Diffuse sclerosing variant of papillary thyroid carcinoma--clinical features and outcome

Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma Is Related to a Poor Outcome: A Comparison Study Using Propensity Score Matching

OBJECTIVE

The clinical outcome of diffuse sclerosing variant of papillary thyroid carcinoma (DSV-PTC) remains controversial. We aimed to determine whether DSV-PTC is associated with an increased risk of persistent/recurrent disease.

METHODS

We performed a retrospective cohort study of DSV-PTC and classic variant of papillary thyroid carcinoma (CV-PTC) after postoperative radioactive iodine therapy. We used propensity score matching (1:3 matching ratio) to account for differences between the recipients of DSV-PTC and CV-PTC. Univariate and multivariate analyses were performed to assess the independent factors for persistent/recurrent disease. The Kaplan-Meier curve analyses were used to compare disease-free survival (DFS).

RESULTS

In total, 35 (12.7%) patients with DSV-PTC and 240 (87.3%) patients with CV-PTC were included. After propensity score matching, 35 pairs of patients were selected (DSV-PTC, n = 35; CV-PTC, n = 105). In the matched analysis, a higher proportion of patients with DSV-PTC experienced persistent/recurrent disease than that of those with CV-PTC (25.7% vs 5.7%, P = .003). In the multivariate analyses of clinical and tumor characteristics, only the histologic type of DSV-PTC (odds ratio, 6.288; 95% confidence interval, 1.900-20.811; P = .003) was associated with an increased risk of persistent/recurrent disease. The 5-year DFS rates for the DSV-PTC and CV-PTC groups were 69.2% and 93.6%, respectively. The Kaplan-Meier analysis indicated that the DSV-PTC group (P= .001) had shorter DFS.

CONCLUSION

This propensity score-matched analysis found that the histologic type of DSV-PTC may increase the risk of persistent/recurrent disease.

Aggressive variants of follicular cell-derived thyroid carcinoma: an overview

PURPOSE

The incidence of thyroid carcinoma has increased globally in the past years. Papillary thyroid carcinoma (PTC) is the most frequent neoplasm of the thyroid gland comprehending the 90% of the thyroid carcinoma and has an indolent clinical behaviour. However, some variants of follicular cell-derived thyroid carcinoma, including variants of classic of PTC, have been identified that show a more aggressive biological behaviour. An accurate diagnosis of these entities is crucial for planning a more aggressive treatment and improving patients' prognosis of patients. The aim of this review is to present the main clinical, histological, and molecular features of aggressive variants of follicular cell-derived thyroid carcinoma, and to provide useful histological parameters for determining the most suitable therapeutic strategy for patients affected by these forms.

RESULTS

Variants of classic PTC such as the diffuse sclerosing variant (DSV), the tall cell variant (TCV), the columnar cell variant (CCV), the solid/trabecular variant (STV) and the hobnail variant (HV), and other variants of follicular cell-derived thyroid carcinoma, such as poorly differentiated thyroid carcinoma (PDTC), and anaplastic thyroid carcinoma (ATC), are associated with aggressive behaviour.

CONCLUSIONS

The correct identification and diagnosis of aggressive variants of follicular cell-derived thyroid carcinoma is important, as they allow the clinician to adopt the most refined therapeutic strategies in order to the survival of the patients.

Clinicopathological Characteristics and Recurrence-Free Survival of Rare Variants of Papillary Thyroid Carcinomas in Korea: A Retrospective Study

BACKGROUND

We aimed to evaluate the clinicopathological features and biological behaviors of Korean thyroid cancer patients with rare variants of papillary thyroid carcinoma (PTC) to address the ambiguity regarding the prognostic consequences of these variants.

METHODS

We retrospectively reviewed the medical records of 5,496 patients who underwent thyroid surgery for PTC, between January and December 2012, in nine tertiary hospitals. Rare PTC variants included tall cell (TCV), columnar cell (CCV), diffuse sclerosing (DSV), cribriform-morular (CMV), solid (SV), hobnail, and Warthin-like variants. Recurrence-free survival (RFS) was defined as the time from the date of thyroidectomy until recurrence.

RESULTS

Rare variants accounted for 1.1% (n=63) of the PTC patients; with 0.9% TCV, 0.02% CCV, 0.1% DSV, 0.1% CMV, and 0.1% SV. The mean age of patients and primary tumor size were 42.1±13.1 years and 1.3±0.9 cm, respectively. Extrathyroidal extension and cervical lymph node metastasis were observed in 38 (60.3%) and 37 (58.7%) patients, respectively. Ultrasonographic findings revealed typical malignant features in most cases. During a median follow-up of 7 years, 6.3% of patients experienced a locoregional recurrence. The 5-year RFS rates were 71.4% in patients with DSV or SV, 95.9% for TCV, or CCV, and 100% for other variants. DSV emerged an independent risk factor associated with shorter RFS.

CONCLUSION

In this multicenter Korean cohort, rare variants accounted for 1.1% of all PTC cases, with TCV being the most frequent subtype. DSV emerged as a significant prognostic factor for RFS.

Surgical Management of Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma. Experience in 25 Patients

PURPOSE

To delineate the clinicopathologic features and biologic behavior of the diffuse sclerosing variant of papillary thyroid carcinoma (DSV-PTC) and to report its outcome.

METHODS

The clinical records of 25 patients who had surgery for DSV-PTC from 2004 to 2017 were retrospectively analyzed. Comparisons were made to similar studies in the literature reporting ≥8 cases and a cohort of classical PTC.

RESULTS

There were 20 females and 5 males with an average age of 23 years (range 10-39 years). Bilateral disease occurred in 80% of cases. The mean size of the dominant mass was 4.2 ± 1.92 cm. In 92% of cases, therapeutic neck dissection was performed. Male sex significantly correlated with a higher yield of positive lymphadenopathy (p = 0.045). 62% of patients had recurrent disease. Recurrence significantly correlated with male sex, the number of metastatic lymph nodes (cutoff: 22 lymph nodes), and multifocality (p = 0.044, p ˂ 0.008, p ˂ 0.003, respectively). However, it did not correlate with the age at presentation. No disease-specific mortality occurred after an average follow-up of 77 months (range 12-168 months). The two comparisons made demonstrated a statistically significant greater tendency of the current series of DSV-PTC toward more aggressive clinicopathologic features and biologic behavior. No differences in overall survival were observed.

CONCLUSION

The DSV-PTC should be considered a high-risk PTC that mandates an aggressive therapeutic strategy with the intent of optimizing disease-free survival.

Papillary Thyroid Cancer-Aggressive Variants and Impact on Management: A Narrative Review

Introduction

Aggressive variants of papillary thyroid cancer (PTC) have been described with increasing frequency. These variants include diffuse sclerosing variant, tall cell variant, columnar cell variant, solid variant, and hobnail variant.

Methods

We have performed a review of the more aggressive variants of PTC with respect to main characteristics, histological and molecular features, and the consequences that the knowledge of these variants should have in the treatment of the patients.

Results

At the present time, we do not know the prognostic value of these aggressive PTC variants. The extent of the surgical treatment and adjuvant therapy necessary should be decided on the basis of the extent of the tumor at presentation and the opinion of experienced clinicians.

Conclusion

These aggressive variants should be known by clinicians, to avoid underdiagnosis, and treated according to the latest recommendations in the literature.

Thyroid Nodules in Pediatric Patients: Sonographic Characteristics and Likelihood of Cancer

Purpose To determine the relationship between demographic and sonographic characteristics of thyroid nodules and malignancy in a pediatric population. Materials and Methods All thyroid nodules in patients younger than 19 years that underwent ultrasound (US)-guided fine-needle aspiration biopsy between January 2004 and July 2017 were retrospectively identified. Age, sex, and background appearance of the thyroid gland were recorded for each patient, and sonographic characteristics and pathologic diagnosis were recorded for each nodule. Demographic and sonographic characteristics were assessed to determine which were associated with malignancy. Categorical and continuous variables and interobserver variability were assessed. Results A total of 404 nodules in 314 patients (82.8% female) (age range, 2-18 years; mean age, 14.9 years) were analyzed. A total of 77 nodules (19.1%) were malignant, the majority of which were papillary thyroid carcinoma (n = 68 [88.3%]). The likelihood of malignancy did not differ between boys and girls (27.8% vs 22.7%, P = .64), nor did it differ between prepubertal and pubertal patients (18.8% vs 19.1%, P > .99). The cancer rate in patients with a solitary nodule was higher than that in patients with multiple nodules (29.4% vs 14.2%, P = .003). Sonographic characteristics associated with malignant nodules included larger size, solid parenchyma, taller-than-wide shape, presence of speckled calcifications, lack of a smooth margin, and presence of abnormal lymph nodes. Interobserver variability for assessment of sonographic characteristics ranged from moderate to very strong. Conclusion In children with thyroid nodules, solitary nodules, larger nodule size, solid parenchyma, taller-than-wide shape, speckled calcifications, irregular margins, and abnormal lymph nodes raise concern for malignancy.

Prognostic significance of diffuse sclerosing variant papillary thyroid carcinoma: a systematic review and meta-analysis

OBJECTIVE

Diffuse sclerosing variant papillary thyroid carcinoma (DSVPTC) is an uncommon variant of papillary thyroid carcinoma (PTC). The biological behaviors and prognostic outcomes of this variant, however, are still controversial. The aim of this systematic review and meta-analysis is to investigate the prognostic significance and outcomes of DSVPTCs in comparison with classical PTCs (cPTCs).

METHODS

An electronic search was performed in five libraries: PubMed, Scopus, ISI, World Health Organization Global Health Library (WHO GHL) and Virtual Health Library (VHL) in June 2016. Published data were extracted and were pooled into odds ratios (OR), mean differences and corresponding 95% confidence intervals (CI) using random-effect model. Publication bias was analyzed using Egger's regression test and funnel plot observation.

RESULTS

From 315 articles, we included 16 articles comprising 732 DSVPTCs for meta-analysis. Overall, DSVPTC manifested more aggressive clinicopathological behaviors than cPTC such as higher rate of vascular invasion (OR: 5.33; 95% CI: 3.08-9.23), extrathyroidal extension (OR: 2.96; 95% CI: 2.04-4.30), lymph node metastasis (OR: 5.40; 95% CI: 2.82-10.35), distant metastasis (OR: 3.61; 95% CI: 1.89-6.88) and were more likely to relapse (OR: 2.83; 95% CI: 1.59-5.05). DSVPTC patients were associated with a worsened overall survival (HR: 1.89; 95% CI: 1.36-2.62).

CONCLUSION

DSVPTCs should be considered high-risk PTCs because of high propensity for tumor invasion, metastasis, relapse and mortality. Aggressiveness of DSVPTCs might be related to a different molecular pathway than that in cPTCs.

High endothelial venule-like vessels and lymphocyte recruitment in diffuse sclerosing variant of papillary thyroid carcinoma

Diffuse sclerosing variant of papillary thyroid carcinoma (DSPTC) is a rare subtype of papillary thyroid carcinoma with a high incidence of lymph node metastasis. One of its characteristic histological features is the presence of dense lymphocyte infiltrates; however, how these lymphocytes are recruited in this pathological setting remains unclear. Here, we analysed 17 DSPTC cases immunohistologically for cell adhesion molecules expressed on endothelial cells. We found that venules morphologically similar to high endothelial venules (HEVs) in secondary lymphoid organs were induced in lymphoid aggregates in DSPTC, and such HEV-like vessels expressed 6-sulfo sialyl Lewis X (sLeX) glycans as well as intercellular adhesion molecule 1 (ICAM-1). Triple immunohistochemistry revealed that CD8⁺ cytotoxic T cells were the major lymphocyte subset attached to the luminal surface of HEV-like vessels. sLeX-type glycans were also expressed on DSPTC carcinoma cells, which in binding assays were decorated with E-selectin•IgM chimaeras calcium-dependently. These findings collectively suggest that 6-sulfo sLeX glycans, together with ICAM-1, on HEV-like vessels may function to recruit CD8⁺ cytotoxic T cells in DSPTC. Additionally, sLeX-type glycans on carcinoma cells might partly contribute to highly metastatic properties of DSPTC through interaction with E-selectin expressed on endothelial cells.

Outcome of the Diffuse Sclerosing Variant of Papillary Thyroid Cancer: A Meta-Analysis

INTRODUCTION

The diffuse sclerosing variant (DSV) of papillary thyroid cancer (PTC) is considered an aggressive histotype associated with poor prognosis. However, the available data for both the outcome and best management of this disease are inconsistent.

METHODS

This study reviewed the current literature by searching PubMed up to November 30, 2015, using the search terms "diffuse sclerosing variant" and "papillary thyroid cancer (or carcinoma)" and selecting only studies evaluating recurrent/persistent disease and cancer-related mortality in both DSV and classic PTC (cPTC). The association with some features of aggressiveness at diagnosis, the risk of recurrence or persistence, and the risk of cancer-related death were reported as odds ratio (OR) with confidence intervals (CI). Meta-regression analysis was used to assess the effect of covariates across the studies.

RESULTS

Ten studies met the eligibility criteria and contributed 585 DSV and 64,611 cPTC patients. Relative to patients with cPTC, patients with DSV exhibited a higher risk of extrathyroidal extension and lymph node and distant metastases. The risk of persistent/recurrent disease was three times higher in patients with DSV than it was in cPTC patients (OR = 3.19 [CI 1.86-5.49]). This risk was not different when only studies where post-surgical (131)I was routinely administered were considered (OR = 2.07 [CI 0.88-4.90]). The risk of cancer-related mortality was not different between DSV and cPTC (OR = 1.34 [CI 0.76-2.38]).

CONCLUSIONS

This meta-analysis confirms the aggressive biological behavior of DSV thyroid cancer. When preoperatively suspected, total thyroidectomy with lymph node excision followed by radioiodine therapy should be the correct management for DSV.

Follicular and Diffuse Sclerosing Variant Papillary Thyroid Carcinomas as Independent Predictive Factors of Loco-Regional Recurrence: A Comparison Study Using Propensity Score Matching

BACKGROUND

Only about half of papillary thyroid carcinoma (PTC) cases are classified as conventional PTC (CV-PTC), whereas various histologic variants constitute the remaining cases. Since controversies about the clinical behavior and outcomes of PTC variants continue, the purpose of this study was to compare the outcomes of patients with PTC variants who were treated at a large tertiary referral center in Korea.

METHODS

The medical records for 15,598 CV-PTCs, 435 follicular variants of PTC (FV-PTCs), and 66 diffuse sclerosing variants of PTC (DSV-PTCs) were retrospectively reviewed. Loco-regional recurrences (LRR) among PTC variants were compared using propensity score matching.

RESULTS

Analysis I compared CV-PTC with FV-PTC. After rigorous matching, 367 pairs were established. Recurrence-free survival (RFS) rates in CV-PTC were 96.1% at 5 years, 92.2% at 10 years, and 92.2% at 15 years, while those for FV-PTC were 98.8% at 5 years, 98.8% at 10 years, and 98.8% at 15 years (p = 0.026). Analysis II compared CV-PTC with DSV-PTC. Rigorous matching yielded 56 pairs. RFS rates for CV-PTC were 87.4% at 5 years, 87.4% at 10 years, and 87.4% at 15 years, while those for DSV-PTC were 68.9% at 5 years, 57.5% at 10 years, and were not available at 15 years (p = 0.013).

CONCLUSIONS

Compared with CV-PTC, FV-PTC showed less aggressive behaviors and more favorable outcomes. However, DSV-PTC showed more aggressive behaviors and a less favorable outcome than CV-PTC did. Therefore, the management strategy and follow-up plan for PTC should be differentiated according to the histologic variant.

Shear wave elastography diagnosis of the diffuse sclerosing variant of papillary thyroid carcinoma: A case report

The present study aimed to report the shear wave elastography (SWE) findings in a patient with the diffuse sclerosing variant of papillary thyroid carcinoma (DSVPTC). Since patients with DSVPTC may present with typical clinicopathological features and initially appear to have Hashimoto's thyroiditis, a thorough clinical evaluation and an early diagnosis are important. A 20-year-old female patient presented with a 1-month history of a neck mass and sore throat. Conventional ultrasound and SWE were performed using an AIXPLORER system with 14-5 MHz linear transducer. The patient had undergone total thyroidectomy and bilateral neck lymph node dissection, and an intraoperative pathology consultation to confirm the malignancy of lymph node metastasis. Pathological diagnosis was DSVPTC in both lobes, with lymph node metastases in the bilateral neck. The clinical presentation and serological findings were all indicative of Hashimoto's thyroiditis. Thyroid ultrasonography revealed diffuse enlargement of the both lobes, heterogenous echogenicity without mass formation, diffuse scattered microcalcifications and poor vascularization. SWE revealed stiff values of the thyroid: The mean stiffness was 99.7 kpa, the minimum stiffness was 59.1 kpa and the maximum stiffness was 180.1 kpa. The maximum stiffness of the DSVPTC (180.1 kpa) was higher compared with the diagnostic criteria of malignant thyroid nodules (65 kPa). SWE may be considered as a novel and valuable method to diagnose DSVPC.

Pediatric Differentiated Thyroid Carcinoma of Follicular Cell Origin: Prognostic Significance of Histologic Subtypes

BACKGROUND

Thyroid cancers are rare in the pediatric age group, and unlike in adults, few data are available regarding the clinical implication of histologic subtypes in the pediatric population. The purpose of the current study was to determine the prognostic significance of histologic subtypes of differentiated thyroid cancer (DTC) in a large series of children and adolescents followed at a single institution.

METHODS

A retrospective review was conducted of all pediatric DTC patients who were treated and followed between 1988 and 2012. Sixty-two patients (median age at diagnosis 13.8 years, median age at follow-up 18 years, 77% female) were assessed. The most common subtypes included classic papillary thyroid carcinoma (PTC; 48%), diffuse sclerosing PTC (16%), and follicular variant PTC (15%); 37% were considered "high-risk" histologies based on adult criteria.

RESULTS

In a multivariate model, only extensive extrathyroidal extension (ETE), defined as the presence of two or more microscopic foci of tumor cells ≤1 mm in size each or any foci >1 mm in size invading beyond the thyroid capsule into perithyroid soft tissue or organs, was significantly associated with extent of disease at presentation. At last follow-up, 76% of subjects had no evidence of disease, 18% had persistent disease, and 5% had recurrent/progressive disease. Event-free survival was associated with extent of disease at presentation (p = 0.01), extensive ETE at diagnosis (p < 0.01), and male sex (p = 0.01), but not histologic subtype (p = 0.20).

CONCLUSIONS

Pediatric DTC carries an excellent prognosis. Extensive ETE at diagnosis was found to be an independent predictor of extent of disease at presentation, as well as event-free survival. Unlike in the adult population, "high-risk" histologic subtypes did not independently predict extent of disease at presentation or event-free survival in this pediatric population with DTC.

Papillary Thyroid Carcinoma Arising in Children and Adolescent Hashimoto's Thyroiditis: Ultrasonographic and Pathologic Findings

Objectives. We compared the ultrasonography and pathology features of papillary thyroid carcinoma (PTC) in pediatric and adolescents with Hashimoto's thyroiditis (HT) with those of non-HT patients. Materials and Methods. Eleven patients who were surgically confirmed to have pediatric or adolescent PTC from 2006 to 2014 were included in this study. We retrospectively analyzed the preoperative ultrasonography and pathology features of PTC arising in HT and non-HT patients. Results. On ultrasonography, thyroid gland was lobulated and enlarged, with many scattered microcalcifications in four of five HT patients. Four of six non-HT patients had suspicious masses with calcifications. The diffuse sclerosing variant of PTC (DSVPTC) was found in three of five HT patients, but none in non-HT patients. Macroscopic or microscopic extrathyroidal extension was evident in all of the HT patients and four of the non-HT patients. Neck lymph node metastases were in all HT patients and five of non-HT patients. Conclusions. Three of five PTCs in pediatric and adolescent HT patients were DSVPTC, whereas all PTCs of the non-HT patients were classic type. On ultrasonography, thyroid gland was diffusely enlarged with scattered microcalcifications in four of five HT patients. All five HT cases had aggressive disease, including extrathyroidal extension and cervical lymph node metastases.

Conservative or radical surgery for pediatric papillary thyroid carcinoma: A systematic review of the literature

BACKGROUND

Pediatric papillary thyroid carcinoma (PTC) is characterized by an aggressive clinical course. Early diagnosis is a challenge and treatment consists principally of partial or total thyroidectomy±neck dissection and radioactive iodine therapy. Due to the rarity of PTC in children, there is no consensus on optimal surgical treatment.

METHODS AND RESULTS

A literature search was carried out using PubMed, Embase, Medline, Cochrane and Web of Science. Seven studies (489 patients) investigating the outcome of surgically managed pediatric PTC were identified. No clear advantage in survival or recurrence rate was found for total thyroidectomy compared to other surgical approaches.

CONCLUSION

Despite the aggressive behavior of PTC, prognosis is good, with low mortality. After removal of disease and prevention of recurrence, reduction of iatrogenic complications are a priority in this age group. Due to the paucity of available evidence, this review cannot recommend conservative or radical surgery for pediatric papillary thyroid carcinoma. To answer this question, we recommend the establishment of a randomized controlled trial with adequately matched baseline variables.

Prognosis and growth activity depend on patient age in clinical and subclinical papillary thyroid carcinoma

In this review, we focused on the patient age as an indicator of tumor growth and prognostic significance in both clinical papillary thyroid carcinoma (PTC) and subclinical papillary microcarcinoma (PMC: PTC ≤ 1 cm). In clinical PTC, young age (< 30 years) and old age (≥ 60 years) significantly affected the disease-free survival of patients, and old age was a strong predictor of carcinoma death. In contrast, in subclinical PMC, growth activity significantly decreased with patient age, and young age (< 40 years) was an independent predictor of carcinoma growth, indicating that old patients with subclinical PMC are the best candidates for observation without immediate surgery. Taken together, our findings indicate that the role of patients' age as an indicator of tumor growth differs significantly between clinical PTC and subclinical PMC.

Different CXCR4 expression according to various histologic subtype of papillary thyroid carcinoma

Functional chemokine (C-X-C motif) receptor 4 (CXCR4) is well known to be over-expressed in papillary thyroid carcinoma (PTC). The aim of this study was to evaluate whether or not the expression of CXCR4 is different by histological subtypes of PTC and to elucidate the relationship between the expression of CXCR4 and clinicopathologic factors. CXCR4 expression in 127 PTC samples was assessed using immunohistochemical staining. The expression of CXCR4 showed different patterns according to the histological subtype of PTC (p < 0.001). A strong expression of CXCR4 was observed more frequently in the poorly differentiated region of PTC (81.0 %) than in classical PTC (50.0 %). Strong CXCR4 expression was less frequently shown in follicular variant (33.9 %) and in diffuse sclerosing variant (14.3 %) of PTC. CXCR4 expression showed a distinct pattern according to the histological subtype of PTC although not associated with other clinicopathological parameters.

Pathological characteristics and clinical perspectives of papillary thyroid cancer: study of 714 patients

Papillary thyroid cancer belongs to most commonly diagnosed well-differentiated malignant tumor of the thyroid gland, with only minority of cases being more aggressive, recurring locoregionally and developing distant metastatic foci. The aim of this study was to determine the clinical relationship between parameters of age, gender, size of primary tumor, intraglandular dissemination and regional metastatic spread and evaluate the importance of each parameter; analyze other major aggressive factors (tumor border, thyroid capsule invasion, perivascular, perilymphatic spread) on prevalence and extent of intraglandular dissemination and relation to metastatic spread in neck. This study is a retrospective analysis of clinical and pathological data from 714 patients with papillary thyroid cancer, presented and operated at the Department of ENT/Head and Neck surgery, Sisters of Charity University Hospital, Zagreb, in the period from 1980 to 2008. All patients were operated upon with total thyroidectomy and some type of neck lymphonode dissection (paratracheal or lateral). In results, we found 46.9% tumors were aggressive; 34.7% tumors were multicentric, with foci in the contralateral lobe nearly twice as often as in the ipsilateral lobe; 27.8% were regionally metastatic, with equal distribution between paratracheal and lateral regions. In conclusion, we revealed contralateral lobe multicentricity and male gender as independent risk factors for regional metastatic dissemination. Nodular goiter has been identified as a protective parameter.

Estrogen receptor- and progesterone receptor-positive diffuse sclerosing variant of papillary thyroid carcinoma: a case report

The diffuse sclerosing variant of papillary thyroid carcinoma (DSV-PTC) is a relatively rare tumor. We herein report the case of young woman with DSV-PTC who developed cervical lymph node recurrence 7 years after the initial surgery. A 15-year-old female patient with no medical or family history of thyroid tumors developed a thyroid neoplasm in the right lobe. Right thyroidectomy and regional lymphadenectomy were performed, and the tumor was diagnosed as DSV-PTC. She was followed up as an outpatient. Seven years after the surgery, cervical lymph node recurrence developed. On microscopic examination, the thyroid tumor showed a papillary growth pattern with numerous psammoma bodies and distinct fibrosis. Immunohistochemically, the tumor cells were estrogen receptor and progesterone receptor positive with reduced membranous expression of E-cadherin and were intermingled with S-100-positive dendritic/Langerhans cells. DSV-PTC is characterized by a strong tendency for invasion and metastasis. Thus, accurate diagnosis is clinically important, and a morphological and immunohistochemical understanding of DSV-PTC is necessary.

Diffuse sclerosing variant of papillary thyroid carcinoma: sonography and specimen radiography

The purpose of this pictorial essay is to show the limitations of sonography and complementary usefulness of specimen radiography in detecting microcalcifications of the diffuse sclerosing variant of papillary thyroid carcinoma, which mostly manifests as diffusely scattered microcalcifications in the thyroid gland.

Diffuse sclerosing variant of papillary thyroid carcinoma with multiple metastases and elevated serum carcinoembryonic antigen level

BACKGROUND

Diffuse sclerosing variant of papillary thyroid carcinoma (DSPC) is a rare variant of papillary thyroid carcinoma (PTC). We report a 61-year-old female of DSPC whose course was complicated by multiple metastases and an elevated serum carcinoembryonic antigen (CEA) level.

SUMMARY

The patient presented with upper back pain. X-ray showed an osteolytic lesion of the sixth cervical spinous process. She had a hard, nonmovable mass with fixed enlarged lymph nodes (LNs) over right neck. Fine-needle aspiration cytology revealed PTC with LNs metastasis. Positron emission tomography demonstrated multiple brain, bone, liver, and lung metastases. However, the patient had an elevated serum CEA level. She underwent a total thyroidectomy and 200 mCi radioactive (131)I therapy. The pathological findings were diffuse sclerosing variant of PTC with capsular and lymph vessel invasion. A double staining of tumor specimen appeared concomitantly positive for CEA and thyroglobulin.

CONCLUSIONS

To our knowledge, DSPC with an elevated CEA level is extremely rare.

Diffuse sclerosing variant of thyroid papillary carcinoma: diagnostic challenges occur with Hashimoto's thyroiditis

Diffuse sclerosing papillary thyroid carcinoma (DSPTC) is a relatively rare variant of papillary thyroid carcinoma with distinct histological features, radiological characteristics, and biological aggressiveness. Compared with conventional papillary thyroid carcinoma, DSPTC is characterized by scattered microscopic tumor islands, diffuse fibrosis, calcification, and abundant lymphocytic aggregation. A preoperative diagnosis is challenging in the absence of nodules and scanty fine needle aspiration cytology samples. We describe a unique DSPTC patient, an 18-year-old woman who presented with a neck mass that grew slowly for 2 years. The palpable neck mass was nontender, well defined, firm, and unmovable. Laboratory studies showed normal thyroid function and positive autoimmune markers: antithyroglobulin antibody = 1:1600 and antimicrosomal antibody = 1:1600. A neck ultrasound showed diffusely prominent microcalcifications with one small vague nodule. Hashimoto's thyroiditis with an accompanying malignancy was suspected. Based on the result of intraoperative pathology reports, the patient was given a total thyroidectomy. Lymph node dissection and histological analysis revealed bilateral DSPTC in addition to lymphocytic thyroiditis in nonmalignant areas of the thyroid. Clinical and histological diagnostic challenges usually occur when DSPTC presents with a diffuse thyroid enlargement, dispersed microscopic tumor islands (frequently without mass formation), extensive fibrosis, and abundant lymphocytic infiltration mimicking thyroiditis.

Collapsing benign cystic nodules of the thyroid gland: sonographic differentiation from papillary thyroid carcinoma

BACKGROUND AND PURPOSE

The US features of benign and malignant nodules overlap, and benign thyroid lesions can mimic thyroid malignancy on US. Benign cystic nodules after spontaneous collapse or needle aspiration, can mimic malignant thyroid nodules. Our aim was to evaluate the US features of CBCNs of the thyroid that distinguish such nodules from malignant thyroid nodules.

MATERIALS AND METHODS

US and clinical findings in 13 patients, each with a single CBCN, were evaluated to determine if they showed >50% cystic content on initial US or CT and >30% decrease in maximum diameter on follow-up US. We compared these findings with those of 26 patients, each with a single surgically confirmed PTMC. US scans were analyzed for internal content, shape, margin, echogenicity, presence of echogenic dots suggesting micro- and macrocalcification, inner isoechoic rim, and low-echoic halo.

RESULTS

Six of the 13 (46%) CBCNs were classified as malignant on US due to their marked hypoechogenicity, microcalcification, or spiculated margins. US features that differed between CBCNs and PTMCs were shape (ovoid-to-round versus taller-than-wide, P = .016); margins (ill-defined versus spiculated, P < .000); low-echoic halo (P < .000); inner isoechoic rim (P < .000) with high negative predictive values (100%, 91%, 91%, and 89%, respectively); and clinically acceptable diagnostic accuracy (59%, 80%, 82%, and 85%, respectively).

CONCLUSIONS

US features helpful for differential diagnosis of CBCNs from PTMCs include shape, margin, and the presence of an inner isoechoic rim and a low-echoic halo. Familiarity with US features suggesting CBCNs may be helpful in reducing unnecessary repeated FNABs.

Papillary thyroid carcinoma: differential diagnosis and prognostic values of its different variants: review of the literature

Papillary thyroid carcinoma is the most common thyroid malignancy, and has an excellent prognosis, even with cervical lymph node metastasis; however, histological variants are considered relevant, which may be associated with familial adenomatous polyposis and tumor aggressiveness. Histological features, such as vascular and/or lymphatic invasion, angiogenesis, multifocality, high cellular proliferation rate, neoplastic cell dissemination, and the histological varieties, are indicative of poor prognosis, together with associated clinical factors: age, sex, and tumor size.

Prognostic factors of papillary and follicular carcinomas in Japan based on data of kuma hospital

There are some important prognostic factors for papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). In this paper, clinicopathological features significantly affecting patient prognosis are described based on our data as well as others. Distant metastasis at diagnosis is the most important prognostic factor for both PTC and FTC. Other than that, preoperative and intraoperative findings are important to evaluate the biological behavior of PTC. Extrathyroid extension, large lymph-node metastasis, and extranodal tumor extension that can be evaluated preoperatively or intraoperatively are significant prognostic factors for PTC patients. In contrast, pathological findings are important not only for diagnosis of FTC, but also for the evaluation of its biological character. Grade of invasiveness (minimally or widely invasive) and degree of differentiation (well differentiated or including a poorly differentiated component) greatly affect the prognosis of FTC patients.

A diffuse sclerosing variant of papillary thyroid carcinoma: clinical and pathologic features and outcomes of 34 consecutive cases

BACKGROUND

The diffuse sclerosing variant of papillary thyroid carcinoma (DSPC) is a relatively rare variant of papillary thyroid cancer. Large studies of patients with DSPC have been infrequently performed, and controversy still exists concerning some DSPC features and outcomes. The aim of the present study was to retrospectively evaluate the clinicopathologic features and outcomes in a series of 34 consecutive patients with DSPC and to compare them with a larger group of 245 consecutive patients with the classic variant of papillary thyroid carcinoma (cPTC) that were evaluated in the same period.

PATIENTS AND METHODS

Clinical and histological features (sex, age, tumor size,multifocality, bilaterality, extra thyroid extension, and local and distant metastases) were recorded in all patients, as well as any persistent or recurrent disease and the patients' disease status at last observation. Patients with cPTC were classified as either low (122) or high risk (123). DSPC and high-risk patients were all treated with the same protocol, including ¹³¹I treatment. All patients were included in a Cox regression model analysis to investigate the effect of each variable on the hazard ratio.

RESULTS

As expected, multifocality, bilaterality, and extra thyroid extension were more frequently noted at presentation, and the pT1 category of TNM classification was less frequently noted in DSPC and high-risk patients with cPTC compared with low-risk patients with cPTC. No significant difference was found between patients with DSPC and those with high-risk cPTC, except that extra thyroid extension was found more frequently in the patients with DSPC. Using multivariate analysis, diffuse sclerosing variant was an independent variable for predicting a high risk of persistent and recurrent disease during initial follow-up. However, at a later time, and after further treatment, the disease status was not different between patients with DSPC and those with high-risk cPTC, and only the presence of distant metastases affected the final outcome.

CONCLUSIONS

DSPC is a thyroid papillary carcinoma variant characterized by high aggressiveness. In patients with DSPC, the outcome is worse than in patients with low-risk cPTC; and, at presentation, characteristics are somewhat worse than for patients with high-risk cPTC.At medium term, the outcome is similar to that observed in patients with high-risk cPTC, provided aggressive treatment is used (additional surgical intervention, when required, and/or ¹³¹I radiotherapy).

Papillary thyroid carcinoma of a diffuse sclerosing variant: ultrasonographic monitoring from a normal thyroid gland to mass formation

A diffuse sclerosing variant of papillary thyroid carcinoma is uncommon and has a tendency for rapid growth and a higher incidence of cervical lymph node metastases. We experienced a case of a diffuse sclerosing variant of papillary thyroid carcinoma in a 48-year-old man. This case showed benign features on initial ultrasonography and positron emission tomography (PET) scan. A new nodule was detected on follow-up ultrasonography that showed rapid enlargement. This case was confirmed by surgical excision. We herein describe the initial and follow-up ultrasonographic findings of a diffuse sclerosing variant of papillary thyroid carcinoma.

Sonographic findings of the diffuse sclerosing variant of papillary carcinoma of the thyroid

OBJECTIVE

The purpose of this series was to describe the sonographic findings of the diffuse sclerosing variant of papillary carcinoma (DSVPC) of the thyroid.

METHODS

The sonographic findings of 8 patients with DSVPC of the thyroid were retrospectively analyzed. The following sonographic features of DSVPC of the thyroid were analyzed: extent of disease, echogenicity, microcalcifications, and cervical metastatic lymphatic nodes.

RESULTS

Three of 8 cases were unilateral, and 5 were bilateral. All 8 cases showed diffuse involvement of at least 1 entire thyroid lobe. Five of 8 cases showed hyperechogenicity, and 3 showed hypoechogenicity. Seven of 8 cases showed diffuse scattered microcalcifications, and 1 showed locally distributed microcalcifications. All 8 cases showed cervical metastatic lymph nodes.

CONCLUSIONS

The sonographic findings of DSVPC of the thyroid are characteristic, and sonography is a useful imaging tool in diagnosis of DSVPC of the thyroid.

Value of specimen radiographs in diagnosing multifocality of thyroid cancer

BACKGROUND

Specimen radiography has been used widely to evaluate the complete excision of calcified breast lesions but has not been evaluated for thyroid cancer.

METHODS

Specimen radiographs were evaluated retrospectively to identify additional cancers that were demonstrated only as calcifications. Receiver operating characteristic curve analysis was performed to compare the combination of specimen radiography and ultrasonography versus ultrasonography alone for detecting multifocality.

RESULTS

Some 122 thyroid cancer specimens were obtained from 122 patients between January and April 2008. Specimen radiography detected 27 cancers (18.5 per cent) not detected by ultrasonography. Diagnoses were changed after evaluation of specimen radiographs in three of these patients. The area under the curve of the combination of specimen radiography and ultrasonography was significantly higher than that of ultrasonography alone (P = 0.005).

CONCLUSION

Specimen radiography is a potentially useful tool for diagnosing cancer type and predicting the extent of thyroid cancer.

Diffuse sclerosing variant is a major subtype of papillary thyroid carcinoma in the young

BACKGROUND

Pediatric thyroid cancer differs from adult thyroid cancer in presentation and outcome. Pediatric thyroid cancer has a higher recurrence rate and greater percentage of lymph node and pulmonary metastasis. The clinicopathologic characteristics of pediatric thyroid cancer according to the histologic subtype have not been reported, however. In this study, we determined the histological subtypes of pediatric thyroid cancer and analyzed other clinicopathologic characteristics.

METHODS

All patients with thyroid cancer who were admitted to Severance Hospital, Seoul, South Korea, were retrospectively reviewed; their age was <20 years at diagnosis, and they were seen between January 1995 and August 2008.

RESULTS

Sixty-eight patients were identified. The histologic types of thyroid carcinoma were papillary thyroid carcinoma (PTC) in 57 (83.8%), follicular carcinoma in 8 (11.8%), and poorly differentiated carcinoma in 3 (4.4%). There were 28 (41.2%) cases of diffuse sclerosing variant of papillary carcinoma (DSVPC), 26 (38.2%) of conventional PTC, 2 (2.9%) of follicular PTC, and 1 (1.5%) cribriform-morular PTC. In patients with PTC, there was a higher incidence of bilateral thyroid involvement (p = 0.003), extrathyroidal extension (p = 0.009), and lymph node involvement (p = 0.018), and lower recurrence-free survival (p = 0.032) in DSVPC than in non-DSVPC. Univariate regression analysis revealed that extrathyroidal extension (p = 0.025) and tumor size (p = 0.001) were positively associated with a shorter time to recurrence.

CONCLUSION

DSVPC is a major subtype of PTC in the young.

I-131, I-123, and F-18 FDG-PET imaging in a patient with diffuse sclerosing variant of papillary thyroid cancer

PURPOSE

To compare the sensitivity of I-123 total body iodine (TBI) scan, I-131 TBI, and PET scanning with 2-deoxy-2[F-18]fluoro-D-glucose (FDG-PET) scans for detection of residual/recurrent disease in patients with diffuse sclerosing variant of papillary thyroid cancer.

MATERIALS

A 45-year-old woman with status post-thyroidectomy and modified neck dissection showed papillary thyroid carcinoma with a diffuse sclerosing variant and positive lymph nodes. Six weeks after surgery, I-131 TBI and FDG-PET scans showed no residual or metastatic disease. However, clinical suspicion for disease remained, and an I-123 TBI scan was performed.

RESULTS

I-123 TBI showed a tiny residual focus in the left thyroid bed. The patient was treated with 150 mCi oral I-131 sodium iodide; posttreatment scan confirmed the presence of residual disease. Follow-up I-123 TBI scans up to 2 1/2 years posttreatment were negative.

CONCLUSION

Total body imaging with I-123 was more sensitive than I-131 TBI scanning for detecting residual or recurrent disease in patients with well-differentiated thyroid cancer presenting with low preoperative thyroglobulin levels.

Prognostic factors and therapeutic strategies for differentiated carcinomas of the thyroid

Differentiated thyroid carcinoma originates from thyroid follicular cells and is the most prominent malignancy of the endocrine organs. There are two histological types of differentiated carcinoma, namely, papillary and follicular carcinoma. According to reports from Western countries, papillary carcinoma comprises 85.3% of thyroid malignancies in whites, and 72.3% in blacks. In Japan, a previous study showed that the prevalence of papillary carcinoma was 78.4% based on material registered between 1977 and 1986, but according to recent findings reported in 2004 by Japanese Society of Thyroid Surgeons (JSTS), papillary carcinoma accounted for as much as 93% of all thyroid carcinomas. Papillary carcinoma frequently metastasizes to the regional lymph node and shows multicentricity in the thyroid gland. It usually shows a typical ultrasonographic appearance and can be rather easily diagnosed by fine needle aspiration biopsy (FNAB). Follicular carcinoma accounts for 10.9-20.5% of the patients in the United States. In Japan, the prevalence of follicular carcinoma was reported to be 17.2%, but it decreased to 5% in a report by JSTS in 2004. This carcinoma is only occasionally diagnosed preoperatively, because it is hard to discriminate follicular carcinoma from benign adenoma on imaging studies and cytologic findings. In contrast to papillary carcinoma, follicular carcinoma more often metastasizes to distant organs than regional lymph nodes. In Japan, the prevalence of papillary carcinoma increased and that of follicular carcinoma decreased between reports from 1977 to 1986 and that in 2004, which may be because follicular variant of papillary carcinoma was classified into follicular carcinoma in the previous results. Generally, these carcinomas show an indolent character, but when the lesion dedifferentiates and becomes undifferentiated carcinoma, it displays very rapid growth with an adverse prognosis and is regarded even as the most aggressive malignancy among human solid carcinomas. Furthermore, cases showing certain characteristics are likely to be constantly progressive and even become life-threatening. Such cases should be regarded as "high-risk" requiring careful and extensive surgical treatment and postoperative follow-up. Indeed, it is most important for physicians to correctly distinguish high-risk cases from those with an indolent character, although how to evaluate the biological characteristics of thyroid carcinoma and how to identify high-risk cases remains highly controversial. In this review, the methods of distinguishing high-risk cases and the appropriate therapeutic strategies for papillary and follicular carcinomas predominantly based on our experience are emphasized and our proposals for therapies including surgical treatment are demonstrated.

Prevalence and biological behaviour of variants of papillary thyroid carcinoma: experience at a single institute

AIMS

There are many variants of papillary carcinoma, and some of these variants have been reported to show biological behaviours differing from that of conventional papillary carcinoma. In this study, we present our experience regarding the prevalence and prognoses of these variants of papillary carcinoma.

METHODS

H&E sections from 1521 patients who underwent initial surgery for papillary carcinoma in Kuma Hospital between 1987 and 1995 were re-reviewed and classified into conventional papillary carcinoma and various histological variants. We investigated the biological behaviours of these lesions, including prognoses.

RESULTS

Follicular, tall cell and oncocytic variants were observed in comparably high incidences: 6.6%, 3.9%, and 1.9%, respectively. Patients with tall cell variant showed significantly worse disease-free survival (DFS) and cause-specific survival (CSS) rates than those with conventional papillary carcinoma. The prognoses of patients with follicular variant did not differ from those of patients with conventional papillary carcinoma. Patients with oncocytic variant have not shown carcinoma recurrence. Among the rare variants, which accounted for less than 1%, columnar cell carcinoma showed a worse prognosis.

CONCLUSIONS

Since patients with some variants show different clinical outcomes from those with conventional papillary carcinoma, classification of variants might be helpful to predict patient prognosis.

Human thyroid tumours, the puzzling lessons from E7 and RET/PTC3 transgenic mice

Human rearranged RET/PTC3 (papillary thyroid carcinoma) proto-oncogene and high-risk human papillomavirus (HPV) type 16 E7 oncogene induces in the mouse a neoplastic transformation of thyroid follicular cells. We present a detailed immuno-histological study (170 mouse thyroids: RET/PTC3, E7, wild type, 2- to 10-month-old) with cell cycle proliferation and signalling pathway indicators. The characteristics of both models are different. There is an 'oncogene dependent' cellular signature, maintained at all studied ages in the E7 model, less in the RET/PTC3 model. During tumour development a large heterogeneity occurred in the Tg-RET/PTC3 model within a same tumour or within a same thyroid lobe. The Tg-E7 model was less heterogeneous, with a dominant goitrous pattern. The solid tumour already described in the RET/PTC3 models associated with cribriform patterns, suggested 'PTC spindle cell changes' as in humans PTC rather than the equivalent of the solid human PTC. Proliferation and apoptosis in the two thyroid models are related to the causal oncogene rather than reflect a general tumorigenic process. The thyroids of RET/PTC3 mice appeared as a partial and transient model of human PTCs, whereas the Tg-E7 mice do not belong to the usual PTC type.

Differentiated thyroid cancers 11-20 mm in diameter have clinical and histopathologic characteristics suggesting higher aggressiveness than those < or =10 mm

OBJECTIVE

To compare characteristics and outcomes of differentiated thyroid cancers < or =10 mm with those 11-20 mm in diameter.

DESIGN

Retrospective chart review of 426 patients with thyroid carcinoma < or =20 mm diagnosed and treated between 1990 and 2004 in one university clinic.

MAIN OUTCOMES

Lymph node metastases were more frequent at diagnosis in 11-20 mm than in < or =10 mm cancers (p < 0.001). The prevalence of distant metastases did not differ between < or =10 mm and 11-20 mm cancers. One hundred and thirty-three patients (73%) with tumors 11-20 mm were disease free 2 years after 131I treatment, and no recurrence has been observed over 2-14 years of follow-up. Forty-one patients (22%) with cancers 11-20 mm (N1 or M1) required 2-4 years to become disease free. Neck lymph node recurrence was observed in nine patients (4.9%) 4 months to 14 years after surgery and (131)I therapy. Four patients (1.6%) with cancers < or =10 mm in diameter had cancer recurrence (p = 0.05 compared to the 11-20 mm cancers). Based on the presence of distant metastases at diagnosis and recurrence of disease during follow-up, cancers 11-20 mm in diameter seemed more aggressive than those < or =10 mm (p < 0.05).

CONCLUSION

Cancers 11-20 mm seem more aggressive than those < or =10 mm.