Management of Papillary Thyroid Microcarcinoma

Comparison of Ultrasound-Guided Percutaneous Microwave Ablation and Conventional Thyroidectomy in the Treatment of Papillary Thyroid Microcarcinoma: Meta-Analysis

Purpose: To perform a meta-analysis of clinical trials comparing percutaneous microwave ablation (PMWA) guided by ultrasound with conventional thyroidectomy for the management of papillary thyroid microcarcinoma (PTMC), analyzing feasibility, safety, and long-term efficacy, and to provide clinical guidance for the treatment selection of PTMC. Methods: Embase, PubMed, Cochrane Library, Web of Science, CNKI, VIP Database, and Wanfang Database were systematically searched to identify clinical studies of PMWA or thyroidectomy for PTMC up to December 2023. The relevant data from the articles were extracted, and the data analysis was performed using RevMan 5.4 software. Results: A total of 442 articles were identified and subsequently screened based on the inclusion and exclusion criteria, 9 clinical studies involving a total of 1577 patients were included, with 788 patients in the PMWA group and 789 patients in the surgery group. Following data extraction and statistical analysis, in comparison to the surgery group, the PMWA group had shorter operation time [mean differences (MD) = -36.36; 95% CI -55.66 to -17.06; P = .0002], shorter hospital stay (MD = -3.93; 95% CI -5.55 to -2.30; P < .00001), less intraoperative bleeding (MD = -21.25; 95% CI -27.36 to -15.15; P < .00001), and lower hospital costs (MD = -1.00; 95% CI -1.33 to -0.66; P < .00001), all with statistical significance. The comparison of postoperative complications revealed a lower incidence of complications in the PMWA group compared to the surgery group [relative risk (RR) = 0.29; 95% CI 0.21 to 0.40; P < .00001], with statistical significance. Thyroid-related hormone analysis showed that the free triiodothyronine (MD = 0.61; 95% CI 0.33 to 0.90; P < .00001) and free thyroxine (MD = 1.81; 95% CI 0.94 to 2.68; P < .0001) levels in the PMWA group were higher than those in the traditional surgery group, while the levels of thyroid-stimulating hormone were lower than those in the traditional surgery group (MD = -7.63; 95% CI -10.25 to -5.01; P < .00001), with statistically significant differences, indicating that PMWA had a smaller impact on thyroid function. In 2 studies, there were no statistically significant disparities in postoperative recurrence or lymph node metastasis (LNM) between the 2 cohorts (RR = 0.70; 95% CI 0.33 to 1.50; P = .36). There were no statistically significant differences in physiological health score between different groups and different time points before and after treatment (P > .05); However, the mental component score and the total score of the Medical Outcomes Study (MOS) item short-form health survey were significantly elevated in the ablation group compared to the excision group post-treatment (P < .05). Conclusion: For patients with low-risk PTMC with definitive diagnosis and precise risk stratification, PMWA can be selected. PMWA treatment for patients with PTMC is comparable to conventional surgical treatment and has the advantages of minimal trauma, rapid recovery, no scarring, and fewer complications, which are superior to open surgery to a certain extent. For patients with ambiguous preoperative diagnosis and uncertainty regarding LNM status, surgical intervention is the optimal choice.

Papillary Thyroid Microcarcinoma: Differences between Lesions in Incidental and Nonincidental Settings-Considerations on These Clinical Entities and Personal Experience

Papillary thyroid microcarcinoma (PTMC) represents 35-40% of all papillary cancers; it is defined as a nodule ≤ 10 mm at the time of histological diagnosis. The clinical significance of PTMC is still controversial, and it may be discovered in two settings: incidental PTMC (iPTMC), in which it is identified postoperatively upon histological examination of thyroid specimens following thyroid surgery for benign disease, and nonincidental PTMC (niPTMC), in which it is diagnosed before surgery. While iPTMC appears to be related to mild behavior and favorable clinical outcomes, niPTMC may exhibit markers of aggressiveness. We retrospectively review our experience, selecting 54 PTMCs: 28 classified as niPTMC (52%) and 26 classified as iPTMC (48%). Patients with niPTMC showed significant differences, such as younger age at diagnosis (p < 0.001); a lower male/female ratio (p < 0.01); a larger mean nodule diameter (p < 0.001); and a higher rate of aggressive pathological findings, such as multifocality, capsular invasion and/or lymphovascular invasion (p = 0.035). Other differences found in the niPTMC subgroup included a higher preoperative serum TSH level, higher hospital morbidity and a greater need for postoperative iodine ablation therapy (p < 0.05), while disease-free long-term survival did not differ between subgroups (p = 0.331) after a mean follow-up (FU) of 87 months, with one nodal recurrence among niPTMCs. The differences between iPTMC and niPTMC were consistent: patients operated on for total thyroidectomy and showing iPTMC can be considered healed after surgery, and follow-up should be designed to properly calibrate hormonal supplementation; conversely, niPTMC may sometimes exhibit aggressive behavior, and so the FU regimen should be closer and aimed at early detection of cancer recurrence.

Thyroid cancer in Ecuador: A genetic variants review and a cross-sectional population-based analysis before and after COVID-19 pandemic

Objectives

The purpose of this study is to describe the genetic variants present in the Ecuadorian population and the incidence and mortality patterns of thyroid cancer in Ecuador from 2016 to 2021.

Methods

The present research constitutes a nationwide cross-sectional study encompassing all reported cases of thyroid cancer (C-73) in Ecuador from 2016 to 2021. Incidence rates were calculated based on the annual population at risk, considering factors such as ethnicity, sex, age group, and the geographic location of the incidence. All data was collected from the Hospital Discharge Statistics and the Statistical Registry of General Deaths Databases.

Results

Between 2016 and 2021, a total of 20,297 hospital admissions and 921 deaths attributed to thyroid cancer were reported in Ecuador. The incidence of thyroid cancer remained relatively stable from 2016 to 2019. However, there was a notable decrease in 2020, followed by an increase in 2021. Notably, thyroid cancer prevalence rates were found to be higher in highlands regions. Moreover, two genetic variants, the BRAFV600E and KITL678F, have been identified in the Ecuadorian population. It is noteworthy that women exhibited a higher susceptibility to thyroid cancer, being five times more likely than men to develop this condition.

Conclusion

Ecuador exhibits one of the highest global incidences of thyroid cancer. Consequently, describing the genetic variants and epidemiological characteristics of thyroid cancer is imperative for enhancing healthcare access and formulating evidence-based public health policies. This research contributes towards a comprehensive understanding of thyroid cancer in the Ecuadorian context, aiming to improve targeted interventions and health outcomes.

Effects of online continuing medical education on perspectives of shared decision-making among Chinese endocrinologists

BACKGROUND

Shared decision-making (SDM) may influence the clinical outcomes of patients with endocrine disorders. There are few studies describing perspectives towards SDM among endocrinologists in China.

METHODS

In the first stage, we conducted a national survey using an online questionnaire about SDM among endocrinologists in China. The national survey focused on attitude and propensity, potential barriers, and the effectiveness of SDM implementation strategies. In the second stage, survey participants were further recruited to participate in a prospective cohort study in the online continuing medical education (CME) program of Peking Union Medical College Hospital in Beijing. The Shared Decision-Making Questionnaire (SDM-Q-Doc) was employed to assess the effects of online CME on physicians' perspectives during the process of SDM, which was conducted before and after the CME course was provided.

RESULTS

In the national survey, 280 endocrinologists (75.7% female, mean age 38.0 ± 4.5 years, 62.5% with a duration of practice of more than ten years) completed the questionnaire. Participants had a generally positive attitude towards SDM in clinical practice. The main perceived barriers included time consumption, information inequality between doctors and patients, and a lack of technical support and training for SDM. The main uncertainties of implementation steps included inviting patients to participate in SDM (16.3%), assisting in decision-making (15.3%), facilitating deliberation and decision-making (13.7%), and providing information on benefits and risks (12.6%). Of the physicians who participated in the national survey, 84 registered for the eight-day online CME course. The SDM-Q-Doc score increased from 87.3 ± 18.2 at baseline to 93.0 ± 9.3 at the end of the 8-day online CME training (p = 0.003, paired t test). The participants' age, sex, education level, practice duration, the annual number of patients with rare endocrine diseases, and the annual number of patients requiring MDT or CME were not significantly related to increased SDM-Q-Doc scores after online CME (all p > 0.05).

CONCLUSIONS

Chinese endocrinologists had a generally positive attitude towards SDM in clinical practice. There were also several uncertainties in the implementation steps of SDM. Regardless of a physician's educational background or prior professional experience, CME may help to improve their perspectives regarding SDM.

Shaving Papillary Thyroid Carcinoma Involving Functioning Recurrent Laryngeal Nerve: Safety of Incomplete Tumor Resection and Nerve Sparing

BACKGROUND

Whether to sacrifice or spare the recurrent laryngeal nerve (RLN) when papillary thyroid carcinoma (PTC) involves a functioning RLN remains controversial. Oncological outcomes after shaving PTC with gross remnant on the RLN have been rarely reported. The objective of this study was to evaluate the oncological outcomes of patients who underwent shaving of a PTC from the RLN, leaving a gross residual tumor with the intent of vocal function preservation.

METHODS

A retrospective, cohort study was conducted in 47 patients who were determined to have PTC invasion of the RLN via intraoperative inspection and underwent tumor shaving with macroscopic remnant (R2 resection) less than 1 cm in length and 4 mm in thickness. Median follow-up period was 93 (range, 60-215) months. The primary endpoint was the recurrence-free survival and the progression-free survival. Secondary endpoints were biochemical outcomes (serum thyroglobulin) and vocal cord function.

RESULTS

Of the 47 patients, five (10.6%) patients showed recurrence (central neck, 3; lateral neck, 2) without death or distant metastasis. The RLN was resected along with the tumor in one (2.1%) patient who presented with progression of the residual tumor. Postoperative temporary vocal cord paralysis occurred in six (12.8%) patients without permanent cases. The final nonstimulated serum thyroglobulin was 0.7 ± 1.8 ng/ml.

CONCLUSIONS

Shaving a tumor from a RLN with gross residual disease may be considered an alternative strategy to preserve vocal function when complete tumor resection with nerve preservation is impossible in patients with PTC invading a functioning RLN.

Incidence and risk factors for occult lesions in low-risk papillary thyroid microcarcinoma patients with tumor characteristics appropriate for thermal ablation: A retrospective study

In recent years, thermal ablation has been increasingly employed for the treatment of low-risk papillary thyroid microcarcinoma (PTMC) across various institutions. Its use as a standard or initial treatment continues to be a subject of debate. Retrospective analyses of the surgical pathology in post-ablation patients have indicated that occult lesions are not uncommon. This retrospective study aimed to examine the incidence and risk factors of occult lesions via postoperative pathology in low-risk PTMC patients who fulfilled the criteria for thermal ablation therapy. We examined the medical records of patients who underwent thyroid surgery and had a Bethesda classification V or VI based on fine needle aspiration cytology between November 22, 2020, and December 31, 2022. A total of 413 patients with preoperative tumor characteristics appropriate for thermal ablation were included in this study. Occult lesions, encompassing ipsilateral or contralateral occult carcinoma or central lymph node metastases may have occurred in 34.7% of patients. Male gender (OR: 2.526, 95% CI: 1.521-4.195, P = .000), tumor location in the lower pole (OR: 1.969, 95% CI: 1.186-3.267, P = .009), multiple microcalcifications (OR: 5.620, 95% CI: 2.837-11.134, P = .000), and Hashimoto's thyroiditis (OR: 2.245, 95% CI: 1.292-3.899, P = .004) were independent risk factors for the presence of occult lesions. In low-risk PTMC patients exhibiting tumor characteristics amenable to thermal ablation, over one-third of the patients may present with occult lesions. Meticulous evaluation of the presence of additional lesions is necessary before performing thermal ablation, particularly in patients exhibiting high-risk factors for occult lesions.

Multimodality US versus Thyroid Imaging Reporting and Data System Criteria in Recommending Fine-Needle Aspiration of Thyroid Nodules

Background Current guidelines recommend the use of conventional US for risk stratification and management of thyroid nodules. However, fine-needle aspiration (FNA) is often recommended in benign nodules. Purpose To compare the diagnostic performance of multimodality US (including conventional US, strain elastography, and contrast-enhanced US [CEUS]) with the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) in the recommendation of FNA for thyroid nodules to reduce unnecessary biopsies. Materials and Methods In this prospective study, 445 consecutive participants with thyroid nodules from nine tertiary referral hospitals were recruited between October 2020 and May 2021. With univariable and multivariable logistic regression, the prediction models incorporating sonographic features, evaluated with interobserver agreement, were constructed and internally validated with bootstrap resampling technique. In addition, discrimination, calibration, and decision curve analysis were performed. Results A total of 434 thyroid nodules confirmed at pathologic analysis (259 malignant thyroid nodules) in 434 participants (mean age, 45 years ± 12 [SD]; 307 female participants) were included. Four multivariable models incorporated participant age, nodule features at US (proportion of cystic components, echogenicity, margin, shape, punctate echogenic foci), elastography features (stiffness), and CEUS features (blood volume). In recommending FNA in thyroid nodules, the highest area under the receiver operating characteristic curve (AUC) was 0.85 (95% CI: 0.81, 0.89) for the multimodality US model, and the lowest AUC was 0.63 (95% CI: 0.59, 0.68) for TI-RADS (P < .001). At the 50% risk threshold, 31% (95% CI: 26, 38) of FNA procedures could be avoided with multimodality US compared with 15% (95% CI: 12, 19) with TI-RADS (P < .001). Conclusion Multimodality US had better performance in recommending FNA to avoid unnecessary biopsies than the TI-RADS. Clinical trial registration no. NCT04574258 © RSNA, 2023 Supplemental material is available for this article.

Integrated gene profiling of fine-needle aspiration sample improves lymph node metastasis risk stratification for thyroid cancer

BACKGROUND

Lymph node metastasis risk stratification is crucial for the surgical decision-making of thyroid cancer. This study investigated whether the integrated gene profiling (combining expression, SNV, fusion) of Fine-Needle Aspiration (FNA) samples can improve the prediction of lymph node metastasis in patients with papillary thyroid cancer.

METHODS

In this retrospective cohort study, patients with papillary thyroid cancer who went through thyroidectomy and central lymph node dissection were included. Multi-omics data of FNA samples were assessed by an integrated array. To predict lymph node metastasis, we built models using gene expressions or mutations (SNV and fusion) only and an Integrated Risk Stratification (IRS) model combining genetic and clinical information. Blinded histopathology served as the reference standard. ROC curve and decision curve analysis was applied to evaluate the predictive models.

RESULTS

One hundred and thirty two patients with pathologically confirmed papillary thyroid cancer were included between 2016-2017. The IRS model demonstrated greater performance [AUC = 0.87 (0.80-0.94)] than either expression classifier [AUC = 0.67 (0.61-0.74)], mutation classifier [AUC = 0.61 (0.55-0.67)] or TIRADS score [AUC = 0.68 (0.62-0.74)] with statistical significance (p < 0.001), and the IRS model had similar predictive performance in large nodule [>1 cm, AUC = 0.88 (0.79-0.97)] and small nodule [≤1 cm, AUC = 0.84 (0.74-0.93)] subgroups. The genetic risk factor showed independent predictive value (OR = 10.3, 95% CI:1.1-105.3) of lymph node metastasis in addition to the preoperative clinical information, including TIRADS grade, age, and nodule size.

CONCLUSION

The integrated gene profiling of FNA samples and the IRS model developed by the machine-learning method significantly improve the risk stratification of thyroid cancer, thus helping make wise decisions and reducing unnecessary extensive surgeries.

Analysis of Therapeutic Effect and Influencing Factors of Ultrasound-Guided Radiofrequency Ablation in the Treatment of Papillary Thyroid Microcarcinoma

OBJECTIVES

The current study sought to explore the effects of ultrasound (US)-guided radiofrequency ablation (RFA) on papillary thyroid microcarcinoma (PTMC) and influencing factors.

METHODS

PTMC patients were assigned to observation (US-guided RFA) and control (surgical operation) groups. A series of operation-related indexes (operation time, intraoperative bleeding, wound closure time, hospital stay, and expenses), visual analogue scale score, lesion size, and thyroid function-related indexes (thyroid-stimulating hormone [TSH], free triiodothyronine*** [FT3], free thyroxine [FT4]), inflammatory factors, and thyroglobulin antibody (TgAb) were assessed and compared. After a 6-month follow-up period, the complications and recurrence were recorded, in addition to analyses of postoperative recurrence cumulative incidence and evaluation of recurrence risk factors.

RESULTS

Operation-related indexes of the observation group were relatively decreased compared with the control group. In addition, the lesion volume in the observation group was lower compared to that in the control group at the 6th month after operation, whereas the volume reduction rate was higher. There were no significant differences in regard to thyroid function-related indexes in the observation group before/after operation. After operation, serum TSH levels and inflammatory factors, and TgAb levels were all diminished, while the FT3 and FT4 levels were both elevated in the observation group relative to the control group, and postoperative recurrence cumulative incidence was lower in the observation group. TSH and TgAb were established as the independent risk factors for recurrence after RFA in PTMC patients.

CONCLUSIONS

Our findings highlighted that US-guided RFA exhibits better efficacy, safety, and postoperative recovery and lower recurrence risk for PTMC.

Latest evidence of microwave ablation for papillary thyroid microcarcinoma compared with surgery: A systematic review and meta-analysis

Background

The most typical thyroid gland malignant lesion is papillary thyroid cancer (PTC). In many nations, the prevalence of thyroid cancer (TC) is rising, particularly papillary thyroid microcarcinoma (PTMC). Microwave ablation (MWA) has been gradually carried out in some patients with benign thyroid nodules, some low-risk PTMC, and metastatic lymph nodes in the neck. The role and safety of MWA remain controversial topics. So we conducted this study to provide the latest evidence of MWA for PTMC compared with surgery.

Methods

Patients' postoperative outcomes (duration of hospital stay and hospitalization expenditures), intraoperative outcomes (surgery time, blood loss, and incision size), and follow-up outcomes were all examined (complication rate, recurrence rate, and lymph node metastasis). The effectiveness and safety of MWA versus surgery for PTMC patients were compared using the weighted mean difference (WMD) and odds ratio (OR).

Results

In total, we included 7 articles (7 trial comparisons) which contained 1, 567 PTMC patients. The results showed that MWA had significant advantages in operative time (WMD = -53.47, 95% CI: -67.62 to -39.32), postoperative hospital stay (WMD =-4.59, 95% CI: -6.40 to -2.77), hospitalization costs (WMD= -70.06, 95% CI: -90.93 to -49.19), blood loss (WMD =-28.07, 95% CI: -33.77 to -22.38), incisions size (WMD =-59.69, 95% CI: -67.79 to -51.59), and complication rates (OR = 0.28; 95% CI: 0.18 to 0.42) compared with surgery. It also showed that recurrence rates and risk of lymph node metastasis are similar to surgery.

Conclusions

For PTMC patients, MWA could be an efficient, safe, and affordable therapy.

The Preferred Route for the Diagnosis and Management of Thyroid Carcinoma Among the General Population in Saudi Arabia

BACKGROUND

 Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Papillary thyroid microcarcinoma (PTMC) is a specific subgroup of PTC. Given their small size, PTMCs are often asymptomatic and behave benignly. This puts physicians in a challenging situation about how to prevent overdiagnosis and overtreatment of PTMC. This study aimed to assess the preferences regarding the route of PTMC diagnosis and treatment among Saudi Arabia's general population.

METHODS

 This is a cross-sectional questionnaire-based-study conducted among the general population in Saudi Arabia. The target subjects were the general population of Saudi Arabia both genders and different age groups from various regions of Saudi Arabia (Western, Central, Eastern, Southern, and North). Participants who did not complete the questionnaire or did not agree to participate were excluded. A self-administered questionnaire was distributed on different social media platforms to collect data from different regions. Data analysis was conducted by using Statistical Package for the Social Sciences (SPSS) 24.0 version (IBM Inc., Chicago, USA) statistical software. A Chi-square test was used to compare categorical variables.

RESULTS

 A total of 1,428 participants were included. The majority of them were females (64.4%), and most of them were aged between 19 and 25 years. Moreover, we found that 4.8% of the study population had a medical history of thyroid cancer. Our results revealed that more than half of respondents (54.6%) would select surgical operation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which turns out to be a PTC. The vast majority of participants (90.1%) would prefer to do cytologic confirmation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which has suspicious characteristics of PTC in neck ultrasound examination. Regarding PTMC operation, 59.8% of responders were more concerned about complications than recurrences. We found that neither age nor gender significantly affects decision-making for management or operative extent for PTC. There was a significant difference between age and decision-making for the diagnosis of suspicious thyroid nodules (p value = 0.041).

CONCLUSION

 Our results concluded that most of the participants preferred to select immediate surgery and cytologic confirmation regarding the management and diagnosis of PTC. More research is advised. The need to inform patients about their disease state and treatment options should be highlighted more.

Identification of KIT and BRAF mutations in thyroid tissue using next-generation sequencing in an Ecuadorian patient: A case report

Background

The incidence of thyroid cancer has increased worldwide. Ecuador presents the highest incidence among Latin American countries and the second around the world. Genetic alteration is the driving force for thyroid tumorigenesis and progression. The change from valine (V) to glutamic acid (E) at codon 600 of the BRAF gene (BRAF^Val600Glu) is the most commonly reported mutation in thyroid cancer. Moreover, the BRAF mutation is not the only mutation that has been correlated with TC. For instance, mutations and overexpression of the KIT gene has been associated with different types of cancer, including lung and colon cancer, and neuroblastoma.

Case presentation

A woman in her early fifties, self-identified as mestizo, from Otavalo, Imbabura-Ecuador had no systemic diseases and denied allergies, but she had a family history of a benign thyroid nodule. Physical examination revealed a thyroid gland enlargement. The fine-needle aspiration biopsy indicated papillary thyroid cancer. The patient underwent a successful total thyroidectomy with an excellent recovery and no additional treatments after surgery. Using Next-Generation sequencing a heterozygous mutation in the BRAF gene, causing an amino acid change Val600Glu was identified. Similarly, in the KIT gene, a heterozygous mutation resulting in an amino acid change Leu678Phe was detected. Moreover, an ancestry analysis was performed, and the results showed 3.1% African, 20.9% European, and 76% Native American ancestry.

Conclusions

This report represents the genetic characteristics of papillary thyroid cancer in an Ecuadorian woman with a mainly Native American ethnic component. Further studies of pathological variants are needed to determine if the combined demographic and molecular profiles are useful to develop targeted treatments focused on the Ecuadorian population.

Machine Learning-Based Shear Wave Elastography Elastic Index (SWEEI) in Predicting Cervical Lymph Node Metastasis of Papillary Thyroid Microcarcinoma: A Comparative Analysis of Five Practical Prediction Models

Purpose

Although many factors determine the prognosis of papillary thyroid carcinoma (PTC), cervical lymph node metastasis (CLNM) is one of the most terrible factors. In view of this, this study aimed to build a CLNM prediction model for papillary thyroid microcarcinoma (PTMC) with the help of machine learning algorithm.

Methods

We retrospectively analyzed 387 PTMC patients hospitalized in the Department of Medical Oncology, Enshi Tujia and Miao Autonomous Prefecture Central Hospital from January 1, 2015, to January 31, 2022. Based on supervised learning algorithms, namely random forest classifier (RFC), artificial neural network(ANN), support vector machine(SVM), decision tree(DT), and extreme gradient boosting gradient(XGboost) algorithm, the LNM prediction model was constructed, and the prediction efficiency of ML-based model was evaluated via receiver operating characteristic curve(ROC) and decision curve analysis(DCA).

Results

Finally, a total of 24 baseline variables were included in the supervised learning algorithm. According to the iterative analysis results, the pulsatility index(PI), resistance index(RI), peak systolic blood flow velocity(PSBV), systolic acceleration time(SAT), and shear wave elastography elastic index(SWEEI), such as average value(Emean), maximum value(Emax), and minimum value(Emix) were candidate predictors. Among the five supervised learning models, RFC had the strongest prediction efficiency with area under curve(AUC) of 0.889 (95% CI: 0.838–0.940) and 0.878 (95% CI: 0.821–0.935) in the training set and testing set, respectively. While ANN, DT, SVM and XGboost had prediction efficiency between 0.767 (95% CI: 0.716–0.818) and 0.854 (95% CI: 0.803–0.905) in the training set, and ranged from 0.762 (95% CI: 0.705–0.819) to 0.861 (95% CI: 0.804–0.918) in the testing set.

Conclusion

We have successfully constructed an ML-based prediction model, which can accurately classify the LNM risk of patients with PTMC. In particular, the RFC model can help tailor clinical decisions of treatment and surveillance.

Meta-Analysis of the Application Effect of Different Modalities of Thermal Ablation and Surgical Treatment in Papillary Thyroid Microcarcinoma

Background

Papillary thyroid microcarcinoma (PTMC) refers to papillary thyroid carcinoma (PTC) with a maximum diameter of 10 mm. Thermal ablation, including radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA), has been applied in the treatment of benign thyroid nodules and captured extensive attention. At present, the application of thermal ablation in PTMC has been extensively reported, but outcomes such as volume reduction rate (VRR), complete remission rate (CRR), and adverse reaction rate (ARR) vary considerably. Therefore, this meta-analysis was performed to evaluate the safety and efficacy of different treatment methods of PTMC.

Methods

We did a systematic review and network meta-analysis. We searched PubMed, EMBase, and Cochrane-Library from the date of inception to January 10, 2022, to retrieve the VRR, CRR, and ARR of MWA, RFA, LA and surgical treatment of PTMC, and a meta-analysis was performed using the R meta-package. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and sensitivity analyses, cumulative meta-analyses, and publication bias were also performed. Relevant literature was retrieved with keywords; the eligible cohort studies were screened based on the established inclusion and exclusion criteria.

Results

A total of 1515 patients were included in the 12-month follow-up. The overall VRR was 86.25% (95% CI: 77.89, 94.60), and the VRR was RFA > WMA > LA, but the differences were not significant. A total of 1483 patients were included in the last follow-up. The overall VRR was 99.41% (95% CI: 99.11, 99.72), and the VRR was RFA > WMA > LA, but the differences were not significant. A total of 1622 patients showed complete remission at the last follow-up, and the overall CRR was 0.63 (95% CI: 0.46, 0.79). The CRR was RFA > LA > WMA, but the differences were not significant. A total of 1883 patients had adverse reactions at the last follow-up, and the overall ARR was 0.06 (95% CI: 0.03, 0.08). The ARR at the last follow-up was RFA = Surg < LA < WMA. The ARR of the RFA and Surg subgroups was significantly lower than that of the WMA subgroup.

Conclusions

Similar good efficacy and safety profiles were observed in WMA, RFA, LA, and surgical treatment in PTMC, among which RFA showed the best volume reduction, complete remission rate, and adverse reaction reduction. However, there is a slight bias in the limited literature included in this study, and we did not conduct or refer to mechanistic studies to confirm its specific mechanism of action. Clinicians are advised to use their discretion in the choice of treatment.

Radioactive Iodine Ablation Can Reduce the Structural Recurrence Rate of Intermediate-Risk Papillary Thyroid Microcarcinoma: A Meta-Analysis

Background

The incidence of papillary thyroid microcarcinoma (PTMC) has significantly increased in recent years, and the decision to use radioactive iodine (RAI) ablation in low-risk (LR) and intermediate-risk (IR) patients is controversial. The aim of this study was to evaluate whether RAI ablation can reduce the recurrence rate in LR-IR PTMC patients.

Methods

A comprehensive literature search of the PubMed, Embase, Cochrane Library, and Web of Science was conducted according to the PRISMA statement.

Results

There were 8 studies in English that fit our search strategy, and a total of 2847 patients were evaluated. The results of the meta-analysis showed RAI ablation in LR-IR PTMC patients did not reduce cancer recurrence (risk radio (RR) 0.56, 95% CI 0.19-1.70, P = 0.31). Nevertheless, we further performed data analysis and found that IR PTMC patients without RAI ablation had a higher rate of cancer recurrence than those who underwent RAI ablation (RR 0.23, 95% CI 0.11-0.49, P = 0.0001). Furthermore, patients with risk factors for lymph node metastasis (RR 0.16, 95% CI 0.06-0.42, P = 0.0002), microscopic extrathyroidal extension (RR 0.19, 95% CI 0.06-0.60, P = 0.005), and multifocality (RR 0.13, 95% CI 0.04-0.45, P = 0.001) in the absence of RAI ablation were more likely to have recurrence.

Conclusions

Based on our current evidence, RAI ablation can reduce the cancer recurrence rate over 5 years in IR PTMC patients, especially when patients have some risk factors, such as lymph node metastasis, microscopic extrathyroidal extension, and multifocality.

Clinicopathological Findings Associated With Cervical Lymph Node Metastasis in Papillary Thyroid Microcarcinoma: A Retrospective Study in China

Objective

The incidence of papillary thyroid microcarcinoma (PTMC) has increased sharply during the past decades. Yet, whether or not nodal dissection should be performed remains controversial. This article aims to assess the high-risk factors associated with cervical lymph node metastasis (LNM) in patients with PTMC, which may potentially guide clinical management decision-making.

Methods

Medical records of 449 PTMC patients who underwent thyroidectomy in our hospital from August 2016 to July 2017 were retrospectively reviewed. Clinical and pathological factors of the patients were anonymously extracted from the charts and analyzed.

Result

The patients were classified into two subgroups according to maximum tumor size measured through post-surgical pathology: smaller PTMC group (≤5 mm) and larger PTMC group (>5 mm). Larger tumor size was found to be associated with a higher rate of LNM (P = .001), particularly central lymph node metastasis (CLNM) (P = .001). Tumor size was also associated with extrathyroidal tumor extension (ETE) (P < .001), bilateral lesions (P = .015), and BRAF^v600e mutation (P = .004). LNM was found to be more common in older patients (>55 y) (P = .030), and those with multifocal cancer (P < .001). In PTMC patients with unilateral lesions without ETE, tumor size was not significantly associated with LNM (P = .121).

Conclusions

For the PTMC population, tumor size was an independent risk factor for LNM, particularly for patients of old age (>55 y), and multifocality. However, in PTMC patients with unilateral lesions without extrathyroidal extension, tumor size was not related to the risk of LNM. These findings may potentially guide clinical decision-making in terms of cervical nodal dissection.

Diagnostic Efficacy of Ultrasound, Cytology, and BRAFV600E Mutation Analysis and Their Combined Use in Thyroid Nodule Screening for Papillary Thyroid Microcarcinoma

Background

Ultrasound, cytology, and BRAF^V600E mutation analysis were applied as valuable tools in the differential diagnosis of thyroid nodules. The aim of the present study was to evaluate the diagnostic efficiency of the three methods and their combined use in screening for papillary thyroid microcarcinoma (PTMC).

Methods

A total of 1,081 patients with 1,157 thyroid nodules (0.5–1 cm in maximum diameter) classified as thyroid imaging reporting and data system (TIRADS) 4–5 were recruited. All patients underwent ultrasound, fine-needle aspiration (FNA) examination, and an additional BRAF^V600E mutation test. TIRADS and Bethesda System for Reporting Thyroid Cytopathology (BSRTC) were adopted to judge the ultrasound and cytological results. The receiver operating characteristic (ROC) curve was established to assess the diagnostic values of different methods.

Results

Of the 1,157 nodules, 587 were benign and 570 were PTMCs. BRAF^V600E mutation test had highest sensitivity (85.4%), specificity (97.1%), accuracy (91.4%), and area under the ROC curve (Az) value (0.913) among the three methods. The combination of BSRTC and BRAF^V600E mutation analysis yielded a considerably high sensitivity (96.0%), accuracy (94.3%), and negative predictive value (95.9%) than either BSRTC or BRAF^V600E mutation alone (P < 0.0001 for all comparisons). Of all the methods, the combined use of the three methods produced the best diagnostic performance (Az = 0.967), which was significantly higher than that (Az = 0.943) for the combination of BSRTC and BRAF^V600E mutation (P < 0.0001). The diagnostic accuracy of the molecular method in the 121 nodules with indeterminate cytology was 90.1% (109/121), which was significantly higher than that of TIRADS classification, 74.4% (90/121) (P = 0.002).

Conclusion

The combined use of ultrasound, cytology, and BRAF^V600E mutation analysis is the most efficient and objective method for diagnosing PTMC. Both BRAF^V600E mutation and TIRADS classification are potentially useful adjuncts to differentiate thyroid nodules, especially indeterminate samples classified as BSRTC III.

Identification of DNA Repair-Related Genes Predicting Clinical Outcome for Thyroid Cancer

Recent studies have demonstrated the utility and superiority of DNA repair-related genes as novel biomarkers for cancer diagnosis, prognosis, and therapy. Here, we aimed to screen the potential survival-related DNA repair-related genes in thyroid cancer (TC). TCGA datasets were utilized to analyze the differentially expressed DNA repair-related genes between TC and nontumor tissues. The K–M approach and univariate analysis were employed to screen survival-related genes. RT-PCR was employed to examine the expression of DNA repair-related genes in TC samples and matched noncancer samples. CCK-8 analyses were used to determine cellular proliferation. Herein, our team discovered that the expression of four DNA repair-related genes was remarkably upregulated in TC samples in contrast to noncancer samples. Survival assays identified 14 DNA repair-related genes. In our cohort, we observed that the expression of TAF13 and DCTN4 was distinctly elevated in TC specimens in contrast to nontumor specimens. Moreover, knockdown of TAF13 and DCTN4 was observed to inhibit the TC cellular proliferation. Overall, the upregulation of TAF13 and DCTN4 is related to decreased overall survival in TC patients. Therefore, the assessment of TAF13 and DCTN4 expression may be useful for predicting prognosis in these patients.

Pathology confirmation of the efficacy and safety of microwave ablation in papillary thyroid carcinoma

BACKGROUND

The incidence of papillary thyroid carcinoma (PTC) has rapidly increased in recent years. Microwave ablation (MWA) was proposed as an alternative treatment for PTC. This study aimed to investigate the efficacy and safety of MWA by exploring the postoperative pathology results of post-ablation lesions in patients with PTC.

METHODS

This study retrospectively analyzed data from 12 patients who underwent thyroid surgery after MWA treatment for primary PTC between January 2015 and November 2021 in six hospitals.

RESULTS

The average age of the 12 patients (8 female) was 45.3 ± 9.7 years. There was one patient with PTC (size > 1 cm) and 11 patients with micro-PTC (size ≤ 1 cm), of which eight patients had unifocal micro-PTC and three patients had multifocal micro-PTC. A total of 17 tumor foci with mean size of 6.2 ± 2.6 mm were treated by MWA. The median interval time between MWA and surgery was 6.6 months (range: 0.4-21.9 months). Intraoperatively, adherence to the anterior cervical muscle group was observed in three cases (3/12). Upon postoperative pathologic examination, all the post-ablation lesions of the eight unifocal micro-PTC and two multifocal micro-PTC showed no residual carcinomas. Outside the ablation zone, PTCs were detected in three cases, including two of the eight patients with unifocal micro-PTC and one of the three patients with multifocal micro-PTC. Cervical lymph node metastases were detected in seven patients (7/12).

CONCLUSION

MWA was feasible for the treatment of primary unifocal low-risk micro-PTC (T1aN0M0) with good efficacy and safety. However, the use of MWA for treating PTC (size > 1 cm) and multifocal micro-PTC remains controversial.

TERT Promoter Mutations Are an Independent Predictor of Distant Metastasis in Middle Eastern Papillary Thyroid Microcarcinoma

BACKGROUND

Papillary thyroid microcarcinomas (PTMCs) have been attributed to the recent increased incidence of thyroid cancer. Although indolent, a subset of PTMC could potentially develop distant metastasis (DM). This study aimed to evaluate the clinico-pathological features and molecular characteristics of PTMC and identify the risk factors for DM in PTMC patients from Middle Eastern ethnicity.

METHODS

We retrospectively analyzed 210 patients with histologically confirmed PTMC. Clinico-pathological associations for DM, BRAF mutation and TERT mutation were analyzed successfully in 184 patients. Multivariate analysis was performed using Cox proportional hazards model and logistic regression analysis.

RESULTS

Among the PTMC patients included in this cohort, DM was noted in 6.0% (11/184), whereas tumor relapse occurred in 29/184 (15.8%). Of the 11 cases with DM, lung metastasis occurred in 8 cases, bone metastasis in 2 cases and brain metastasis in 1 case. Presence of extrathyroidal extension and male sex were significantly associated with DM. Molecular analysis showed BRAF V600E mutations to be the most frequent, being detected in 45.7% (84/184). TERT promoter mutations were detected in 16 (8.7%) cases and were significantly associated with DM and shorter metastasis-free survival in multivariate analysis.

CONCLUSIONS

Our study indicates a surprisingly high frequency of TERT promoter mutation in Saudi patients with PTMC. Identifying TERT promoter mutations as an independent predictor of DM in patients with microcarcinoma could explain the inherent aggressive nature of PTMC from Middle Eastern ethnicity and magnify its role in patient risk stratification, which might help in improving therapeutic strategy for these patients.

Total tumor diameter is a better indicator of multifocal papillary thyroid microcarcinoma: A propensity score matching analysis

BACKGROUND

Accurate evaluation of the risk of papillary thyroid microcarcinoma (PTMC) is the key to treatment. However, the maximum diameter (MD), which is currently used in various staging systems, may not truly reflect the aggressiveness of multifocal tumors.

METHODS

Clinical and pathological data for 1001 patients with papillary thyroid carcinoma who underwent surgery at the Hangzhou First People's Hospital were retrospectively analyzed. First, the relationship between total tumor diameter (TTD) and clinicopathological features in multifocal PTMC was explored. Then, patients were divided into subgroups according to the TTD. The baseline was consistent after using the propensity score matching method, and the differences between groups were compared. In addition, the effectiveness of TTD and MD in evaluating central lymph node metastasis (CLNM) was analyzed and compared.

RESULTS

TTD is associated with a range of clinicopathological features, including lymph node metastasis, extrathyroidal extension, and risk stratification. Assuming the same MD and number of foci, the invasiveness of multifocal PTMC with TTD >1 cm was significantly higher than that with TTD <1 cm, and even higher than unifocal non-PTMC. Moreover, the efficiency of TTD in predicting CLNM was also significantly higher than that of MD.

CONCLUSION

For multifocal PTMC, TTD is a more realistic indicator of tumor biological characteristics than MD. The aggressiveness of PTMC with TTD >1 cm was significantly enhanced, and surgical treatment should be actively sought in such cases.

Reconceptualize tall-cell variant papillary thyroid microcarcinoma: From a "sonographic histology" perspective

OBJECTIVE

This study aimed to examine the relationship between sonographic features and histological manifestations in the tall-cell variant of papillary thyroid microcarcinoma (TCV-PTMC), thus proposing the concept of "sonographic histology" and examine its value in the clinical management of the aggressive tall-cell variant.

METHODS

This study retrospectively included 104 participants who were admitted to Peking University Third Hospital from 2015 to 2022 and were histopathologically confirmed as having TCV-PTMC or classical PTMC. We mainly compared the general characteristics, sonographic characteristics, and pathological specimens between the two cohorts.

RESULTS

Hypoechoic nodules with a localized central isoechoic lesion and hypoechoic halo around nodules were most often observed in TCV-PTMC, which correlated with circumferentially distributed tumor epithelium and densely distributed tumor stroma histopathologically. Additionally, TCV-PTMC showed nodules with a more regular margin and less microcalcification than classical PTMC, which led to an underestimation of the risk of TCV-PTMC.

CONCLUSION

The good association between the ultrasound echo pattern and tissue cell arrangement was defined as sonographic histology in this study and can be applied in the preoperative identification of TCV-PTMC. This concept may provide novel insight for the identification of special subtypes of thyroid tumors and may modify pitfalls of the Thyroid Imaging Reporting and Data System in aggressive variants of microcarcinoma.

One year follow-up of US-Guided radiofrequency ablation for low-risk papillary thyroid microcarcinoma: The first experience in Taiwan

BACKGROUND

The incidence of papillary thyroid microcarcinoma (PTMC) has increased rapidly in recent decades, with a favorable overall prognosis. We aimed to evaluate the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) for treating low-risk PTMC in Taiwan.

METHODS

This prospective study included patients with PTMC who were ineligible or refused surgery and underwent US-guided RFA between October 2018 and June 2020. US and computed tomography (CT) were performed before RFA to assess tumor lesions and exclude cervical lymph node metastasis. Sequential US follow-up following RFA was performed after 1, 3, 6, and 12 months, and yearly thereafter. Volume reduction ratio (VRR) and complete disappearance rate of tumor at one year were evaluated.

RESULTS

13 PTMCs in 12 patients were enrolled with a mean follow-up of 16.2 ± 8.1 months (range, 1-24 months). The median largest tumor diameter and tumor volume before RFA were 0.76 cm and 0.15 ml (range, 0.02-0.37 ml). The median (interquartile range, IQR) volume and VRR at 12 months post-RFA were 0 (0, 0.03) ml (p = 0.033) and 100% (84.26%, 100%) (p = 0.008). Eight tumors (61.54%) were completely disappeared at 12 months post-RFA and no tumor recurrence, lymph nodes, or distant metastasis were noted. All tumors were successfully treated without complications.

CONCLUSION

Minimally invasive US-guided RFA is an effective and safe alternative for low-risk PTMC, resulting a satisfied VRR.

Predicting factors of central lymph node metastasis and BRAFV600E mutation in Chinese population with papillary thyroid carcinoma

Objective

The aim of this study was to evaluate the predictive factors of central lymph node metastasis (CLNM) and BRAF^V600E mutation in Chinese patients with papillary thyroid carcinoma (PTC).

Methods

A total of 943 PTC patients who underwent thyroidectomy from 2014 to 2016 at our hospital were enrolled. Those patients were divided into PTC > 10 mm and papillary thyroid microcarcinoma (PTMC) groups by tumor size. The BRAF^V600E mutation was examined by quantitative real-time PCR. Univariate and multivariate analyses were used to examine risk factors associated with CLNM and the BRAF^V600E mutation.

Results

The frequency of CLNM was 53% (505/943). Both univariate and multivariate analyses suggested that the risk factors for CLNM in PTC patients were male, younger age, and larger tumor size (P < 0.05). Coexistent Hashimoto thyroiditis (HT) was an independent protective factor against CLNM when the tumor was > 10 mm (P = 0.006). Stratified analysis revealed that male, age ≤ 30 years, and tumor size > 5 mm were independent risk factors for CLNM. The BRAF^V600E mutation rate was 85%. Multivariate logistic regression analysis revealed that age (P < 0.001) and coexistent HT (P = 0.005) were independent predictive factors of BRAF^V600E mutation in PTC patients. Only age was a risk factor for the BRAF^V600E mutation when the tumor was > 10 mm (P = 0.004). In the PTMC group, the BRAF^V600E mutation was significantly correlated with tumor size (P < 0.001) and coexistent HT (P = 0.03). Stratified analysis revealed that age > 30 years and tumor size > 5 mm were independent predictive factors of BRAF^V600E mutation. Furthermore, the incidence of CLNM was significantly higher in BRAF^V600E mutation-positive patients (P = 0.009) when the tumor was ≤ 5 mm.

Conclusion

The factors male, younger age (≤ 30 years), large tumor size (> 5 mm), and coexistent HT are independent predicative factors for CLNM. The BRAF^V600E mutation is associated with both large size and without HT in PTMC patients, age > 30 years in the PTC > 10 mm group. The BRAF^V600E mutation was an independent risk factor for CLNM when the tumor was ≤ 5 mm. For optimal management, these features should be comprehensively evaluated to determine the initial surgical approach for PTC patients.

Margin Positivity and Survival in Papillary Thyroid Microcarcinoma: A National Cancer Database Analysis

BACKGROUND

The rising incidence of thyroid cancer has been attributed to increased detection of papillary thyroid microcarcinoma (PTMC). Although some PTMCs are thought to harbor aggressive pathologic features, the clinical significance of these features remains unclear. This study examines factors associated with survival in this patient population.

STUDY DESIGN

Adults with PTMC, defined as papillary thyroid carcinoma ≤ 1.0 cm, who underwent thyroidectomy between 2004 and 2016, were identified in the National Cancer Database. Demographic and clinical variables were analyzed. The primary aim was to identify factors associated with survival. The secondary aim was to assess the association of microscopic margins on survival and to identify factors associated with margin positivity. Overall survival was estimated using Kaplan-Meier methods and compared using log rank tests. Cox proportional hazards and binary logistic regression models identified factors associated with survival and margin positivity, respectively.

RESULTS

Of 77,817 patients with PTMC, 13,507 met inclusion criteria; 2,649 (20%) of these patients presented with advanced features: extrathyroidal extension (n = 916, 7%), lymphovascular invasion (n = 398, 3%), lymph node involvement (n = 2,003, 15%), and distant metastasis (n = 39, <1%). Microscopic margin positivity was present in 906 patients and associated with increased risk of death (hazard ratio 1.58, 95% CI 1.04-2.41). Academic facilities (odds ratio [OR] 0.75, 95% CI 0.59-0.95) and operative volume (OR 0.98, 95% CI 0.97-0.98) were associated with decreased margin positivity.

CONCLUSIONS

Positive margin status was significantly associated with increased risk of death for PTMC. Higher operative volume and treatment at academic centers were associated with lower rates of margin positivity and may help improve survival outcomes in PTMC patients with aggressive features.

Papillary thyroid microcarcinomas: does subtyping predict aggressive clinical behavior?

The most common malignant neoplasm affecting the thyroid gland is papillary thyroid carcinoma (PTC). PTC can demonstrate a number of morphologic variants including, but not limited to, classic, follicular, and tall cell. Each of these morphologic subtypes carry distinct clinical characteristics such that certain variants, like tall cell, behave more aggressively than others. PTCs measuring less than or equal to 1.0 cm are classified as microcarcinomas. Although these lesions are thought to be clinically indolent, we hypothesized that, like their larger counterparts, certain histologic variants may lead to worse patient outcomes. To test our hypothesis, we analyzed our pathology archives between the years 2009 and 2020 for papillary thyroid microcarcinomas and assessed whether different morphologic features correlated with more aggressive clinical behavior. Our findings suggest that certain variants exhibit features that portend a more worrisome clinical course and thus papillary thyroid microcarcinomas should be subtyped to help predict patient outcome.

Fine Needle Biopsy Versus Core Needle Biopsy Combined With/Without Thyroglobulin or BRAF 600E Mutation Assessment for Detecting Cervical Nodal Metastasis of Papillary Thyroid Carcinoma

Objectives

To analyze the diagnostic benefit of fine needle aspiration biopsy cytology (FNAB-C) and core needle biopsy tissue (CNB-T) with the addition of thyroglobulin (Tg) in the washout of the needle or BRAF V600E mutation assessment in assessing cervical lymph node metastasis (LNM) in papillary thyroid carcinoma.

Materials and Methods

A total of 186 lymph nodes were punctured by fine or core needle. The diagnostic performance of FNAB-C and CNB-T with Tg in the washout or BRAF V600E mutation assessment was compared.

Results

The optimal cutoff value of FNAB-Tg was 1.0 ng/ml, with an AUC of 0.976. The sensitivity and specificity of FNAB-C in predicting cervical LNM were 97.4% and 71.4%, respectively, and the addition of FNAB-Tg could contribute to a sensitivity of 100% and a specificity of 95%, but the introduction of BRAF V600E mutation assessment was associated with a decreased sensitivity of 96.3% and a decreased specificity of 50.0%. The FNAB-Tg level showed a comparable distribution in malignant lymph nodes with different TgAb statuses, serum TSH levels, and serum Tg levels. The sensitivity and specificity of CNB-T in predicting cervical LNM were 98.9% and 100%, respectively. The addition of CNB-Tg did not alter the diagnostic ability, but the introduction of BRAF V600E mutation assessment obtained the best performance, with a sensitivity of 100% and specificity of 100%.

Conclusion

The sensitivity and specificity of FNAB-C could be increased if combined with FNAB-Tg. CNB-T alone could provide satisfactory diagnostic reliability.

Deltex3 inhibits Epithelial Mesenchymal Transition in Papillary Thyroid Carcinoma via promoting ubiquitination of XRCC5 to regulate the AKT signal pathway

Background: Papillary thyroid carcinoma (PTC) is one of the most common endocrine malignant tumors. Poor prognoses such as high recurrence rate always appear in PTC patients with cervical lymph node metastasis. The process of ubiquitination plays important roles in PTC. As ubiquitin E3 ligases, Deltex (DTX) family proteins were reported to associate with multiple cancers. However, functions and mechanisms of DTX3 in PTC are currently unknown.

Methods: In this study, DTX3 expressions were examined in 114 PTC and paired paracancerous normal tissues through quantitative real-time polymerase chain reaction and western blot. The clinical significances of DTX3 expressions in PTC patients were also investigated. After stable transfection with either short hairpin RNA to knock down DTX3 expression or full-length complementary DNA to upregulate DTX3 expression, changes of malignant phenotypes in two PTC cell lines K1 and TPC-1 were observed using cell viability, flow cytometry, wound healing and transwell assays. Afterwards, altered expressions of epithelial-mesenchymal transition (EMT) and AKT signal pathway related proteins were measured by western blot. Immunoprecipitation and mass spectrometry (IP-MS), immunofluorescence and Co-IP were utilized to identify the possible DTX3 interacting proteins.

Results: Both mRNA and protein expressions of DTX3 were lower in PTC tissues and correlated with the presence of cervical lymph node metastasis (P<0.05). DTX3 overexpression inhibited migration and invasion of PTC cells, decreased Vimentin and phosphorylated AKT expressions, but promoted E-cadherin expression (P<0.05). Moreover, knockdown of DTX3 led to opposite changes (P<0.05). Total 46 probable DTX3 interacting proteins were identified by IP-MS. Among them, X-ray repair cross-complementing protein 5 (XRCC5) and NADH: Ubiquinone Oxidoreductase Complex Assembly Factor 5 (NDUFAF5) were verified to be associated with DTX3. Moreover, DTX3 was proved to be co-localized with XRCC5 in nucleus and promote ubiquitination of XRCC5.

Conclusions: DTX3 suppresses EMT by partially facilitating ubiquitination of XRCC5 to inhibit AKT signal pathway in PTC.

Advancements in the treatment of differentiated thyroid cancer

Derived from follicular epithelial cells, differentiated thyroid cancer (DTC) accounts for the majority of thyroid malignancies. The threefold increase in DTC incidence over the last three decades has been largely attributed to advancements in detection of papillary thyroid microcarcinomas. Efforts to address the issue of overtreatment have notably included the reclassification of encapsulated follicular variant papillary thyroid cancers (EFVPTC) to non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). In the last 5 years, the overall management approach for this relatively indolent cancer has become less aggressive. Although surgery and radioiodine ablation remain the mainstay of DTC therapy, the role of active surveillance is being explored. Furthermore, the most recent American Thyroid Association (ATA) guidelines offer flexibility between lobectomy and total thyroidectomy for thyroid nodules between 1 cm and 4 cm in the absence of extrathyroidal extension or nodal disease. As our understanding of the natural history and molecular underpinnings of DTC evolves, so might our approach to managing low-risk patients, obviating the need for invasive intervention. Simultaneously, advances in interventional and systemic therapies have greatly expanded treatment options for high-risk surgical candidates and patients with widespread disease, and continue to be areas of active investigation. Continued research efforts are essential to improve our ability to offer effective individualized therapy to patients at all disease stages and to reduce the incidence of recurrent and progressive disease.

Long-Term Results of Treating With Ethanol Ablation 15 Adult Patients With cT1aN0 Papillary Thyroid Microcarcinoma

Background

Currently acceptable management options for patients with adult papillary thyroid microcarcinoma (APTM) range from immediate surgery, either unilateral lobectomy or bilateral lobar resection, to active surveillance (AS). An alternative minimally invasive approach, originally employed for eliminating neck nodal metastases, may be ultrasound-guided percutaneous ethanol ablation (EA). Here we present our experience of definitively treating with EA 15 patients with APTM.

Patients and Methods

During 2010 through 2017, the 15 cT1aN0M0 patients selected for EA were aged 36 to 86 years (median, 45 years). Tumor volumes (n = 17), assessed by sonography, ranged from 25 to 375 mm³ (median, 109 mm³). Fourteen of 15 patients had 2 ethanol injections on successive days; total volume injected ranged from 0.45 to 1.80 cc (median, 1.1 cc). All ablated patients were followed with sonography and underwent recalculation of tumor volume and reassessment of tumor perfusion at each follow-up visit.

Results

The ablated patients have now been followed for 10 to 100 months (median, 64 months). There were no complications and no ablated patient developed postprocedure recurrent laryngeal nerve dysfunction. All 17 ablated tumors shrank (median 93%) and Doppler flow eliminated. Median tumor volume reduction in 9 identifiable avascular foci was 82% (range, 26%-93%). After EA, 8 tumors (47%) disappeared on sonography after a median of 10 months. During follow-up no new PTM foci and no nodal metastases have been identified.

Conclusions

Definitive treatment of APTM by EA is effective, safe, and inexpensive. Our results suggest that, for APTM patients who do not wish neck surgery and are uncomfortable with AS, EA represents a well-tolerated and minimally invasive outpatient management option.

Elimination of Locoregional Recurrences and Skin Metastases in Papillary Thyroid Cancer by Ethanol Ablation and Mohs Surgery

Ultrasound-guided percutaneous ethanol ablation procedures for locoregional recurrences in papillary thyroid carcinoma (PTC) can be repeatedly performed over years. Skin metastases (SM) from PTC generally portend a lethal prognosis. Our patient case report demonstrates the innovative use in low-risk PTC (LRPTC) of treatment modalities designed to prevent neck re-explorations and capable of eliminating both locoregional recurrences and SM. In 2004, a 48-year-old man presented with neck nodal metastases due to PTC. He underwent a near-total thyroidectomy and nodal dissection, confirming an 8-mm PTC involving 2 ipsilateral node metastases. Postoperatively, he received 2 doses of radioactive iodine (RAI) for remnant uptake (cumulative dose 338 mCi); posttherapy scanning was unrevealing. In 2007, he underwent right neck dissection for further node metastases. In 2008, a guided biopsy confirmed a level IV node metastasis. He was referred to our institution for ethanol ablation. Two node metastases were ablated and subsequently disappeared. During 2010-2016, he developed an additional 6 node metastases, which were treated with ethanol ablation; all disappeared on high-resolution sonography. FDG-PET-CT scans in 2009 and 2016 were negative for distant spread. In 2016, a SM in his right neck was removed by dermatologic surgery. In 2017-2018, 2 further SM were excised with negative margins, one after Mohs surgery. He has now been disease-free for 20 months. In conclusion, despite 3 neck surgeries and 2 RAI therapies, our patient repeatedly developed both locoregional recurrences and SM. All 11 disease foci were eliminated with minimally invasive procedures which should more often be considered as effective treatment options in LRPTC.

Impact of prophylactic unilateral central neck dissection needed for patients with papillary thyroid microcarcinoma

Background

Papillary thyroid microcarcinoma (PTMC), the increase in the diagnosis of which has led to an overall rise in the diagnostic rate of thyroid malignancies, is generally managed through a reduction in the surgical extent. Nevertheless, a considerable number of patients with PTMC experience subclinical central lymph node (LN) metastases following prophylactic central neck dissection (CND). This study aimed to investigate the impact of prophylactic CND on locoregional recurrence in PTMC patients who underwent hemithyroidectomy.

Methods

We reviewed the medical records of 1,071 patients with clinically LN-negative PTMC who underwent hemithyroidectomy between 2004 and 2012. Cox proportional hazards regression analysis was performed to investigate the predictive factors for recurrence. The median follow-up duration was 79 months (range, 12-176 months).

Results

Totally, 613 patients underwent hemithyroidectomy only, whereas 458 underwent hemithyroidectomy plus prophylactic unilateral CND. Recurrence was observed in 27 patients (eight and 19 patients in the prophylactic and non-prophylactic CND groups, respectively). Patients with a tumor size ≤6 mm (hazard ratio, 2.927; 95% confidence interval, 1.372-6.245; P=0.005) had favorable recurrence-free survival (RFS); however, there was no relationship between prophylactic unilateral CND and RFS.

Conclusions

The incidence of locoregional recurrence was low in patients with PTMC who underwent hemithyroidectomy. In addition, prophylactic unilateral CND performance was not associated with RFS in PTMC. Accordingly, the use of prophylactic unilateral CND for clinically LN-negative PTMC should be avoided.