitivity for the occurrence of ETE was 100.0% and specificity was 45.7% when the TV was ≤9.49 cm3. There was no significant difference in the five-year disease-free survival between tumor diameter and TV.

CONCLUSIONS

In contrary to studies with other cancer types in the literature, there was a significant but negative relationship between TV and LNM. Further large-scale studies are needed to determine whether TV can be used as a prognostic factor in PTC.

Inflammation and Thyroid Cancer: Deciphering the Role of Blood Immune Indexes

BACKGROUND

Inflammation within tumor microenvironments has been correlated to numerous malignancies. This study aims to explore its significance in thyroid cancer (TC).

METHODS

Retrospective analysis of 157 thyroid carcinomas and 40 benign cases involved initial univariate analysis. The value of neutrophils/value of lymphocytes (NLR), value of platelets/value of lymphocytes (PLR), value of lymphocytes/value of monocytes (LMR), and value of platelets × value of neutrophils/value of lymphocytes (SII) indexes were related to TC characteristics and number and location of involved lymph nodes using χ2 or Fischer's exact tests for categorical variables and Student's t-tests for continuous ones. A 1:1 propensity score matching balanced malignant and benign TC groups based on age, sex, and tumor size was used. Post-matching, a multivariate logistic model integrated sex, age, Central lymph node metastases (CLNM), and SII index. Statistically significant immune index values underwent ROC curve analysis for determining cut-offs. Among the 157 malignant TC, median test and density plots were performed.

RESULTS

The SII index emerged as a predictor of malignancy in both univariate and multivariate analyses (p-value = 0.0202). The ROC curve indicated a cut-off SII value of 465.71, (specificity = 58% [95% CI: 0.43-0.73]; sensitivity = 80% [95% CI: 0.68-0.93]). Median SII index values for tumor sizes of 1 and >1 were 522.8 and 654.8, respectively (p-value = 0.016). When central lymph nodes metastases(CLNMs) was considered (CLNM = 0 vs. CLNM > 0), median SII values were 530.7 and 1121.7, respectively (p-value = 0.011).

CONCLUSIONS

The SII index appears to be a valuable tool in the presence of TC, showing correlations with malignancy, tumor size, and CLNMs.

Comparison of K-TIRADS, EU-TIRADS and ACR-TIRADS Guidelines for Malignancy Risk Determination of Thyroid Nodules

Background/Objectives: Thyroid nodules are commonly observed in neck ultrasonography. Most nodules are benign; hence, several nodules require biopsy to accurately identify the malignant ones. Numerous risk classification guidelines have been developed for thyroid nodules, varying in their indications for fine-needle aspiration biopsy (FNAB). The aim of this study is to evaluate the performances of three internationally recognized thyroid imaging reporting and data systems (TIRADS) for risk stratification of malignancy in comparison to one another. Methods: A total of 225 thyroid nodules with definitive FNAB cytology or histopathological diagnoses were included in this study. Various ultrasound (US) features were classified into categories based on three TIRADS editions. The guidelines were assessed regarding sensitivity, specificity, predictive values, and diagnostic accuracy to compare diagnostic value. Results: The American College of Radiology (ACR)-TIRADS demonstrated the best diagnostic accuracy (63.1%), the highest specificity (58.7%) and positive predictive value (36.3%), among three different TIRADS systems. Korean (K)-TIRADS exhibited the highest sensitivity (94.2%), negative predictive value (96.1%), and the most favorable negative likelihood ratio (0.13). The European (EU)-TIRADS had a sensitivity of 90.4%, specificity of 48.6%, and diagnostic accuracy of 58.2%, ranking between the other two guidelines across most parameters. Conclusions: The rigorous use of the guidelines established by each of the three TIRADS systems would have markedly reduced the number of FNABs performed. The comparison of the three guidelines in our study indicated that they are effective screening methods for identifying malignant thyroid nodules. Among them, K-TIRADS showed the most effective diagnostic performance in sensitivity, while ACR-TIRADS yielded the best specificity.

Neuroinflammation in diabetic peripheral neuropathy and therapeutic implications

Diabetic peripheral neuropathy (DPN) is a serious complication of diabetes mellitus, which is a common cause of disability in individuals with diabetes mellitus. Multiple mechanisms may be involved in the development of DPN. Neuroinflammation is a critical factor contributing to nerve damage during diabetes. Inflammation can induce the development of diabetes mellitus, and long-term hyperglycemia also causes increased oxidative stress and promotes the release of inflammatory cytokines. After reading through the literature, the association of inflammation with the induction of diabetes and DPN was discussed in the review. Inflammation induces nerve damage and nerve conduction impairment. The neuropathic pain in diabetes-induced DPN is also closely associated with the inflammatory response. Given the important roles of inflammation in diabetes-induced DPN, explicit elucidation of neuroinflammation during diabetes mellitus and DPN should hold the potential for developing novel therapeutic strategies for DPN. Experimental studies and limited clinical trials support the value of anti-inflammatory reagents in treating DPN, and the positive outcomes of these investigations warrant further clinical trials.

Prevalence and Clinical Impact of BRAF p.V600E Mutation in Papillary Thyroid Carcinoma

Identifying risk factors in papillary thyroid carcinoma (PTC) that warrant more aggressive treatment is paramount. Importantly, the prevalence and clinical significance of BRAF p.V600E mutation in PTC remain debatable. This study aims to determine the association of BRAF p.V600E with demographic and clinicopathologic characteristics, including recurrence. Single institution data from consecutive PTC patients with BRAF p.V600E immunohistochemistry and/or molecular testing was collected between 2018 and 2022, including BRAF status, morphologic subtype, TN category, tumor size, nodal disease burden, tumor multifocality, extrathyroidal extension, treatment, follow-up time, loco-regional and distant recurrence, and mortality. This study included 301 patients, 30% male. The majority had BRAF p.V600E mutation (78.7%), and BRAF p.V600E was associated with morphologic subtype (p < 0.001), with 88% of classic subtype PTCs, 38% of PTCs with extensive follicular growth, and 100% of tall cell subtype expressing BRAF p.V600E. BRAF p.V600E was not associated with tumor size (p = 0.696) or nodal disease burden (p = 0.962). On multivariate analysis using Cox proportional hazard model, large volume nodal disease burden (HR 3.37, 95%CI 1.49-7.64, p = 0.004) and male gender (HR 2.29, 95%CI 1.23-4.26, p = 0.009) were significantly associated with recurrence. BRAF p.V600E (HR 0.71, 95% CI 0.31-1.65, p = 0.4) was not significantly associated with recurrence. In conclusion, presence of BRAF p.V600E in the absence of high risk histologic features does not have an impact on PTC recurrence, and thus, its utility in risk stratification is questionable in the setting of other clinicopathologic risk factors.

The ability of anexelekto (AXL) expression and TERT promoter mutation to predict radioiodine-refractory differentiated thyroid carcinoma

BACKGROUND

Differentiated thyroid carcinoma (DTC) generally has a favourable prognosis with standard treatments; however, the risks of local recurrence and distant metastases remain a concern, affecting a substantial proportion of patients. Radioactive iodine (RAI) refractoriness further complicates DTC management, leading to substantially reduced survival rates. In this study, we aimed to identify anexelekto (AXL) expression and TERT promoter mutation as potential predictors of RAI-refractory DTC.

METHODS

We conducted a retrospective analysis of 81 DTC patients who underwent thyroidectomy and received at least two courses of RAI therapy. After a median follow-up period of 30 months (range: 6-60 months), therapy response was categorized as nonrefractory or refractory. AXL expression and TERT promoter mutation were evaluated in all patients to discern any associations with the development of RAI refractoriness.

RESULTS

The overall prevalence of refractory RAI in DTC patients was 44.4% (36/81). AXL expression was high in 30/36 patients (83.3%) with RAI-refractory DTC and negative/low in 24/45 patients (53.3%) with non-RAI-refractory DTC (OR adjusted: 44.98, CI 95%: 1.41-1439.03, p = 0.031). TERT promoter mutation occurred in 21/36 (58.3%) RAI-refractory DTCs and in 2/45 (4.4%) non-RAI-refractory DTCs (OR adjusted: 10.95, CI 95%: 1.06-112.92, p = 0.044). Despite similar age, sex, and histological type distributions between the RAI-refractory and non-RAI-refractory groups, significant differences in clinicopathological characteristics emerged. Multivariate analysis confirmed that aggressive subtype, elevated AXL expression, and TERT promoter mutation independently correlated with RAI-refractory status.

CONCLUSIONS

Our predictive model highlights the association of elevated AXL expression, TERT promoter mutation, and an aggressive tumour subtype with the risk of RAI refractoriness. This information has the potential to aid in making informed treatment decisions. Furthermore, AXL is a potential therapeutic target for RAI-refractory disease.