Well differentiated thyroid carcinoma: current treatment

An integrated nomogram combining deep learning, clinical characteristics and ultrasound features for predicting central lymph node metastasis in papillary thyroid cancer: A multicenter study

OBJECTIVE

Central lymph node metastasis (CLNM) is a predictor of poor prognosis for papillary thyroid carcinoma (PTC) patients. The options for surgeon operation or follow-up depend on the state of CLNM while accurate prediction is a challenge for radiologists. The present study aimed to develop and validate an effective preoperative nomogram combining deep learning, clinical characteristics and ultrasound features for predicting CLNM.

MATERIALS AND METHODS

In this study, 3359 PTC patients who had undergone total thyroidectomy or thyroid lobectomy from two medical centers were enrolled. The patients were divided into three datasets for training, internal validation and external validation. We constructed an integrated nomogram combining deep learning, clinical characteristics and ultrasound features using multivariable logistic regression to predict CLNM in PTC patients.

RESULTS

Multivariate analysis indicated that the AI model-predicted value, multiple, position, microcalcification, abutment/perimeter ratio and US-reported LN status were independent risk factors predicting CLNM. The area under the curve (AUC) for the nomogram to predict CLNM was 0.812 (95% CI, 0.794-0.830) in the training cohort, 0.809 (95% CI, 0.780-0.837) in the internal validation cohort and 0.829(95%CI, 0.785-0.872) in the external validation cohort. Based on the analysis of the decision curve, our integrated nomogram was superior to other models in terms of clinical predictive ability.

CONCLUSION

Our proposed thyroid cancer lymph node metastasis nomogram shows favorable predictive value to assist surgeons in making appropriate surgical decisions in PTC treatment.

Coexistence of submandibular epithelioid angiosarcoma and papillary thyroid carcinoma: A case report

INTRODUCTION

Reports on the coexistence of epithelioid angiosarcoma (EA) and papillary thyroid carcinoma (PTC) are rare. Over the past 50 years, only 2 cases of coexistence of EA and PTC have been reported in English literature. Therefore, we report a rare case of coexistence of EA and PTC treated with surgery and adjuvant radiation therapy.

PATIENT CONCERNS

A 64-year-old man visited our hospital with a painless mass in the left submandibular gland, with poor mobility.

DIAGNOSIS

Neck ultrasonography revealed nodules in the left submandibular gland and multiple cystic-solid mixed nodules in the left thyroid gland. Pathological findings revealed coexistence of EA in the left submandibular gland area and PTC in the left thyroid gland.

INTERVENTIONS

The patient underwent resection of the left submandibular gland, deep maxillofacial tumor, total thyroidectomy, left neck I, II, III, and VI regional lymph node dissection, and recurrent laryngeal nerve exploration under general anesthesia. Two months postoperatively, the patient also received adjuvant radiation therapy in the local and adjacent areas, with 4MV-X IMRT DT50GY at 2Gy/day 25 fractions.

OUTCOMES

The follow-up period was 37 months. The patient recovered well without focal neurological deficits, local recurrence, or distant metastasis after surgery, except for grade I skin reaction after adjuvant radiation therapy.

CONCLUSIONS

This is a rare case report of the coexistence of EA in the left submandibular gland and PTC in the left thyroid gland. Although multiple examinations were used, precise preoperative diagnosis was challenging owing to the coexistence of EA and PTC. Surgery and radiotherapy were effective treatments for the coexistence of EA and PTC in this case.

The Impact of the Extent of Surgery on the Long-Term Outcomes of Patients with Low-Risk Differentiated Non-Medullary Thyroid Cancer: A Systematic Meta-Analysis

Recently, the management of patients with low-risk differentiated non-medullary thyroid cancer (DTC), including papillary and follicular thyroid carcinoma subtypes, has been critically appraised, questioning whether these patients might be overtreated without a clear clinical benefit. The American Thyroid Association (ATA) guideline suggests that thyroid lobectomy (TL) could be a safe alternative for total thyroidectomy (TT) in patients with DTC up to 4 cm limited to the thyroid, without metastases. We conducted a meta-analysis to assess the clinical outcomes in patients with low-risk DTC based on the extent of surgery. The risk ratio (RR) of recurrence rate, overall survival (OS), disease-free survival (DFS) and disease specific survival (DSS) were estimated. In total 16 studies with 175,430 patients met the inclusion criteria. Overall, low recurrence rates were observed for both TL and TT groups (7 vs. 7%, RR 1.10, 95% CI 0.61-1.96, I² = 72%), and no statistically significant differences for OS (TL 94.1 vs. TT 94.4%, RR 0.99, CI 0.99-1.00, I² = 53%), DFS (TL 87 vs. TT 91%, RR 0.96, CI 0.89-1.03, I² = 85%), and DSS (TL 97.2 vs. TT 95.4%, RR 1.01, CI 1.00-1.01, I² = 74%). The high degree of heterogeneity of the studies is a notable limitation. Conservative management and appropriate follow-up instead of bilateral surgery would be justifiable in selected patients. These findings highlight the importance of shared-decision making in the management of patients with small, low-risk DTC.

Role of ultrasonographic features and quantified BRAFV600E mutation in lymph node metastasis in Chinese patients with papillary thyroid carcinoma

The association between cervical lymph node metastasis (LNM) and ultrasonographic features as well as BRAF^V600E mutations in patients with papillary thyroid carcinoma (PTC) remained controversial. This study investigated the association between LNM and ultrasonographic features as well as BRAF^V600E mutation in Chinese patients with PTC. A total of 280 patients with PTC in China were included in this study. 108 had cervical lymph node metastasis, while 172 had not. Younger age (<45years) and several ultrasonographic features were significantly associated with cervical LNM (Ps < 0.05). The BRAF^V600E mutation was detected in 81.0% of patients with PTC (226/280). The status of BRAF^V600E mutation was not associated with cervical LNM. However, Ct values by PCR and intensity of reactions by immunohistochemistry (IHC) for BRAF^V600E expression had shown significant difference between group with and without LNM. Furthermore, an increased proportion of LNM was also found with the incremental intensity of IHC for BRAF^V600E expression from weak to strong reaction after adjusted potential confounders. Further studies are required to verify this association and explore the intrinsic mechanism.

Punicalagin induces senescent growth arrest in human papillary thyroid carcinoma BCPAP cells via NF-κB signaling pathway

Papillary thyroid carcinoma (PTC) is the most common endocrine carcinoma. Our previous study revealed that punicalagin (PUN), an active component from pomegranate, triggered autophagic cell death and DNA damage response (DDR) in papillary thyroid carcinoma BCPAP cells. But the detailed anti-cancer mechanisms of punicalagin against PTC still remained to be further explored. DDR activation is a proven cause of cellular senescence, which mediates anti-tumor processes under certain circumstances. In this study, we reported that punicalagin treatment generated a senescent phenotype of BCPAP cells characterized as altered morphology, increased cell granularity and senescence-associated β-galactosidase (SA-β-Gal) staining. Senescence induced by punicalagin treatment was further confirmed by cell cycle arrest and upregulation of cyclin-dependent kinase inhibitor p21. Meanwhile, the senescence-associated secretory phenotype (SASP) included high levels of inflammatory cytokines, principally IL-6 and IL-1β. Furthermore, punicalagin exposure caused the phosphorylation and subsequent degradation of IκBα as well as the nuclear translocation of p65, suggesting the activation of NF-κB signaling pathway. Inhibition of NF-κB by pyrrolidine dithiocarbamate (PDTC), a selective inhibitor of NF-κB, partially reversed the cellular senescent phenotype induced by punicalagin in BCPAP cells as evidenced by the decreased fraction of SA-β-Gal staining positive cells and blockage of SASP generation. These results collectively showed that punicalagin treatment induced senescent growth arrest and SASP via triggering NF-κB activation. These observations elucidated novel anti-cancer mechanisms of punicalagin and might provide new potential prospects for PTC therapy.

IAPs cause resistance to TRAIL-dependent apoptosis in follicular thyroid cancer

Follicular thyroid cancer's (FTC) excellent long-term prognosis is mainly dependent on postoperative radioactive iodine (RAI) treatment. However, once the tumour becomes refractory, the 10-year disease-specific survival rate drops below 10%. The aim of our study was to evaluate the prognostic and biological role of the TRAIL system in FTC and to elucidate the influence of small-molecule-mediated antagonisation of inhibitor of apoptosis proteins (IAPs) on TRAIL sensitivity in vitro Tissue microarrays were constructed from forty-four patients with histologically confirmed FTC. Expression levels of TRAIL and its receptors were correlated with clinicopathological data and overall as well as recurrence-free survival. Non-iodine-retaining FTC cell lines TT2609-bib2 and FTC133 were treated with recombinant human TRAIL alone and in combination with Smac mimetics GDC-0152 or Birinapant. TRAIL-R2/DR5 as well as TRAIL-R3/DcR1 and TRAIL-R4/DcR2 were significantly higher expressed in advanced tumour stages. Both decoy receptors were negatively associated with recurrence-free and overall survival. TRAIL-R4/DcR2 additionally proved to be an independent negative prognostic marker in FTC (HR = 1.446, 95% CI: 1.144-1.826; P < 0.001). In vitro, the co-incubation of Birinapant or GDC-0152 with rh-TRAIL-sensitised FTC cell lines for TRAIL-induced apoptosis, through degradation of cIAP1/2. The TRAIL system plays an important role in FTC tumour biology. Its decoy receptors are associated with poor prognosis as well as earlier recurrence. The specific degradation of cIAP1/2 sensitises FTC cells to TRAIL-induced apoptosis and might highlight a new point of attack in patients with RAI refractory disease.

A novel integrative risk index of papillary thyroid cancer progression combining genomic alterations and clinical factors

Although the majority of papillary thyroid cancer (PTC) is indolent, a subset of PTC behaves aggressively despite the best available treatment. A major clinical challenge is to reliably distinguish early on between those patients who need aggressive treatment from those who do not. Using a large cohort of PTC samples obtained from The Cancer Genome Atlas (TCGA), we analyzed the association between disease progression and multiple forms of genomic data, such as transcriptome, somatic mutations, and somatic copy number alterations, and found that genes related to FOXM1 signaling pathway were significantly associated with PTC progression. Integrative genomic modeling was performed, controlling for demographic and clinical characteristics, which included patient age, gender, TNM stages, histological subtypes, and history of other malignancy, using a leave-one-out elastic net model and 10-fold cross validation. For each subject, the model from the remaining subjects was used to determine the risk index, defined as a linear combination of the clinical and genomic variables from the elastic net model, and the stability of the risk index distribution was assessed through 2,000 bootstrap resampling. We developed a novel approach to combine genomic alterations and patient-related clinical factors that delineates the subset of patients who have more aggressive disease from those whose tumors are indolent and likely will require less aggressive treatment and surveillance (p = 4.62 × 10-10, log-rank test). Our results suggest that risk index modeling that combines genomic alterations with current staging systems provides an opportunity for more effective anticipation of disease prognosis and therefore enhanced precision management of PTC.

Selectively false-positive radionuclide scan in a patient with sarcoidosis and papillary thyroid cancer: a case report and review of the literature

Background

Radioiodine and Tc-99 m pertechnetate scans are routinely relied upon to detect metastasis in papillary thyroid cancer; false-positive scans are relatively rare. To our knowledge, no published reports exist of sarcoidosis causing such selectively false-positive scans.

Methods

We present a case of a 41-year-old woman with known metastatic papillary thyroid cancer (T1bN1aMx) in whom sarcoidosis-affected cervical and mediastinal lymph nodes demonstrated uptake of thyroid-targeting radionuclides. Only the minority of these nodes demonstrated radionuclide uptake, raising the suspicion of adjacent or coexisting sarcoid and metastatic involvement. Selective uptake of thyroid-targeted radionuclides by isolated sarcoidosis is, to our knowledge, a previously undocumented occurrence.

Results

Biopsies of uptake-negative mediastinal nodes revealed sarcoidosis. Pathology from a subsequent neck dissection excising uptake-positive cervical nodes also showed sarcoidosis, with no coinciding malignancy.

Conclusions

We document a case of sarcoidosis causing a selectively false-positive thyroid scintigraphy scan. It is useful for clinicians to be aware of potential false-positives and deceptive patterns on radionuclide scans when managing patients with both well-differentiated thyroid cancer and a co-existing disease affecting the nodal basins draining the thyroid gland.

Differentiated thyroid cancer: focus on emerging treatments for radioactive iodine-refractory patients

BACKGROUND

The treatment of differentiated thyroid cancer refractory to radioactive iodine (RAI) had been hampered by few effective therapies. Recently, tyrosine kinase inhibitors (TKIs) have shown activity in this disease. Clinical guidance on the use of these agents in RAI-refractory thyroid cancer is warranted.

MATERIALS AND METHODS

Molecular mutations found in RAI-refractory thyroid cancer are summarized. Recent phase II and III clinical trial data for TKIs axitinib, lenvatinib, motesanib, pazopanib, sorafenib, sunitinib, and vandetinib are reviewed including efficacy and side effect profiles. Molecular targets and potencies of these agents are compared. Inhibitors of BRAF, mammalian target of rapamycin, and MEK are considered.

RESULTS

Routine testing for molecular alterations prior to therapy is not yet recommended. TKIs produce progression-free survival of approximately 1 year (range: 7.7-19.6 months) and partial response rates of up to 50% by Response Evaluation Criteria in Solid Tumors. Pazopanib and lenvatinib are the most active agents. The majority of patients experienced tumor shrinkage with TKIs. Common adverse toxicities affect dermatologic, gastrointestinal, and cardiovascular systems.

CONCLUSION

Multiple TKIs have activity in RAI-refractory differentiated thyroid cancer. Selection of a targeted agent should depend on disease trajectory, side effect profile, and goals of therapy.

Protection of parathyroid function using carbon nanoparticles during thyroid surgery

OBJECTIVE

To investigate the hypothesis that injected carbon nanoparticle (CN) suspension helps identify parathyroid glands (PGs) during thyroid cancer surgery, thereby reducing PG injury.

STUDY DESIGN

A prospective, randomized controlled trial. Setting Sun Yet-san Memorial Hospital, Guangzhou, China.

SUBJECTS AND METHODS

Thyroid cancer surgeries were performed on 72 consenting patients who were randomized for conventional surgery (control group) or surgery with CN suspension injection (CN group). The primary end point was the prevalence of symptomatic hypocalcemia and serum calcium levels <1.9 mmol/L.

RESULTS

From 36 patients diagnosed with thyroid cancer in each group, symptomatic hypocalcemia was found in 10 patients without CN injection and 3 patients with CN suspension injection (P = .032). In total, 5.6% of patients in the CN group presented with muscle cramps compared with 22.2% of the control group (P = .041), which showed a significant difference.

CONCLUSION

Our randomized study revealed that CN suspension injection was feasible and appeared to be beneficial for patients undergoing thyroid surgery because the incidence of symptomatic hypocalcemia was lower compared with controls. Therefore, this technology and technique should be more widely considered for thyroid cancer therapy. Additional studies with more patients and longer follow-up times will be needed for a thorough evaluation of this methodology.