Preoperative prediction of central lymph node metastasis in cN0T1/T2 papillary thyroid carcinoma: A nomogram based on clinical and ultrasound characteristics

Positive preoperative circulating tumor cells level associated with lymph node metastasis in papillary thyroid carcinoma patients with capsular invasion

OBJECTIVE

Capsular invasion in papillary thyroid cancer(PTC) refers to thyroid cancer penetrating the capsule without attaching to the surrounding tissue. Patients with and without capsular invasion may differ in the likelihood of lymph node metastasis(LNM). The purpose of this study is to study the relationship between circulating tumor cells(CTCs) and LNM in PTC with or without capsular invasion.

METHODS

The clinical records of patients (age, gender, CTCs, thyroid function, Hashimoto's thyroiditis, lesions number, lesions diameter, capsular invasion, clinical stage, and LNM) were analyzed retrospectively. The relationship between CTCs level and LNM was analyzed. Logistic regression analyses were used to evaluate the relationship between CTCs and LNM after adjusting for confounding factors.

RESULTS

A total of 746 PTC patients were included, and 320 patients with capsular invasion and 426 without. The patients with capsular invasion had higher proportions of multifocality, maximum lesion diameter > 1 cm, T3-T4 stage, and LNM than patients without (all p < 0.05). In multivariate logistic regression analyses, maximum lesion diameter > 1 cm (odds ratio(OR): 4.108, 95% confidence interval(CI): 2.459-6.862, p < 0.001) was associated with LNM in patients without capsular invasion; positive preoperative CTCs levels (OR: 1.705, 95% CI: 1.023-2.842, p = 0.041), multifocality (OR: 2.811, 95% CI: 1.669-4.736, p < 0.001), and maximum lesion diameter > 1 cm (OR: 3.233, 95% CI: 1.884-5.546, p < 0.001) were associated with LNM in patients with capsular invasion.

CONCLUSIONS

Maximum lesion diameter > 1 cm was associated with LNM in PTC patients with and without capsular invasion. Positive preoperative CTCs levels and multifocality were associated with LNM in patients with capsular invasion, but not in patients without capsular invasion.

Development of a nomogram incorporating BRAF-V600E to predict central lymph node metastasis in papillary thyroid carcinoma

ObjectiveThis study aims to identify risk factors associated with central lymph node metastasis (CLNM) in individuals with papillary thyroid carcinoma (PTC) and to develop a predictive nomogram model, thereby offering clinicians a valuable tool for guiding surgical treatment decisions in PTC management.MethodsClinical and ultrasound data were collected from 348 patients with PTC who underwent surgical treatment at our hospital between July 2022 and November 2023. The cohort was randomly divided into a training group (n = 243) and a validation group (n = 105 cases). Independent risk factors for CLNM were identified using multivariate logistic regression analysis, which was subsequently used to construct a predictive nomogram. The performance of the model was internally validated, and its predictive accuracy was evaluated using receiver operating characteristic (ROC) curves, decision curve analysis (DCA), and calibration curves.ResultsAmong the 348 patients, CLNM was observed in 115 (47.33%) patients in the training group and 48 (45.71%) patients in the validation group. Univariate and multivariate logistic regression analyses revealed that male sex, age under 55 years, nodular anteroposterior diameter of ≥1 cm, BRAF-V600E gene mutation, and tumor capsule invasion were independent risk factors for CLNM in PTC (P < 0.05). The constructed nomogram demonstrated strong predictive capability, with areas under the ROC curve (AUC) of 0.84 (95% CI, 0.78-0.89) for the training group and 0.85 (95% CI, 0.78-0.93) for the validation group.ConclusionThe nomogram constructed based on ultrasound and BRAF-V600E gene mutation status is a reliable predictive tool for CLNM in patients with PTC, potentially aiding clinicians in the formulation of personalized surgical treatment strategies.

The role of intraoperative central lymph node biopsy in the treatment of clinically low-risk PTMC

PURPOSE

To evaluate the role of intraoperative frozen biopsy of central lymph nodes in central neck dissection and thyroidectomy in patients of unilateral, clinically negative nodes (cN0) papillary thyroid microcarcinoma (PTMC) without extra-glandular invasion.

METHODS

The clinical data of 465 patients were collected retrospectively. Part of prelaryngeal, pretracheal and ipsilateral paratracheal lymph nodes were taken for frozen pathological examination during the operation. Then the thyroid lobe on the tumor side and isthmus were excised, and central neck dissection of the affected side was performed in all patients. The number of metastases in entire central lymph nodes of the affected side can be obtained by postoperative paraffin pathology. If the number of positive lymph nodes during surgery is ≥3, contralateral gland resection was performed.

RESULTS

In this group of 465 patients, there were 186 cases with central lymph node metastasis. The Kappa coefficient of consistency between frozen pathology and paraffin pathology in central lymph nodes was 0.605. The ROC curve for the number of intraoperative frozen metastases-postoperative pathological metastases over 5 showed that the AUC of the curve was 0.793, while the maximum Youden index was 0.5259, whose corresponding number of positive lymph nodes was 3.

CONCLUSION

Intraoperative central lymph nodes biopsy can be used as an important indicator for the status of central lymph node metastasis in unilateral cN0 PTMC patients without extra-glandular invasion and a determinant for central lymph node dissection. While the number of positive lymph nodes intraoperatively is ≥3, total thyroidectomy should be considered.

Predicting central lymph node metastasis in papillary thyroid cancer: A nomogram based on clinical, ultrasound and contrast‑enhanced computed tomography characteristics

Central lymph node (CLN) status is considered to be an important risk factor in patients with papillary thyroid carcinoma (PTC). The aim of the present study was to identify risk factors associated with CLN metastasis (CLNM) for patients with PTC based on preoperative clinical, ultrasound (US) and contrast-enhanced computed tomography (CT) characteristics, and establish a prediction model for treatment plans. A total of 786 patients with a confirmed pathological diagnosis of PTC between January 2021 to December 2022 were included in the present retrospective study, with 550 patients included in the training group and 236 patients enrolled in the validation group (ratio of 7:3). Based on the preoperative clinical, US and contrast-enhanced CT features, univariate and multivariate logistic regression analyses were used to determine the independent predictive factors of CLNM, and a personalized nomogram was constructed. Calibration curve, receiver operating characteristic (ROC) curve and decision curve analyses were used to assess discrimination, calibration and clinical application of the prediction model. As a result, 38.9% (306/786) of patients with PTC and CLNM(-) status before surgery had confirmed CLNM using postoperative pathology. In multivariate analysis, a young age (≤45 years), the male sex, no presence of Hashimoto thyroiditis, isthmic location, microcalcification, inhomogeneous enhancement and capsule invasion were independent predictors of CLNM in patients with PTC. The nomogram integrating these 7 factors exhibited strong discrimination in both the training group [Area under the curve (AUC)=0.826] and the validation group (AUC=0.818). Furthermore, the area under the ROC curve for predicting CLNM based on clinical, US and contrast-enhanced CT features was higher than that without contrast-enhanced CT features (AUC=0.818 and AUC=0.712, respectively). In addition, the calibration curve was appropriately fitted and decision curve analysis confirmed the clinical utility of the nomogram. In conclusion, the present study developed a novel nomogram for preoperative prediction of CLNM, which could provide a basis for prophylactic central lymph node dissection in patients with PTC.

Development and validation of a clinical predictive model for high-volume lymph node metastasis of papillary thyroid carcinoma

The central lymph node metastasis (CLNM) status in the cervical region serves as a pivotal determinant for the extent of surgical intervention and prognosis in papillary thyroid carcinoma (PTC). This paper seeks to devise and validate a predictive model based on clinical parameters for the early anticipation of high-volume CLNM (hv-CLNM, > 5 nodes) in high-risk patients. A retrospective analysis of the pathological and clinical data of patients with PTC who underwent surgical treatment at Medical Centers A and B was conducted. The data from Center A was randomly divided into training and validation sets in an 8:2 ratio, with those from Center B serving as the test set. Multifactor logistic regression was harnessed in the training set to select variables and construct a predictive model. The generalization ability of the model was assessed in the validation and test sets. The model was evaluated through the receiver operating characteristic area under the curve (AUC) to predict the efficiency of hv-CLNM. The goodness of fit of the model was examined via the Brier verification technique. The incidence of hv-CLNM in 5897 PTC patients attained 4.8%. The occurrence rates in males and females were 9.4% (128/1365) and 3.4% (156/4532), respectively. Multifactor logistic regression unraveled male gender (OR = 2.17, p < .001), multifocality (OR = 4.06, p < .001), and lesion size (OR = 1.08 per increase of 1 mm, p < .001) as risk factors, while age emerged as a protective factor (OR = 0.95 per an increase of 1 year, p < .001). The model constructed with four predictive variables within the training set exhibited an AUC of 0.847 ([95%CI] 0.815-0.878). In the validation and test sets, the AUCs were 0.831 (0.783-0.879) and 0.845 (0.789-0.901), respectively, with Brier scores of 0.037, 0.041, and 0.056. Subgroup analysis unveiled AUCs for the prediction model in PTC lesion size groups (≤ 10 mm and > 10 mm) as 0.803 (0.757-0.85) and 0.747 (0.709-0.785), age groups (≤ 31 years and > 31 years) as 0.778 (0.720-0.881) and 0.837 (0.806-0.867), multifocal and solitary cases as 0.803 (0.767-0.838) and 0.809 (0.769-0.849), and Hashimoto's thyroiditis (HT) and non-HT cases as 0.845 (0.793-0.897) and 0.845 (0.819-0.871). Male gender, multifocality, and larger lesion size are risk factors for hv-CLNM in PTC patients, whereas age serves as a protective factor. The clinical predictive model developed in this research facilitates the early identification of high-risk patients for hv-CLNM, thereby assisting physicians in more efficacious risk stratification management for PTC patients.

Nomogram model of serum thymidine kinase 1 combined with ultrasonography for prediction of central lymph node metastasis risk in patients with papillary thyroid carcinoma pre-surgery

Objective

The aim of this study was to develop a nomogram, using serum thymidine kinase 1 protein (STK1p) combined with ultrasonography parameters, to early predict central lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) pre-surgery.

Methods

Patients with PTC pre-surgery in January 2021 to February 2023 were divided into three cohorts: the observation cohort (CLNM, n = 140), the control cohort (NCLNM, n = 128), and the external verification cohort (CLNM, n = 50; NCLNM, n = 50). STK1p was detected by an enzyme immunodot-blot chemiluminescence analyzer and clinical parameters were evaluated by ultrasonography.

Results

A suitable risk threshold value for STK1p of 1.7 pmol/L was selected for predicting CLNM risk by receiver operating characteristic (ROC) curve analysis. Multivariate analysis identified the following six independent risk factors for CLNM: maximum tumor size >1 cm [odds ratio (OR) = 2.406, 95% confidence interval (CI) (1.279-4.526), p = 0.006]; capsule invasion [OR = 2.664, 95% CI (1.324-5.360), p = 0.006]; irregular margin [OR = 2.922; 95% CI (1.397-6.111), p = 0.004]; CLN flow signal [OR = 3.618, 95% CI (1.631-8.027), p = 0.002]; tumor-foci number ≥2 [OR = 4.064, 95% CI (2.102-7.859), p < 0.001]; and STK1p ≥1.7 pmol/L [OR = 7.514, 95% CI (3.852-14.660), p < 0.001]. The constructed nomogram showed that the area under the ROC curve for the main dataset was 0.867 and that for the validation dataset was 0.830, exhibiting effectivity, and was recalculated to a total score of approximately 383. Through monitoring the response post-surgery, all patients were assessed as tumor-free at 12 months post-surgery, which was significantly associated with a reduction in STK1p to disease-free levels.

Conclusion

We demonstrate for the first time that a novel nomogram including STK1p combined with ultrasonography can assist in the clinical prevention of CLNM, by facilitating timely, individualized prophylactic CLNM dissection, thereby reducing the risk of secondary surgery and the probability of recurrence.

Accurate preoperative prediction of nodal metastasis in papillary thyroid microcarcinoma: Towards optimal management of patients

OBJECTIVE

To enhance the accuracy in predicting lymph node metastasis (LNM) preoperatively in patients with papillary thyroid microcarcinoma (PTMC), refining the "low-risk" classification for tailored treatment strategies.

METHODS

This study involves the development and validation of a predictive model using a cohort of 1004 patients with PTMC undergoing thyroidectomy along with central neck dissection. The data was divided into a training cohort (n = 702) and a validation cohort (n = 302). Multivariate logistic regression identified independent LNM predictors in PTMC, leading to the construction of a predictive nomogram model. The model's performance was assessed through ROC analysis, calibration curve analysis, and decision curve analysis.

RESULTS

Identified LNM predictors in PTMC included age, tumor maximum diameter, nodule-capsule distance, capsular contact length, bilateral suspicious lesions, absence of the lymphatic hilum, microcalcification, and sex. Especially, tumors larger than 7 mm, nodules closer to the capsule (less than 3 mm), and longer capsular contact lengths (more than 1 mm) showed higher LNM rates. The model exhibited AUCs of 0.733 and 0.771 in the training and validation cohorts respectively, alongside superior calibration and clinical utility.

CONCLUSION

This study proposes and substantiates a preoperative predictive model for LNM in patients with PTMC, honing the precision of "low-risk" categorization. This model furnishes clinicians with an invaluable tool for individualized treatment approach, ensuring better management of patients who might be proposed observation or ablative options in the absence of such predictive information.

Predicting central cervical lymph node metastasis in papillary thyroid carcinoma with Hashimoto's thyroiditis: a practical nomogram based on retrospective study

Background

In papillary thyroid carcinoma (PTC) patients with Hashimoto's thyroiditis (HT), preoperative ultrasonography frequently reveals the presence of enlarged lymph nodes in the central neck region. These nodes pose a diagnostic challenge due to their potential resemblance to metastatic lymph nodes, thereby impacting the surgical decision-making process for clinicians in terms of determining the appropriate surgical extent.

Methods

Logistic regression analysis was conducted to identify independent risk factors associated with central lymph node metastasis (CLNM) in PTC patients with HT. Then a prediction model was developed and visualized using a nomogram. The stability of the model was assessed using ten-fold cross-validation. The performance of the model was further evaluated through the use of ROC curve, calibration curve, and decision curve analysis.

Results

A total of 376 HT PTC patients were included in this study, comprising 162 patients with CLNM and 214 patients without CLNM. The results of the multivariate logistic regression analysis revealed that age, Tg-Ab level, tumor size, punctate echogenic foci, and blood flow grade were identified as independent risk factors associated with the development of CLNM in HT PTC. The area under the curve (AUC) of this model was 0.76 (95% CI [0.71-0.80]). The sensitivity, specificity, accuracy, and positive predictive value of the model were determined to be 88%, 51%, 67%, and 57%, respectively.

Conclusions

The proposed clinic-ultrasound-based nomogram in this study demonstrated a favorable performance in predicting CLNM in HT PTCs. This predictive tool has the potential to assist clinicians in making well-informed decisions regarding the appropriate extent of surgical intervention for patients.

Construction of a nomogram for central lymph node metastasis in papillary thyroid cancer based on gender grouping

BACKGROUND

The status of central lymph nodes is crucial for determining the surgical approach to papillary thyroid carcinoma (PTC). Because of the differences between genders in central lymph node metastasis (CLNM), we aimed to construct separate predictive models for CLNM according to gender.

METHODS

In our study, a total of 1258 PTC patients who underwent thyroid cancer surgery from September 2021 to March 2023 were analyzed retrospectively. The data were analysed univariately and multivariately using SPSS software grouped according to gender and nomograms of CLNM were plotted using R software. The variables included in this study were sex, Age, body mass index, Diabetes, chronic lymphocytic thyroiditis (CLT), Suspicious central lymph node (SCLN), A/T, Margin, Microcalcification (MC), BRAF, Number, Location, CLNM.

RESULTS

The preoperative nomogram in male patients included four clinical variables: CLT, Margin, Number, Size. The preoperative nomogram of female patients included six clinical variables: Age, SCLN, Margin, MC, Number, Size. The calibration curves showed great agreement in both the training group and the validation group. The decision curve analysis showed the feasibility of nomogram in predicting CLNM in both man and woman.

CONCLUSION

Based on the successful establishment of nomogram, we can analyze the variability of CLNM between male and female, which may provide clinicians with personalized clinical schemes in the treatment of PTC.

Clinical value of dual-energy CT for predicting occult metastasis in central neck lymph nodes of papillary thyroid carcinoma

OBJECTIVES

To predict the probability of occult lymph node metastasis (OLNM) in the central cervical by analyzing the dual-energy computed tomography (DECT) parameters derived from papillary thyroid carcinoma (PTC).

METHODS

Data were retrospectively collected from patients with pathologically confirmed PTC who underwent arterial and venous phases of enhanced DECT with concurrent central neck lymph node dissection (CLND). Three clinical features, three shape-related features, and twenty-six DECT-derived parameters were measured. The univariate and multivariate analyses were applied to select the relevant parameters and develop the nomogram.

RESULTS

A total 140 cases with negative diagnosis of cervical central lymph node metastases by preoperative evaluation were included, among which 88 patients with metastasis (OLNM +) and 52 patients without metastasis (OLNM -) were finally confirmed by pathology. (1) Anteroposterior/transverse diameter ratio (A/T) derived from the PTC focus had significant difference between the OLNM + and OLNM - groups (p < 0.05). (2) In the arterial phase, iodine concentration (ICarterial), normalized iodine concentration (NICarterial), effective atomic number (Zeff-arterial), electron density (EDarterial), and slope of energy curve (karterial) from PTC focus showed significant difference (all p < 0.05) between the two groups. In the venous phase, only the CT value under the 40 keV (HU40keVvenous) had differences (p < 0.05). (3) The nomogram was produced to predict the probability of OLNM, and the AUC, sensitivity, and specificity in the training and test cohort were 0.830, 75.0%, 76.9%, and 0.829, 65.9%, 84.6%, respectively.

CONCLUSIONS

DECT parameters combined with shape-related feature derived from PTC might be used as predictors of OLNM in the central neck.

CLINICAL RELEVANCE STATEMENT

Preoperative imaging evaluation combining shape-related features and dual-energy CT parameters could serve as a reference to discern occult lymph node metastasis in central neck during the surgically planning of papillary thyroid carcinoma.

KEY POINTS

• Papillary thyroid carcinoma (PTC) patients may have occult lymph node metastasis (OLNM) in the central neck, which is extremely difficult to find by preoperative imaging examination. • Dual-energy CT quantitative evaluation has higher accuracy than conventional CT and can predicting OLNM in the central neck of PTC. • Dual-energy CT quantitative parameters and morphology of PTC can serve as a useful tool in predicting OLNM in the central neck, and as a guide for personalized treatment.

Clinical features and imaging examination assessment of cervical lymph nodes for thyroid carcinoma

BACKGROUNDS

The purpose of this study is to investigate the relationship between clinical characteristics and cervical lymph node metastasis (LNM) in patients with thyroid carcinoma, as well as estimate the preoperative diagnosis values of ultrasound (US) and contrast enhanced computed tomography (CECT) examinations on the neck for detection of cervical LNM in thyroid carcinoma.

METHODS

A retrospective analysis of 3 026 patients with surgically proven thyroid carcinoma was conducted. Patients' clinical characteristics, including gender, age, tumor size, bilateral lesions, multifocality, adenomatous nodules, Hashimoto's thyroiditis (HT), and extrathyroidal extension, were collected to explore their association with cervical LNM in thyroid carcinoma. Preoperative assessments for central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) were conducted through US and CECT. The diagnostic value of US, CECT and US combined with CECT for detection of LNM located in various cervical compartments was estimated based on the pathological results.

RESULTS

The risk of cervical LNM was higher in thyroid cancer patients who were male, age < 55 years old, tumor size > 10 mm, bilateral lesions, and extrathyroidal extension, while multifocality, adenomatous nodules and HT had no significant effect on LNM. US, CECT and US combined with CECT all had a higher sensitivity to LLNM (93.1%, 57.8%, 95.4%) than to CLNM (32.3%, 29.0%, 43.4%). US and CECT had a high specificity to both CLNM and LLNM (94.3-97.8%).

CONCLUSION

Preoperative clinical characteristics and imaging examinations on patients with thyroid carcinoma are crucial to the evaluation of cervical lymph nodes and conducive to individualizing surgical treatments by clinicians. US combined with CECT are superior to single US or CECT alone in detection of CLNM and LLNM.

Prediction model of cervical lymph node metastasis based on clinicopathological characteristics of papillary thyroid carcinoma: a dual-center retrospective study

BACKGROUND

The overall prevalence of papillary thyroid carcinoma (PTC) patients is expanding along with an ongoing increase in thyroid cancer incidence. Patients with PTC who have lymph node metastases have a poor prognosis and a high death rate. There is an urgent need for indicators that can predict lymph node metastasis (LNM) before surgery as current imaging techniques, such as ultrasonography, do not have sufficient sensitivity to detect LNM. To predict independent risk factors for Central lymph node metastasis (CLNM) or Lateral lymph node metastasis (LLNM), we therefore developed two nomograms based on CLNM and LLNM, separately.

METHODS

In two centers, the Second Affiliated Hospital of Nanchang University and Yichun People's Hospital, we retrospectively analyzed clinicopathological characteristics of PTC patients. We utilized multivariate analysis to screen for variables that might be suspiciously related to CLNM or LLNM. Furthermore, we developed nomograms to graphically depict the independent risk valuables connected to lymph node metastasis in PTC patients.

RESULT

Ultimately, 6068 PTC patients in all were included in the research. Six factors, including age<45, male, mETE, TSH>1.418, tumor size>4cm, and location (multicentric and lobe), were observed to be related to CLNM. Age<45, male, mETE (minimal extrathyroidal extension), multifocality, TSH≥2.910, CLNM positive, and tumor size>4cm were regarded as related risk factors for LLNM. The two nomograms developed subsequently proved to have good predictive power with 0.706 and 0.818 and demonstrated good clinical guidance functionality with clinical decision curves and impact curves.

CONCLUSION

Based on the successful establishment of this dual-institution-based visual nomogram model, we found that some clinical features are highly correlated with cervical lymph node metastasis, including CLNM and LLNM, which will better help clinicians make individualized clinical decisions for more effectively rationalizing managing PTC patients.