1
|
Ma T, Semsarian CR, Barratt A, Parker L, Kumarasinghe MP, Bell KJL, Nickel B. Rethinking Low-Risk Papillary Thyroid Cancers < 1cm (Papillary Microcarcinomas): An Evidence Review for Recalibrating Diagnostic Thresholds and/or Alternative Labels. Thyroid 2021; 31:1626-1638. [PMID: 34470465 DOI: 10.1089/thy.2021.0274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Recalibrating diagnostic thresholds or using alternative labels may mitigate overdiagnosis and overtreatment of papillary microcarcinoma (mPTC). We aimed at identifying and collating relevant epidemiological evidence on mPTC, to assess the case for recalibration and/or new labels. Methods: We searched EMBASE and PubMed databases from inception to December 2020 for natural history, autopsy, diagnostic drift, and diagnostic reproducibility studies. Where a relevant systematic review was pre-identified, only new articles were additionally included. Non-English articles were excluded. One author screened titles and abstracts. Two authors screened full text articles, performed quality assessments, and extracted data. We undertook narrative synthesis of included evidence (pooled estimates from systematic reviews and single estimates from primary studies). Results: One systematic review of patients undergoing active surveillance found that after 5 years of follow-up, 5.3% (95% confidence interval [CI 4.4-6.4%]) of the mPTC lesions had increased in size by ≥3 mm, and 1.6% [CI 1.1-2.4%] of patients had lymph node metastases. Among 7 new primary studies (including 3 updates on 2 studies included in the systematic review), 1-5% of patients undergoing active surveillance had lymph node metastases after a median follow-up of 1-10 years. One systematic review found that subclinical thyroid cancer incidentally discovered at autopsy is relatively common, with a pooled prevalence of 11.2% [CI 6.7-16.1%] among studies that examined the whole thyroid. Four diagnostic drift studies evaluated the new classification of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Three studies of cases previously diagnosed as papillary thyroid cancer found 1.3-2.3% were reclassified as NIFTP (reclassifications were from follicular variation of papillary thyroid cancer [FVPTC]). One study of 48 cases previously diagnosed as mPTC found that 23.5% were reclassified as NIFTP. Thirteen reproducibility studies of papillary thyroid lesions found substantial variation in the histopathological diagnosis of thyroid lesions, including FVPTC and NIFTP classifications (no study evaluated mPTC). Conclusions: This review supports consideration of recalibrating diagnostic thresholds and/or alternative labels for low-risk mPTC.
Collapse
Affiliation(s)
- Tara Ma
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin R Semsarian
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Parker
- Charles Perkins Centre, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Marian Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
- Discipline of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Katy J L Bell
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Anand D, Yashashwi K, Kumar N, Rane S, Gann PH, Sethi A. Weakly supervised learning on unannotated hematoxylin and eosin stained slides predicts BRAF mutation in thyroid cancer with high accuracy. J Pathol 2021; 255:232-242. [PMID: 34346511 DOI: 10.1002/path.5773] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/18/2021] [Accepted: 07/28/2021] [Indexed: 11/08/2022]
Abstract
Deep neural networks (DNNs) that predict mutational status from H&E slides of cancers can enable inexpensive and timely precision oncology. Although expert knowledge is reliable for annotating regions informative of malignancy and other known histological patterns (strong supervision), it is unreliable for identifying regions informative of mutational status. This poses a serious impediment to obtaining higher prognostic accuracy and discovering new knowledge of pathobiology. We used a weakly supervised learning technique to train a DNN to predict BRAF V600E mutational status, determined using DNA testing, in H&E stained images of thyroid cancer tissue without regional annotations. Our discovery cohort was a tissue microarray of only 85 patients from a single hospital. Yet, on a large independent external cohort of 444 patients from other hospitals, the trained model gave an AUC = 0.98 (95% CI: 0.97-1.00), which is much higher than the previously reported results for detecting any mutation using H&E by DNNs trained using strong supervision. We also developed a visualization technique that can automatically highlight regions the DNN found most informative for predicting mutational status. Our visualization is spatially granular and highly specific in highlighting regions with strong negative and positive regions and move us towards explainable artificial intelligence. Using t-tests, we confirmed that the proportions of follicular or papillary histology and oncocytic cytology, as noted for each patient by a pathologist who was blinded to the mutational status, were significantly different between mutated and wildtype patients. However, based solely on these features noted by the pathologist, a logistic regression classifier gave an average AUC = 0.78 in 5-fold CV, which is much lower than that obtained using the DNN. These results highlight the potential of weakly supervised learning for training DNN models for problems where the informative visual patterns and their locations are not known a priori. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Deepak Anand
- Department of Electrical Engineering, Indian Institute of Technology Bombay, Mumbai, MH, India
| | - Kumar Yashashwi
- Department of Electrical Engineering, Indian Institute of Technology Bombay, Mumbai, MH, India
| | - Neeraj Kumar
- Department of Computing Science, University of Alberta, Edmonton, Alberta, Canada.,Alberta Machine Intelligence Institute, Edmonton, Alberta, Canada
| | - Swapnil Rane
- Department of Pathology, Tata Memorial Centre-ACTREC, HBNI, Mumbai, MH, India
| | - Peter H Gann
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amit Sethi
- Department of Electrical Engineering, Indian Institute of Technology Bombay, Mumbai, MH, India.,Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| |
Collapse
|
3
|
Fisher SB, Cote GJ, Bui-Griffith JH, Lu W, Tang X, Hai T, Fisher KE, Williams MD, Wistuba II, Waguespack SG, Dorman CM, Ludwig MS, Graham PH, Perrier ND, Lee JE, Grubbs EG. Genetic characterization of medullary thyroid cancer in childhood survivors of the Chernobyl accident. Surgery 2019; 165:58-63. [PMID: 30392857 DOI: 10.1016/j.surg.2018.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/01/2018] [Accepted: 08/06/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Radiation-associated fusion oncogenes play a direct role in papillary thyroid cancer development and pathogenic fusions have recently been reported in medullary thyroid cancer. To date, no studies have evaluated oncogenic events in medullary thyroid cancer in a radiation-exposed population. METHODS Somatic and germline alterations, including RET fusions, were evaluated in paired medullary thyroid cancer tumor and normal samples from the Chernobyl Tissue Bank, a heavily screened population affected by the Chernobyl disaster. RESULTS Tissue was available for 49 individuals. The median age of diagnosis was 26 years (range 9 to 43 years); 16 were radiation-exposed at a median age of 6 (range 2 days to 17 years). A total of 21 patients harbored germline RET mutations (codons 634[13], 918[5], 790[1], 609[1], and 620[1]); 4 had family history. Sporadic medullary thyroid cancer was identified in 27 patients (RET[18], KRAS[1], RET+KRAS[1], TP53[1], wild type [6]), with 1 RET fusion (1/49;2%). The age at operation for patients with hereditary medullary thyroid cancer was not different than sporadic medullary thyroid cancer (23.5 vs 28 years, P = .063). In sporadic medullary thyroid cancer, radiation was not associated with a difference in age at operation, tumor size, or tumor stage (P > .05). CONCLUSION In a heavily screened cohort, genetic analysis revealed germline RET mutations in previously unrecognized probands and a remarkable number of sporadic medullary thyroid cancer cases with a young age at presentation.
Collapse
Affiliation(s)
- Sarah B Fisher
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, Texas
| | - Gilbert J Cote
- University of Texas MD Anderson Cancer Center, Department of Endocrine Neoplasia and Hormonal Disorders, Houston, Texas
| | | | - Wei Lu
- University of Texas MD Anderson Cancer Center, Department of Translational Molecular Pathology, Houston, Texas
| | - Ximing Tang
- University of Texas MD Anderson Cancer Center, Department of Translational Molecular Pathology, Houston, Texas
| | - Tao Hai
- University of Texas MD Anderson Cancer Center, Department of Endocrine Neoplasia and Hormonal Disorders, Houston, Texas
| | - Kevin E Fisher
- Baylor College of Medicine, Department of Pathology and Immunology, Houston, Texas
| | - Michelle D Williams
- University of Texas MD Anderson Cancer Center, Department of Pathology, Houston, Texas
| | - Ignacio I Wistuba
- University of Texas MD Anderson Cancer Center, Department of Translational Molecular Pathology, Houston, Texas
| | - Steven G Waguespack
- University of Texas MD Anderson Cancer Center, Department of Endocrine Neoplasia and Hormonal Disorders, Houston, Texas
| | - Clark M Dorman
- University of Texas at Houston Medical School, Houston, Texas
| | - Michelle S Ludwig
- Baylor College of Medicine, Department of Radiation Oncology, Houston, Texas
| | - Paul H Graham
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, Texas
| | - Nancy D Perrier
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, Texas
| | - Jeffrey E Lee
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, Texas
| | - Elizabeth G Grubbs
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, Texas.
| |
Collapse
|
4
|
Jonklaas J, Sarlis NJ, Litofsky D, Ain KB, Bigos ST, Brierley JD, Cooper DS, Haugen BR, Ladenson PW, Magner J, Robbins J, Ross DS, Skarulis M, Maxon HR, Sherman SI. Outcomes of patients with differentiated thyroid carcinoma following initial therapy. Thyroid 2006; 16:1229-42. [PMID: 17199433 DOI: 10.1089/thy.2006.16.1229] [Citation(s) in RCA: 429] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This analysis was performed to determine the effect of initial therapy on the outcomes of thyroid cancer patients. The study setting was a prospectively followed multi-institutional registry. Patients were stratified as low risk (stages I and II) or high risk (stages III and IV). Treatments employed included near-total thyroidectomy, administration of radioactive iodine, and thyroid hormone suppression therapy. Outcome measures were overall survival, disease-specific survival, and disease-free survival. Near-total thyroidectomy, radioactive iodine, and aggressive thyroid hormone suppression therapy were each independently associated with longer overall survival in high-risk patients. Near-total thyroidectomy followed by radioactive iodine therapy, and moderate thyroid hormone suppression therapy, both predicted improved overall survival in stage II patients. No treatment modality, including lack of radioactive iodine, was associated with altered survival in stage I patients. Based on our overall survival data, we confirm that near-total thyroidectomy is indicated in high-risk patients. We also conclude that radioactive iodine therapy is beneficial for stage II, III, and IV patients. Importantly, we show for the first time that superior outcomes are associated with aggressive thyroid hormone suppression therapy in high-risk patients, but are achieved with modest suppression in stage II patients. We were unable to show any impact, positive or negative, of specific therapies in stage I patients.
Collapse
|
5
|
Montanaro F, Pury P, Bordoni A, Lutz JM. Unexpected additional increase in the incidence of thyroid cancer among a recent birth cohort in Switzerland. Eur J Cancer Prev 2006; 15:178-86. [PMID: 16523016 DOI: 10.1097/01.cej.0000197450.94980.36] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Data collected by the Swiss Cancer Registries Network (ASRT/VSKR) have been used to analyse trends in thyroid cancer during the last available 20 years, to make within-country geographical comparisons for current incidence rates. Age-standardized (European population) incidence rates per 100,000 for all morphologies combined ranges from 1.62 to 2.99 among males and from 2.13 to 8.09 among females in Switzerland. Regression analyses for both sexes combined detected an increase in time for papillary cases and a decrease for other types. Age-period-cohort analyses revealed that the youngest cohorts of men and women born after 1940 had an increased risk of all types of thyroid cancer while the cohort of people born between 1920 and 1939 were at increased risk of the papillary subtype. Assuming a higher sensitivity to ionizing radiation among the youngest people, a Chernobyl effect cannot be definitively excluded and continuous study of this topic should be encouraged.
Collapse
Affiliation(s)
- Fabio Montanaro
- Ticino Cancer Registry, Institute of Pathology, Locarno, Switzerland
| | | | | | | |
Collapse
|