Anaplastic Thyroid Cancer Successfully Treated With Radiation and Immunotherapy: A Case Report

Recurrent Poorly Differentiated Thyroid Cancer Successfully Treated With Radiation and Immunotherapy

A 65-year-old patient presented with recurrent, locally advanced poorly differentiated thyroid cancer despite 2 neck surgeries, and with newly diagnosed brain and skull base metastases. He was treated with palliative stereotactic radiosurgery to the brain and skull base lesions. Thereafter, as no targetable genetic alteration was identified and antiangiogenic multikinase inhibitors were deemed at high risk of hemorrhagic complications, off-label systemic therapies were considered. The mechanistic target of rapamycin (mTOR) inhibitor everolimus could not be obtained due to lack of insurance coverage, so the patient was treated with single-agent pembrolizumab. He showed an initial remarkable response, but unfortunately had disease progression in the neck and upper mediastinum after 1 year of therapy. At that time, he was treated with external beam radiotherapy, with concomitant pembrolizumab. He was then found to have an CTSB::ALK fusion, which has previously been described in 2 cases of thyroid cancer. However, as he showed a positive response to radiation with pembrolizumab, he continued single-agent immune checkpoint inhibition and had a persistent marked response almost a year after completing radiation. The patient was then followed at an outside institution and was transitioned to hospice at time of progression per his preference. He died 4 years after his initial diagnosis.

Exploring the role of immunotherapy in the management of follicular cell-derived thyroid cancer

Anaplastic and poorly differentiated thyroid carcinomas are the two most aggressive forms of thyroid cancers and carry significant morbidity and mortality despite multimodal therapeutic approaches. Anaplastic thyroid carcinoma (ATC) and, to a lesser degree, poorly differentiated thyroid carcinoma (PDTC) have a high tumor mutation burden, and immunologically hot tumor microenvironment when compared to well-differentiated thyroid carcinomas. As such, immunotherapy, and in particular immune checkpoint inhibitors, have been hypothesized to be effective against these cancers. This review aims to explore the biological rationale for immunotherapy in dedifferentiated thyroid carcinomas and to summarize the current evidence underlying this treatment modality.

Initial Management of BRAF V600E-Variant Anaplastic Thyroid Cancer: The FAST Multidisciplinary Group Consensus Statement

Importance

BRAF/MEK inhibitors revolutionized the treatment of BRAF V600E-variant anaplastic thyroid carcinoma (BRAFv-ATC), offering improved outcomes for patients with this previously incurable disease.

Observations

Anaplastic thyroid carcinoma (ATC) accounts for approximately half of thyroid cancer-related deaths. It presents as a rapidly growing tumor that often invades locoregional structures and spreads to distant sites early; therefore, prompt diagnosis, staging, and treatment initiation are of the essence in the treatment of ATC. Although most oncologists will encounter a patient with ATC in their practice, the rarity of this disease makes treatment challenging, particularly because those with BRAFv-ATC no longer have a dismal prognosis. BRAF/MEK kinase inhibitors have transformed the outlook and treatment of BRAFv-ATC. Therefore, molecular profiling to identify these patients is critical. More recently, the addition of immunotherapy to BRAF/MEK inhibitors as well as the use of the neoadjuvant approach were shown to further improve survival outcomes in BRAFv-ATC. Many of these recent advances have not yet been incorporated in the currently available guidelines, allowing for disparities in the treatment of patients with BRAFv-ATC across the US. With the increasing complexity in the management of BRAFv-ATC, this Consensus Statement aims to formulate guiding recommendations from a group of experts to facilitate therapeutic decision-making.

Conclusions and Relevance

This Consensus Statement from the FAST (Facilitating Anaplastic Thyroid Cancer Specialized Treatment) group at MD Anderson Cancer Center emphasizes that rapid identification of a BRAF V600E pathogenic variant and timely initiation of sequential therapy are critical to avoid excess morbidity and mortality in patients with BRAFv-ATC. In the past decade, remarkable progress has been made in the treatment of patients with BRAFv-ATC, justifying these new evidence-based recommendations reached through a consensus of experts from a high-volume center.

Neoadjuvant treatment with lenvatinib and pembrolizumab in a BRAF V600E-mutated anaplastic thyroid cancer: a case report

Background

Tyrosine kinase inhibitors (TKIs) and immunotherapy have been proposed for advanced metastatic anaplastic thyroid cancer (ATC). We report a case of BRAF V600E-mutated ATC in which lenvatinib (L) plus pembrolizumab (P) enabled neoadjuvant treatment.

Case presentation

A male patient aged 65 years presented with a rapidly enlarging left latero-cervical mass. Fine needle aspiration was suggestive of ATC. Surgical consultation excluded radical surgery. While awaiting molecular profile analysis and considering the fast evolution of the disease, treatment with L and P was started. L was started at a dose of 14 mg daily, while P was started at the standard regimen (200 mg every 3 weeks). After 1 month, computerized tomography showed a reduction in the mass with almost complete colliquative degeneration, and the carotid artery wall was free from infiltration. Radical surgery was performed. Histology confirmed papillary thyroid cancer (PTC) in the left lobe and ATC with extensive necrosis in the left latero-cervical lymph node metastasis. The margins were free of tumors (R0). A BRAF V600E mutation was present in both PTC and ATC. At the 1-year follow-up, the patient was free of disease.

Conclusion

L and P in combination also appeared to be effective as a neoadjuvant treatment for BRAF V600E-mutated ATC. This combination treatment could be used when there is an opportunity for complete resection of the cancer, and as soon as possible. The intermediate dose of 14 mg of L appeared to be well tolerated and effective.

Tumor microenvironment in thyroid cancer: Immune cells, patterns, and novel treatments

The tumor immune microenvironment of thyroid cancer is the heterogeneous histological space in which tumor cells coexist with host cells. Published data from this review were identified by search and selection database of Pubmed, Elsevier, and Science Direct. Searching was made in two steps using different keywords. In thyroid pathology, the inflammatory response is very important, and might have a key role finding new diagnostic and therapeutic methods, particularly in thyroid cancer. Different immune cells may be more or less present in different types of thyroid cancer and may even have different functions, hence the importance of knowing their presence in different thyroid tumor pathologies. Cancer-related inflammation could be a useful target for new diagnostic and therapeutic strategies by analyzing peritumoral and intratumoral immune cells in different types of thyroid tumors. Moreover, novel strategies for thyroid cancer treatments, such as monoclonal antibodies targeting checkpoint inhibitors, are emerging as promising alternatives.

Radiotherapy combined with immunotherapy successfully treated one case of anaplastic thyroid cancer: A case report

Background

Anaplastic thyroid cancer (ATC) is a rare but highly fatal form of thyroid cancer. This highly malignant tumor progresses rapidly and is prone to relapse and metastasis, with a poor prognosis. Novel treatments have improved survival in recent years, but the outcome of treatment is not satisfactory.

Case presentation

We report a case of multiple postoperative recurrences of papillary thyroid carcinoma that later transformed into undifferentiated carcinoma. The patient's neck mass was huge and the operation was unsuitable. Then, she achieved remarkable tumor shrinkage by tislelizumab immunotherapy combined with radiotherapy.

Conclusion

This case indicates that radiotherapy combined with immunotherapy is a promising treatment for ATC. Such a combined approach warrants further study.

Combination of Novel Therapies and New Attempts in Anaplastic Thyroid Cancer

Anaplastic thyroid cancer (ATC) is one of the most lethal human malignancies, and it is rapidly falling without any effective therapeutic options. Although radical surgery, radiotherapy, and chemotherapy are performed on patients, the curative effect is suboptimal, and the survival rate is still poor. The discovery of altered gene pathways involved in this aggressive disease has advanced, but molecular targeted drugs targeting these pathways are still in clinical trials. To date, there is no effective way to treat this disease, so it is particularly urgent to find new treatments. At present, multimodal therapy is gradually being applied in clinical practice, which provides a new possibility for prolonging the survival time and improving the prognosis of anaplastic thyroid carcinoma. In this study, we retrospectively analyzed the current clinical multimodal therapy for patients with anaplastic thyroid cancer to evaluate its effect on improving the survival of patients with anaplastic thyroid cancer at different stages.

Anaplastic Thyroid Cancer: New Horizons and Challenges

Anaplastic thyroid cancer (ATC) remains one of the most aggressive and deadliest malignancies. Traditionally, treatment consisted of cytotoxic chemotherapy and radiation therapy, with or without surgery, although a large proportion of patients were often directed toward palliative/hospice care. In the past decade, significant advances have been made through the advent of targeted therapies and immunotherapy. For patients with targetable disease and considerable treatment response, surgery and other multidisciplinary adjuvant therapies can now be considered. Overall, the era of untreatable ATC is progressively being replaced by highly personalized multidisciplinary therapies, actively shifting the treatment pendulum of this disease.

High Expression of THBS1 Leads to a Poor Prognosis in Papillary Thyroid Cancer and Suppresses the Anti-Tumor Immune Microenvironment

Objectives: To study the role of thrombospondin-1 (THBS1) in papillary thyroid cancer (PTC) prognosis and the immune microenvironment. Methods: A retrospective cohort study was designed, and data from The Cancer Genome Atlas database and PTC tissues from Fudan University Shanghai Cancer Center were used. Weighted gene co-expression network analysis was performed to build a THBS1-immune-related gene prognostic index (T-I index). Results: High THBS1 expression was correlated with advanced TNM stage, higher recurrence risk, and shorter progression-free interval. High THBS1 expression correlated with MAPK and PD1 pathways indicating a tumor promoting and immunity-inhibiting tendency. The T-I index showed a powerful capacity to predict progression-free survival and immunotherapy benefit. Conclusion: High expression of THBS1 leads to a poor prognosis in PTCs and suppresses the anti-tumor immune microenvironment.