An International Multi-Institutional Validation of Age 55 Years as a Cutoff for Risk Stratification in the AJCC/UICC Staging System for Well-Differentiated Thyroid Cancer

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.

Survival benefit of postoperative radioiodine therapy among patients with intermediate-risk differentiated thyroid carcinoma

BACKGROUND

The 2015 American Thyroid Association (ATA) guidelines proposed the use of the ATA Risk Stratification System and American Joint Committee on Cancer Tumor-Node-Metastasis (AJCC/TNM) Staging System for postoperative radioiodine decision-making. However, the management of patients with intermediate-risk differentiated thyroid carcinoma (DTC) is not well defined. In this study, we aimed to evaluate the therapeutic efficacy of radioactive iodine therapy (RAIT) among various subgroups of patients with intermediate-risk DTC after surgery.

METHODS

This was a retrospective study based on the Surveillance, Epidemiology, and End Results (SEER) database (2010-2015). The DTC patients with intermediate risk of recurrence were divided into two groups (treated or not treated with radioactive iodine (RAI)). As the treatment was not randomly assigned, stabilized inverse probability treatment weighting (sIPTW) was used to reduce selection bias. We used the Kaplan-Meier method and log-rank test to analyze overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Kaplan-Meier analysis after sIPTW found a significant difference in OS and CSS between no RAIT and RAIT (log-rank test, P < 0.0001; P = 0.0019, respectively). The Kaplan-Meier curves of CSS in age cutoff of 55 years showed a significant association between no RAIT and RAIT (log-rank test, P = 0.0045). Univariate and multivariate Cox regression showed RAIT was associated with a reduced risk of mortality compared with no RAIT (hazard ratio [HR] 0.59, 95% confidence interval [95% CI 0.44-0.80]). Age (≥ 55) years showed a worse CSS regardless of whether or not a patient was treated or not treated with RAI ([HR] 8.91, 95% confidence interval [95% CI 6.19-12.84]).

CONCLUSIONS

RAIT improves OS and CSS in patients with intermediate-risk DTC after surgery. 55 years is a more appropriate prognostic age cutoff for the relevant classification systems and is a crucial consideration in RAI decision-making. Therefore, we need individualized treatment plans.

The value of multimodal treatment in anaplastic thyroid cancer patients with distant metastasis

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare and aggressive malignancy with a poor prognosis, particularly in patients presenting with distant metastasis (DM). This study aimed to assess the effect of combination treatment strategies on survival in ATC patients with DM.

METHODS

A retrospective analysis was conducted using data from the Surveillance, Epidemiology, and End Results (SEER) database to identify primary ATC cases with DM at diagnosis. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify independent risk factors for survival.

RESULTS

Of the 315 ATC patients with DM included in the study, surgery to the primary tumor, radiotherapy, chemotherapy, and lung metastasis were identified as independent risk factors for survival. Patients who received primary tumor surgery plus chemotherapy or surgery plus chemoradiation exhibited a superior outcome compared to those who received only one treatment modality.

CONCLUSION

Our findings suggest that a combination treatment approach, particularly surgery combined with radiotherapy or surgery combined with chemoradiotherapy, may provide the most optimal treatment option for ATC patients with DM. These results may provide some evidence for clinical decision making, but larger sample cohorts are still needed for validation.

A rare case of thyroid carcinosarcoma arising from recurrent papillary thyroid cancer: Case report and review of the literature

BACKGROUND

Thyroid carcinosarcoma represents a rare subtype of thyroid cancer, distinguished by its unique histopathology-simultaneous malignant epithelial and mesenchymal cells. The occurrence of thyroid carcinosarcoma arising from recurrent papillary thyroid cancer is exceptionally infrequent.

METHODS

Study outlines a patient's thyroid carcinosarcoma journey, covering presentation, recurrence, diagnostics, surgeries, and follow-up. A PubMed search gathered data on pathological features and treatment approaches for thyroid carcinosarcoma.

RESULTS

The patient initially diagnosed with papillary thyroid cancer underwent thyroidectomy, neck dissection, and radioactive iodine therapy. Recurrence revealed thyroid carcinosarcoma, featuring papillary carcinoma, squamous cell carcinoma, and spindle cell components. Total laryngectomy followed by adjuvant radiotherapy and chemotherapy. The patient was followed for 17 months with no evidence of disease.

CONCLUSIONS

This extraordinary case exemplifies a rare instance of local relapse in form of thyroid carcinosarcoma following an initial diagnosis of papillary thyroid carcinoma. Surgical resection and chemoradiotherapy show promising outcomes in managing this challenging condition.

Prognostic Factors Improving ATA Risk System and Dynamic Risk Stratification in Low- and Intermediate-Risk DTC Patients

CONTEXT

American Thyroid Association (ATA) guidelines do not consider age at diagnosis as a prognostic factor on the estimation of the risk of persistent/recurrent disease in differentiated thyroid carcinoma (DTC) patients. While age at diagnosis has already been assessed in high-risk patients, it remains to be established in low- and intermediate-risk patients.

OBJECTIVE

The aim of our study was to investigate the role of age as a prognostic factor in the short- and long-term outcome of DTC patients classified at low and intermediate risk according to the ATA stratification risk system.

METHODS

We retrospectively evaluated 863 DTC patients (mean follow-up: 10 ± 6.2 years) 52% classified as low (449/863) and 48% as intermediate risk (414/863). For each ATA-risk class patients were divided into subgroups based on age at diagnosis (<55 or ≥55 years).

RESULTS

In the intermediate-risk group, patients aged 55 years or older had a higher rate of structural disease (11.6% vs 8.9%), recurrent disease (4.1% vs 0.7%), and death (4.1% vs 1%) when compared with younger patients (<55 years) (P = .007). Multivariate analysis confirmed that older age at diagnosis (odds ratio [OR] = 3.9; 95% CI, 1.9-8.6; P < .001) was an independent risk factor for worse long-term outcome together with response to initial therapy (OR = 13.0; 95% CI, 6.3-27.9; P < .001), and T (OR = 32; 95% CI, 1.4-7.1; P = .005) and N category (OR = 2.3; 95% CI, 1.1-5.0; P = .03). Nevertheless, a negative effect of older age was documented only in the subgroup of intermediate DTC patients with persistent structural disease after initial therapy. Indeed, the rate of worse long-term outcome rose from 13.3% in the whole population of intermediate DTC patients to 47.8% in patients with persistent structural disease after initial therapy (P < .001) and to 80% in patients older than 55 years and persistent structural disease after initial therapy (P = .02).

CONCLUSION

Our results suggest that age at diagnosis further predict individual outcomes in Intermediate-Risk DTC allowing ongoing management to be tailored accordingly.

A diagnostic model based on DNA methylation haplotype block characteristics for identifying papillary thyroid carcinoma from thyroid adenoma

Papillary thyroid carcinoma (PTC) is the most prevalent form of thyroid cancer. Methylation of some genes plays a crucial role in the tendency to malignancy as well as poor prognosis of thyroid cancer, suggesting that methylation features can serve as complementary markers for molecular diagnosis. In this study, we aimed to develop and validate a diagnostic model for PTC based on DNA methylation markers. A total of 142 thyroid nodule tissue samples containing 84 cases of PTC and 58 cases of thyroid adenoma (TA) were collected for reduced representation bisulfite sequencing (RRBS) and subsequent analysis. The diagnostic model was constructed by the logistic regression (LR) method followed by 5-cross validation and based on 94 tissue methylation haplotype block (MHB) markers. The model achieved an area under the receiver operating characteristic curve (AUROC) of 0.974 (95% CI, 0.964-0.981) on 108 training samples and 0.917 (95% CI, 0.864-0.973) on 27 independent testing samples. The diagnostic model scores showed significantly high in males (P = 0.0016), age ≤ 45 years (P = 0.026), high body mass index (BMI) (P = 0.040), lymph node metastasis (P = 0.00052) and larger nodules (P = 0.0017) in the PTC group, and the risk score of this diagnostic model showed significantly high in recurrent PTC group (P = 0.0005). These results suggest that the diagnostic model can be expected to be a powerful tool for PTC diagnosis and there are more potential clinical applications of methylation markers to be excavated.

Radio-iodine refractory thyroid cancer patients: a tailored follow-up based on clinicopathological features

OBJECTIVE

To report the experience of a single center for the selection of radioiodine-refractory (RAIR) thyroid cancer patients (RAIR-TC) who needed tyrosine kinase inhibitor (TKIs) treatment.

PATIENTS AND METHODS

We evaluated all features of 279 RAIR-TC patients both at the time of diagnosis and at the RAIR diagnosis.

RESULTS

Ninety-nine patients received indication to TKIs (Group A), while 180 remained under active surveillance (Group B). Group A had greater tumor size, more aggressive histotype, more frequent macroscopic extrathyroidal extension, distant metastases, advanced AJCC stage, and higher ATA risk of recurrence. After RAIR diagnosis, 93.9% of Group A had progression of disease (PD) after which TKIs' therapy was started. The remaining 6.1% of patients had a so severe disease at the time of RAIR diagnosis that TKIs' therapy was immediately started. Among Group B, 42.7% had up to 5 PD, but the majority underwent local treatments. The mean time from RAIR diagnosis to the first PD was shorter in Group A, and the evidence of PD within 25 months from RAIR diagnosis was associated with the decision to start TKIs.

CONCLUSIONS

According to our results, a more tailored follow-up should be applied to RAIR-TC patients. A too strict monitoring and too many imaging evaluations might be avoided in those with less-aggressive features and low rate of progression. Conversely, RAIR-TC with an advanced stage at diagnosis and a first PD occurring within 25 months from RAIR diagnosis would require a more stringent follow-up to avoid a late start of TKIs.

Comparison of staging and recurrence predictors in patients with differentiated thyroid cancer between the 7th and 8th editions of the American Joint Committee on Cancer staging systems

BACKGROUND

The predictive value of American Joint Committee on Cancer (AJCC) 8 for recurrence in differentiated thyroid cancer (DTC) is not known. We aimed to compare AJCC 7 and 8 regarding the differences in staging and recurrence predictors in DTC.

METHODS

Demographic, clinical (duration of disease and follow-up, the extent of surgery), laboratory (TSH, fT4, thyroglobulin, and antithyroglobulin), pathological (type of thyroid cancer, localization, multifocality, diameter, extrathyroidal extension [ETE], and lymph node [LN] metastasis), and imaging findings (sonography, and whole-body scan), and follow-up features (metastases, recurrence and/or persistence, and RAI need) were retrospectively analyzed in adult patients with DTC followed-up for at least six months. Staging was determined in accordance with AJCC 7 and AJCC 8, prediction of recurrence and persistence by ATA risk stratification, and death risk by AMES systems. The alterations in staging and recurrence predictors were analyzed.

RESULTS

A majority of study patients (N.=524) were female (N.=424) and diagnosed with papillary cancer (N.=511), the median age at diagnosis was 44. 97.89% (N.=93) of stage 2-4 patients (N.=95) in AJCC 7 were down-staged in AJCC 8. We down-staged 41 patients of 45-55 years of age into stage 1 in AJCC 8 independent of LN status. A percentage of 26.71% of patients (N.=140) did have persistence, 9.54% (N.=50) persistence at the last follow-up, and 9.54% (N.=50) had recurrence. According to AJCC 8, T4 and AMES high risk were predictors for recurrence (hazard ratio: 3.053, P=0.023; hazard ratio:2.465, and P=0.005; respectively). Both AJCC 7 and 8 were associated with recurrence (P=0.008 and P<0.001, respectively). Stage 4 in AJCC 7, and stages 3 and 4 in AJCC 8 better predicted the probability of recurrence.

CONCLUSIONS

Our findings suggest that AJCC 8 better predicted the recurrence in DTC than AJCC 7. In AJCC 8, T4 tumor, AMES high risk, stages 3 and 4 predicted recurrence. The vast majority of patients with stages 2-4 in AJCC 7 were down-staged in AJCC 8.

Different Molecular Phenotypes of Progression in BRAF- and RAS-Like Papillary Thyroid Carcinoma

BACKGRUOUND

Papillary thyroid carcinoma (PTC) can be classified into two distinct molecular subtypes, BRAF-like (BL) and RASlike (RL). However, the molecular characteristics of each subtype according to clinicopathological factors have not yet been determined. We aimed to investigate the gene signatures and tumor microenvironment according to clinicopathological factors, and to identify the mechanism of progression in BL-PTCs and RL-PTCs.

METHODS

We analyzed RNA sequencing data and corresponding clinicopathological information of 503 patients with PTC from The Cancer Genome Atlas database. We performed differentially expressed gene (DEG), Gene Ontology, and molecular pathway enrichment analyses according to clinicopathological factors in each molecular subtype. EcoTyper and CIBERSORTx were used to deconvolve the tumor cell types and their surrounding microenvironment.

RESULTS

Even for the same clinicopathological factors, overlapping DEGs between the two molecular subtypes were uncommon, indicating that BL-PTCs and RL-PTCs have different progression mechanisms. Genes related to the extracellular matrix were commonly upregulated in BL-PTCs with aggressive clinicopathological factors, such as old age (≥55 years), presence of extrathyroidal extension, lymph node metastasis, advanced tumor-node-metastasis (TNM) stage, and high metastasis-age-completeness of resection- invasion-size (MACIS) scores (≥6). Furthermore, in the deconvolution analysis of tumor microenvironment, cancer-associated fibroblasts were significantly enriched. In contrast, in RL-PTCs, downregulation of immune response and immunoglobulin-related genes was significantly associated with aggressive characteristics, even after adjusting for thyroiditis status.

CONCLUSION

The molecular phenotypes of cancer progression differed between BL-PTC and RL-PTC. In particular, extracellular matrix and cancer-associated fibroblasts, which constitute the tumor microenvironment, would play an important role in the progression of BL-PTC that accounts for the majority of advanced PTCs.

Patient's age with papillary thyroid cancer: Is it a key factor for cervical lymph node metastasis?

BACKGROUND

Age is one of the important prognostic indicators of papillary thyroid cancer (PTC). However, the distinct metastatic patterns and prognosis of age-related lymph node metastasis (LNM) are unclear. This study aims to investigate the impact of age on LNM.

METHODS

We conducted two independent cohort studies to assess age-nodal disease association using logistic regression analysis and a restricted cubic splines model. A multivariable Cox regression model was utilized to test the impact of nodal disease on cancer-specific survival (CSS) after age stratification.

RESULTS

For this study, we included 7572 and 36,793 patients with PTC in Xiangya and SEER cohorts, respectively. After adjustment, advanced age was linearly associated with decreasing risk of central LNM. Patients of age ≤18 years (OR = 4.41, P < 0.001) and 19-45 years (OR = 1.97, P = 0.002) had a higher risk of developing lateral LNM than patients of age >60 years in both cohorts. Furthermore, CSS is significantly reduced in N1b disease (P < 0.001), not N1a disease, regardless of age. The incidence of high-volume LNM (HV-LNM) was significantly higher in patients of age ≤18 years and 19-45 years than in those of age >60 years (P < 0.001), in both cohorts. In addition, CSS was compromised in patients with PTC of age 46-60 years (HR = 1.61, P = 0.022) and those of age >60 (HR = 1.40, P = 0.021) after developing HV-LNM.

CONCLUSIONS

Patient age is significantly associated with LNM and HV-LNM. Patients with N1b disease or patients with HV-LNM of age >45 years have significantly shorter CSS. Age can, thus, be a useful guide for determining treatment strategies in PTC.

[Predictive value of PTH level on day 1 after surgery for papillary thyroid carcinoma in patients with permanent hypoparathyroidism]

Objective:To investigate the relationship between parathyroid hormone（PTH） level and permanent hypoparathyroidism（PHPP） on the first day after radical papillary thyroidectomy, and its predictive value. Methods:A total of 80 patients with papillary thyroid cancer who underwent total thyroid resection and central lymph node dissection were collected and analyzed from January 2021 to January 2022. According to whether PHPP occurred after surgery, the patients were divided into hypoparathyroidism group and normal parathyroid function group, and univariate and binary logistics regression were used to analyze the correlation between PTH and serum calcium levels and PHPP on the first day after surgery in two groups. The dynamic changes of PTH at different time points after operation were analyzed. The area under the receiver operating characteristic was used to evaluate the predictive power of PTH on the development of PHPP after surgery. Results:Among the 80 patients with papillary thyroid cancer, 10 cases developed PHPP, with an incidence rate of 12.5%. Binary logistics regression analysis showed that PTH on the first postoperative day（OR=14.534, 95%CI: 2.377-88.858, P=0.004） was an independent predictive risk factor for postoperative PHPP. Taking PTH=8.75 ng/L on the first postoperative day as the cut-off value, the AUC of the area under the curve was 0.874（95%CI: 0.790-0.958, P<0.001）, the sensitivity was 71.4%, the specificity was 100%, and the Yoden index was 0.714. Conclusion:PTH level on the first day after total thyroid papillary carcinoma surgery is closely related to PHPP, and is an independent predictor of PHPP.

Thyroid surgery outcomes in octogenarians: A national analysis

BACKGROUND

The incidence of thyroid pathology increases with age. Yet octogenarians may face increased rates of complications after thyroid surgery. Using a nationally representative cohort, we evaluated the outcomes of thyroidectomy among octogenarians.

METHODS

All patients ≥55 years who underwent inpatient thyroidectomy were identified using the 2010 to 2020 National Readmissions Database. Patients ≥80 years were classified as octogenarians (others: nonoctogenarians). Multivariable models were built to evaluate independent associations between octogenarians and key clinical and financial outcomes.

RESULTS

Of 120,164 hospitalizations, 9,163 (7.6%) were octogenarians. The proportion of octogenarians undergoing thyroidectomy increased from 7.7% (2010) to 8.7% (2020) (nptrend <0.001). Octogenarians were more frequently female (72.1 vs 70.5%, P < .001), presented with a higher Elixhauser comorbidity index (3 [2-4] vs 2 [1-3], P < .001), and more commonly faced thyroid cancer (41.3 vs 32.7%, P < .001). After risk adjustment, octogenarians were associated with greater odds of experiencing any perioperative complication (adjusted odds ratio 1.36, 95% confidence interval 1.25-1.48). Octogenarians were further linked with greater odds of respiratory (adjusted odds ratio 1.82, 95% confidence interval 1.52-2.17) and renal complications (adjusted odds ratio 1.90, 95% confidence interval 1.45-2.49), dysphagia (adjusted odds ratio 1.51, 95% confidence interval 1.33-1.72), laryngeal edema (adjusted odds ratio 2.03, 95% confidence interval 1.30-3.18), vocal cord paralysis (adjusted odds ratio 1.79, 95% confidence interval 1.53-2.09), and stridor (adjusted odds ratio 1.42, 95% confidence interval 1.01-2.00). No difference in hypocalcemia was observed. Furthermore, octogenarians demonstrated an increased likelihood of in-hospital mortality (adjusted odds ratio 6.34, 95% confidence interval 3.11-12.53), hospitalization expenditures (+$910, 95% confidence interval +$420-1,400), and nonelective readmission within 30 days of discharge (adjusted odds ratio 1.54, 95% confidence interval 1.32-1.79).

CONCLUSION

Octogenarians are associated with greater morbidity after thyroidectomy. Patients ≥80 years should be counseled about increased perioperative risk when discussing surgical versus nonsurgical treatments for thyroid disease.

Migration of Risk Classification Between the JAES Versus ATA guidelines for Papillary Thyroid Carcinoma

BACKGROUND

This study aimed to investigate outcomes in the same cohort of patients with papillary thyroid carcinoma (PTC) risk-stratified according to the Japan Association of Endocrine Surgery (JAES) and American Thyroid Association (ATA) guidelines.

METHODS

A total of 1044 patients with PTC who underwent initial thyroidectomy at Yokohama City University Medical Center between January 2000 and June 2022 were included.

RESULTS

According to the JAES guidelines, 480 (46%), 386 (37%), and 178 (17%) patients were classified as low, intermediate, or high risk, respectively. Furthermore, according to the ATA guidelines, 590 (57%), 261 (25%), and 193 (18%) patients were reclassified as low, intermediate, or high risk, respectively. Among 1044 patients with PTC, the 10-year cause-specific survival (CSS) rates of patients with JAES low and intermediate risk were 99.7 and 98.6%, respectively, and there was no statistically difference (p = 0.096). However, the 10-year CSS rates of patients with ATA low and intermediate risk were 100 and 99.5%, respectively (p = 0.007). Among 1001 patients with M0 PTC, the 10-year distant metastasis-free survival (DMFS) rates of patients with JAES intermediate and high risk were 94.2, and 76.7%, respectively (p < 0.001). However, the 10-year DMFS rates of patients with ATA intermediate and high risk were 88.1 and 86.6%, respectively (p = 0.233), and there was no statistically difference.

CONCLUSIONS

Both JAES and ATA risk classifications properly stratified the PTC patients. Furthermore, the ATA risk classification more precisely extracted patients with better and worse prognoses.

Log odds of negative lymph nodes/T stage ratio (LONT): A new prognostic tool for differentiated thyroid cancer without metastases in patients aged 55 and older

BACKGROUND

The optimal approach to assess the postoperative status of lymph nodes in differentiated thyroid cancer (DTC) remains controversial. Our aim was to determine if the log odds of negative lymph nodes/T stage ratio (LONT) could serve as a new prognostic and predictive tool for DTC without metastases in patients aged ≥ 55 years.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to study the role of LONT in patients aged ≥55 years diagnosed with DTC without metastases. The primary outcome was overall survival (OS). The Kaplan-Meier method and the Cox proportional hazard regression model were used to calculate the outcome. Moreover, the robustness of research findings was evaluated using sensitivity analyses.

RESULTS

A total of 21,172 DTC patients aged ≥55 years without distant metastasis were enrolled. Multivariate Cox regression analyses and a "floating absolute risk" analysis showed that a LONT ≥0.920 (vs. -0.56 to 0.92) was a protective factor for OS in DTC patients. Sensitivity analyses revealed an E-value of 1.98 for the obtained LONT value. In subgroup analyses, LONT was correlated significantly with OS in different subgroups of negative lymph nodes, stage-I-II subgroups and the N0 subgroup. The conditional probability of survival of DTC improved with prolonged survival time in the LONT ≥0.920 group.

CONCLUSION

A high LONT was associated with longer OS compared with low LONT in patients aged ≥55 years with non-metastatic DTC. LONT could provide valuable information for undertaking postoperative evaluations.

Role of PET/Computed Tomography in Elderly Thyroid Cancer: Tumor Biology and Clinical Management

PET/computed tomography (CT) studies can be potentially useful in elderly thyroid carcinoma patients for exploring the disease biology, especially in metastatic setting and thereby directing appropriate therapeutic management on case-to-case basis, adopting nuclear theranostics, and disease prognostication. With the availability of multiple PET radiopharmaceuticals, it would be worthwhile to evolve and optimally use FDG and the other non-fluorodeoxyglucose and investigational PET/CT tracers as per the clinical situation and need and thereby define their utilities in a given case scenario. In this regard, (I) differentiated thyroid carcinoma (DTC) including radioiodine refractory disease, poorly differentiated thyroid cancer (PDTC) and TENIS, (II) medullary thyroid carcinoma (MTC), (III) anaplastic carcinoma and (IV) Primary thyroid lymphoma (PTL) should be viewed and dealt separately.

A practical dynamic nomogram model for predicting bone metastasis in patients with thyroid cancer

PURPOSE

The aim of this study was to established a dynamic nomogram for assessing the risk of bone metastasis in patients with thyroid cancer (TC) and assist physicians to make accurate clinical decisions.

METHODS

The clinical data of patients with TC admitted to the First Affiliated hospital of Nanchang University from January 2006 to November 2016 were included in this study. Demographic and clinicopathological parameters of all patients at primary diagnosis were analyzed. Univariate and multivariate logistic regression analysis was applied to build a predictive model incorporating parameters. The discrimination, calibration, and clinical usefulness of the nomogram were evaluated using the C-index, ROC curve, calibration plot, and decision curve analysis. Internal validation was evaluated using the bootstrapping method.

RESULTS

A total of 565 patients were enrolled in this study, of whom 25 (4.21%) developed bone metastases. Based on logistic regression analysis, age (OR=1.040, P=0.019), hemoglobin (HB) (OR=0.947, P<0.001) and alkaline phosphatase (ALP) (OR=1.006, P=0.002) levels were used to construct the nomogram. The model exhibited good discrimination, with a C-index of 0.825 and good calibration. A C-index value of 0.815 was achieved on interval validation analysis. Decision curve analysis showed that the nomogram was clinically useful when intervention was decided at a bone metastases possibility threshold of 1%.

CONCLUSIONS

This dynamic nomogram, with relatively good accuracy, incorporating age, HB, and ALP, could be conveniently used to facilitate the prediction of bone metastasis risk in patients with TC.

Clinicopathologic and Prognostic Features of Pediatric Follicular Cell-derived Thyroid Carcinomas: A Retrospective Study of 222 Patients

Pediatric thyroid carcinomas (TCs) are rare and mainly approached based on data extrapolated from adults. We retrospectively reviewed 222 pediatric TCs (patient age less than or equal to 21 y). Lymph node (LN) disease volume at presentation was considered high if the largest positive LN measured ≥1 cm and/or >5 LNs were positive. High-grade follicular cell-derived thyroid carcinoma (HGFCTC) were defined by the presence of marked mitotic count and/or tumor necrosis and considered as high-risk histology along with papillary thyroid carcinomas (PTC) diffuse sclerosing variant (DSV). Disease-free survival (DFS) was analyzed. LN involvement at presentation was significantly associated with male sex, larger tumor size, lymphatic invasion, positive surgical margins, and distant metastases at presentation. Five- and 10-year DFS was 84% and 77%, respectively. Only 1 patient with HGFCTC died of disease. Within PTC variants, PTC-DSV was associated with adverse histopathologic parameters and higher regional disease spread, unlike PTC tall cell variant which did not portend worse behavior. The presence of necrosis conferred worse DFS ( P =0.006), while increased mitotic activity did not. While the entire HGFCTC group did not correlate with outcome ( P =0.071), HGFCTC with necrosis imparted worse DFS ( P =0.006). When restricted to PTC-DSV and HGFCTC with necrosis, high-risk histologic classification emerged as an independent prognostic parameter of DFS ( P =0.020). The excellent prognosis of pediatric TCs differs from that of adult TCs showing similar histologic features. While neither increased mitotic activity nor PTC tall cell variant histology predict adverse outcome, PTC-DSV and tumors with necrosis constitute high-risk histologic variants with an increased risk of protracted disease.

Clinical characteristics and survival outcomes in patients with ovarian strumal carcinoid

BACKGROUND

Ovarian strumal carcinoid is an extremely rare ovarian malignant tumor with limited data on clinical characteristics and survival outcomes.

METHODS

A retrospective study of 119 patients was conducted, including 98 cases identified from literature review, and their clinical characteristics were investigated. The overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and potential prognostic factors of these patients were also evaluated.

RESULTS

Lesions of 115 cases were confined to the ovarian while four patients presented with extra-ovarian disease upon initial diagnosis. Surgical treatment options performed in this cohort varied, 5.0% received ovarian cystectomy, 36.1% received unilateral salpingo-oophorectomy (USO), 7.6% received bilateral salpingo-oophorectomy (BSO), 42.0% received hysterectomy with BSO, and 8.4% underwent debulking surgery. Moreover, one patient did not undergo any surgery. No postoperative adjuvant therapy was administered in 89.9% patients, while 7.6% and 2.5% received adjuvant radiotherapy and chemotherapy, of which two patients received combined radiation and chemotherapy. At the final follow-up, 89.1% patients showed no evidence of the disease, and 5.0% were alive with the disease. Only seven deaths occurred, with two attributed to the tumor. The 5-year, 10-year, and 20-year OS rates were 96.0%, 85.0%, and 85.0%, respectively, with a 15-year recurrence rate of 4.4%. The 5-year and 20-year DSS rate were 98.5% and 95.9%. Multivariate Cox regression showed age ≥ 55 years was the only risk factor associated with the OS (P = 0.014, OR 7.988; 95% CI 1.519 - 42.004). However, the univariate and multivariate Cox regression showed no potential risk factor for RFS and DSS.

CONCLUSION

Patients with ovarian strumal carcinoid have an excellent prognosis irrespective of the surgical option. Conservative surgery especially USO with individualized adjuvant therapy is recommended.

Using 18F-FDG-PET/CT Metrics to Predict Survival in Ra-Dio-Iodine Refractory Thyroid Cancers

Radio-iodine refractory (RAI-R) differentiated thyroid cancer (DTC) is a rare disease with a poor prognosis and limited therapeutic resources. Therefore, identifying prognostic factors is essential in order to select patients who could benefit from an early start of treatment. The aim of this study is to identify positron emission tomography with 18F-fluorodeoxyglucose with integrated computed tomography (18F-FDG-PET/CT) parameters to predict overall survival (OS) in patients with RAI-R DTC. In this single-center retrospective study, we analyze the 18F-FDG-PET/CT parameters of 34 patients with RAI-R DTC between April 2007 and December 2019. The parameters collected are MTV, SUVmax and progression for each site of metastasis (neck, mediastinum, lungs, liver, bone) and total sites. ROC curves, Kaplan–Meier survival analysis curves, univariate and multivariate Cox analyses determine prognostic factors for 1-year and 5-year OS. The parameters for mediastinum, liver and total sites are significantly associated with worse 1-year and 5-year OS by both ROC curve analysis and Kaplan–Meier survival analysis. Univariate Cox analysis confirms significance of mediastinum SUVmax (HR 1.08; 95% CI [1.02–1.15]; p = 0.014) and total SUVmax (HR 1.06; 95% CI [1–1.12]; p = 0.042) for worse 1-year OS; of mediastinum SUVmax (HR 1.06; 95% CI [1.02–1.10]; p = 0.003), liver SUVmax (HR 1.04; 95% CI [1.01–1.08]; p = 0.02), liver MTV (HR 2.56; 95% CI [1.13–5.82]; p = 0.025), overall SUVmax (HR 1.05; 95% CI [1.02–1.08]; p = 0.001) and total MTV (HR 1.41; 95% CI [1.07–1.86]; p = 0.016) for worse 5-year OS. Multivariate Cox analysis confirms a significant association between liver MTV (HR 1.02; 95% CI [1–1.04]; p = 0.042) and decrease 1-year OS. In this study, we demonstrate that in RAI-R DTC, 18F-FDG-PET/CT parameters of the mediastinum, liver and overall tumor burden were prognostic factors of poor 1-year and 5-year OS. Identifying these criteria could allow early therapeutic intervention in order to improve patients’ survival.

Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

Increasingly sensitive diagnostic methods, better understanding of molecular pathophysiology, and well-conducted prospective studies have changed the current approach to patients with thyroid cancer, requiring the implementation of individualized management. Most patients with papillary thyroid carcinoma (PTC) are currently considered to have a low risk of mortality and disease persistence/recurrence. Consequently, current treatment recommendations for these patients include less invasive or intensive therapies. We used the most recent evidence to prepare a position statement providing guidance for decisions regarding the management of patients with low-risk PTC (LRPTC). This document summarizes the criteria defining LRPTC (including considerations regarding changes in the TNM staging system), indications and contraindications for active surveillance, and recommendations for follow-up and surgery. Active surveillance may be an appropriate initial choice in selected patients, and the criteria to recommend this approach are detailed. A section is dedicated to the current evidence regarding lobectomy versus total thyroidectomy and the potential pitfalls of each approach, considering the challenges during long-term follow-up. Indications for radioiodine (RAI) therapy are also addressed, along with the benefits and risks associated with this treatment, patient preparation, and dosage. Finally, this statement presents the best follow-up strategies for LRPTC after lobectomy and total thyroidectomy with or without RAI.

Risk stratification in patients with anaplastic thyroid carcinoma: role of age

BACKGROUND

Thyroid carcinoma is the only cancer that regards age as an important predictor of thyroid cancer-specific survival (CSS). While the 8th American Joint Committee on Cancer (AJCC) staging system raised the age cutoff from 45 to 55 years for differentiated thyroid carcinoma (DTC) to more accurately predict the prognosis, there is no new information regarding the role of age in the prognosis of anaplastic thyroid carcinoma (ATC). The aim of this study was to determine the optimal age cutoff values for mortality risk stratification in ATC patients. Furthermore, a nomogram to predict ATC CSS was developed in each age group.

METHODS

Patients diagnosed with ATC between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. After applying inclusion and exclusion criteria, a total of 1140 patients were enrolled as cohort 1 to describe the characteristics of ATC, while a total of 556 patients were included as cohort 2 to determine age cutoff values for risk stratification by X-tile program. Training set and testing set were randomly generated to develop and validate a predictive nomogram of CSS in each age group.

RESULTS

The 6-month, 1-year, and 2-year survival was 27.6%, 15.1%, and 6.2%, respectively, in cohort 1. X-tile program results showed that the optimal age cutoff values for mortality risk stratification were 65 and 85 years old (p < 0.001). Distant metastasis was independently associated with CSS in patients younger than 85 years old, and these patients benefited more from complete resection of the tumor and radiotherapy/chemotherapy. However, no predictors of CSS were identified in patients over 85 years old, and interventions (surgery, radiotherapy, and chemotherapy) targeting ATC had little role in disease control in these patients. The nomogram was developed and validated based on the independent CSS predictors in each age group. The C-index values of the training set and testing set were 0.735 [95% CI, 0.696-0.774] and 0.733 [95% CI, 0.663-0.804] for CSS in patients of ≤64 years old, while the values were 0.767 [95% CI, 0.730-0.804] and 0.783 [95% CI, 0.718-0.848] in patients of 65-84 years old. All of the C-index values were larger than 0.7, which showed acceptable prediction performance of the nomograms.

CONCLUSIONS

Age can be used as an auxiliary stratification factor of prognosis in ATC patients. The survival may be improved in patients younger than 85 years old if combination therapy (surgery, radiotherapy, and chemotherapy) was indicated and applicable, while no optimal therapeutic strategy was determined in patients older than 85 years old. The established nomograms can provide good prediction of CSS according to age group.

Double-Staged Sleeve Resection of Laryngotracheal Tumor of Papillary and Follicular Thyroid Carcinoma

Advanced thyroid carcinoma involving the upper aerodigestive tract confers a poor prognosis mainly due to airway complications. The management of thyroid carcinoma with infiltration to the aerodigestive tract has been widely discussed with no consensus regarding the best surgical technique. Complete surgical resection is the aim of the surgery. However, it has high morbidity if the postsurgical care is compromised, which will lead to airway obstruction, bleeding, infection, and anastomotic dehiscence. In our center, complete resection was achieved through cricotracheal window resection with partial closure and tracheostomy tube insertion. This procedure was chosen due to the time-sensitive nature of surgery in these patients with airway compromise and postoperative limitation of intensive care unit (ICU) bed availability. In our case series, we present six cases of papillary and follicular thyroid carcinoma complicated with intraluminal laryngotracheal infiltration and discuss its management and outcome.

Comparison of the prognostic value of AJCC cancer staging system 7th and 8th editions for differentiated thyroid cancer

BACKGROUND

In the last American Joint Committee on Cancer/Tumor, Node, Metastasis (AJCC/TNM) 8th edition (TNM8), several changes were introduced to this risk stratification system to improve the prognosis of differentiated thyroid cancer (DTC).

AIM

To validate the impact of TNM8 vs. TNM 7th edition (TNM7) in DTC in terms of predictive value in two hospitals from Buenos Aires, Argentina.

METHODS

Retrospective study of DTC patients from two institutions. Reclassification from TNM7 to TNM8, disease-specific survival (DSS), and final clinical outcomes at the end of follow-up (recurrent/persistent structural disease) (median 5 years) were analyzed. The proportion of variation explained (PVE) was used to compare the predictive capability of DSS of both classification systems.

RESULTS

Reclassification of 245 patients, aged (mean ± SD) 55 ± 15.36 years, 91% women, to TNM8 from TNM7 showed: 82% vs 57% stage I (SI), 10% vs 8.5% SII, 5% vs 22% SIII, 3% vs 12% SIV (p < 0.01). Forty percent of the population was downstaged with TNM8. Ten-year DSS rates for SI, SII, SIII and SIV in TNM7 were 100, 100, 100 and 74%, respectively and in TNM8: 97.6, 100, 100 and 37.5%, respectively. Out of 4 disease-specific deaths in SIV TNM7, one was subclassified to SI TNM8, corresponding to a 53-year-old patient with structural persistence. PVE for TNM8 (29%) was more than twice that of TNM7 (13%).

CONCLUSION

In this Argentinian DTC patients sample, it was confirmed that the new TNM8 classification is more accurate in predicting survival attributable to cancer than its previous version.

Differentiated thyroid carcinoma in the elderly: influence of age on disease-free and overall survival

PURPOSE

We investigated whether age at diagnosis of differentiated thyroid carcinoma (DTC) may be a risk factor for structural disease and mortality after primary treatment in aging patients.

METHODS

A multicenter, retrospective analysis including patients older than 60 years at DCT diagnosis was designed. All subjects were treated by surgery with or without radioiodine adjuvant therapy and had a minimum follow-up of one year. We compared elderly patients (group 1, 60-74 years) with very old patients (group 2, ≥75 years).

RESULTS

The study involved 1668 patients (74.3% women, median age 67 years, 87.6% papillary thyroid cancer, 73.3% treated with radioiodine), including 1397 in group 1 and 271 in group 2. Patients in group 2 had larger tumor size (1.8 [0.8-3.0] vs 1.5 [0.7-2.8] cm; P = 0.005), higher proportions of tumors with vascular invasion (23.8 vs 16.4%; P = 0.006), and lower proportion of lymphocytic thyroiditis (18.6 vs 24.9%; P = 0.013) than subjects in group 1. Kaplan-Meier survival analysis showed that patients in group 2 had significantly lower structural disease-free survival (DFS) and overall survival (OS) than patients in group 1 (P = 0.035 and <0.001, respectively). In multivariate Cox regression analysis, age was a risk factor significantly associated with OS. However, age was significantly associated with DFS in unadjusted analysis and in analysis adjusted by gender and risk classification variables, but not when pathological and therapy-related variables were introduced in the model. On the other hand, patients who received radioiodine had worse DFS (P < 0.001) compared to those who did not.

CONCLUSION

Although age is a conditioning factor for OS, very old patients do not have a greater risk of developing structural disease throughout the follow-up than elderly patients with DTC.

Is Gross Extrathyroidal Extension to Strap Muscles (T3b) Only a Risk Factor for Recurrence in Papillary Thyroid Carcinoma? A Propensity Score Matching Study

Simple Summary

In papillary thyroid carcinoma (PTC), staging classification of gross and minimal extrathyroidal extension (ETE) has been recently modified in the eighth edition of the American Joint Commission on Cancer/Union for International Cancer Control (AJCC/UICC) TNM staging system. In this study, we compared the clinicopathological characteristics and recurrence rates between minimal and gross ETE. No significant differences in the recurrence and disease-free survival rates were found between the two groups. Whether gross ETE invading strap muscles (T3b) only could be a risk factor for recurrence in PTC remains questionable.

Abstract

The presence of extrathyroidal extension (ETE) is associated with locoregional recurrence and distant metastases in papillary thyroid carcinoma (PTC). This study was designed to compare the recurrence risk between minimal ETE (mETE) and gross ETE (gETE) in patients with PTC using propensity score matching. In this study, 4452 patients with PTC who underwent thyroid surgery in a single center were retrospectively analyzed, and clinicopathological characteristics were compared according to the ETE status. Disease-free survival (DFS) and recurrence risk were compared between mETE and gETE after propensity score matching. The mean follow-up duration was 122.7 ± 22.5 months. In multivariate analysis, both mETE and gETE were not associated with recurrence risk before propensity score matching (p = 0.154 and p = 0.072, respectively). After propensity score matching, no significant difference in recurrence rates was observed between the two groups (p = 0.668). DFS of the gETE group did not significantly differ from that of the mETE group (log-rank p = 0.531). This study revealed that both mETE and gETE are not independent risk factors for the risk of recurrence in PTC. Our findings suggest that gETE invading strap muscles only might not be associated with worse oncological outcomes in PTC.

Histopathological Characteristics of N1b Papillary Thyroid Carcinoma are Associated with Risk of Recurrence

BACKGROUND

The presence of cervical lymph node (LN) metastasis at the initial presentation of papillary thyroid carcinoma (PTC) constitutes an independent risk factor for disease recurrence, increases the risk for mortality, and impacts overall outcome. The 2016 American Joint Committee on Cancer raised the age cutoff for PTC staging from 45 to 55 years for better prediction of overall survival. Age > 55 years is considered a significant risk factor for a more aggressive and advanced disease with worse outcomes. We identified histopathological factors for disease recurrence in PTC patients younger and older than 55 years of age.

METHODS

Data on all patients who underwent thyroid surgery due to PTC between 2006 and 2018 in the Tel Aviv Sourasky Medical Center were retrieved for this retrospective cohort study. Patients with lymph node (LN) metastases were further investigated for preoperative presentation, pathological characteristics, and recurrence. A multivariate analysis was used to detect predictors for recurrence and patient outcome for each age-group.

RESULTS

Twenty-two of the 183 patients (12%) with PTC who met the inclusion criteria and had sufficient follow-up period sustained recurrence. The predictors of recurrence varied between the two age-groups. The size of thyroid lesions (p = 0.003) was identified as a risk factor in the older group, while the number of metastatic cervical LNs (p = 0.001) and the ratio of metastatic-to-total dissected cervical LNs (p = 0.027) were the main predictors of recurrence for the younger group.

CONCLUSION

The histopathological factors predictive for disease recurrence differed among PTC patients younger and older than 55 years of age.

Population-level Outcomes of Early Thyroid Cancers: A Need to Revisit Current Practice

BACKGROUND

Early thyroid cancers have excellent long-term outcomes, yet the word "cancer" draws unnecessary apprehension. This study aimed to define when the recommendations for observation and surveillance may be extended to early thyroid cancers at the population level.

METHODS

Non-metastasized thyroid cancers ≤40 mm diameter were identified from the 1975-2016 Surveillance, Epidemiology and End Results (SEER) database. Causes of death were compared across demographic data. Disease-specific outcomes were compared to the age-adjusted healthy United States (US) population. Survival estimates were computed using Kaplan-Meier and compared using the Cox proportional hazard model. Dynamic benchmarks impacting disease-specific overall survival were determined by decision tree modeling and tested by the Cox model.

RESULTS

Of the 28,728 thyroid cancers included in this study, 98.4% underwent some form of thyroid-specific treatment and were followed for a maximum of 10.9 years. This group had a 4.3% mortality rate at the end of follow-up (10.9 years maximum), with 13 times more deaths attributed to competing risks rather than thyroid cancer (stage T1a versus stage T1b, P=1.000; T1 versus T2, P<0.001). Among the untreated T1a or T1b tumors, the risk of disease-specific death was 21 times lower than death due to other causes. There was no significant difference between T1a and T1b tumors nor across sex. The age-adjusted risk of death for the healthy US population was higher than for the population with thyroid cancer. Dynamic categorization demonstrated worsening outcomes up to 73 years, uninfluenced by sex or tumor size. For patients over 73 years of age, only tumors >26 mm impacted outcomes.

CONCLUSION

Based on the current data, T1a and T1b nodules have similar survival outcomes and are not significantly impacted even when left untreated. Multi-institutional prospective studies are needed to confirm these findings so that current observation and surveillance recommendations can be extended to certain T1 thyroid nodules.

Frozen section analysis of central lymph nodes in papillary thyroid cancer: the significance in determining the extent of surgery

BACKGROUND

The indolent feature of papillary thyroid cancer (PTC) has recently led to an increase in less aggressive treatment options instead of total thyroidectomy (TT). We aimed to investigate the clinical significance of elective central compartment neck dissection (CCND) with intraoperative frozen analyses of the central lymph nodes (LNs) to determine the surgical extent of unilateral clinically node-negative PTC.

METHODS

We retrospectively reviewed the medical records of 290 patients with unilateral clinically node-negative PTC who underwent surgery and performed frozen analyses of the central LNs from 2020 to 2021 using our own nodal criteria with cut-off size 5 mm. The patients were divided and investigated according to the surgical extent and the National Comprehensive Cancer Network (NCCN) guidelines; diagnostic accuracy of the frozen analyses was estimated.

RESULTS

TT was performed in 16.2% of patients. The TT group had more metastatic nodes with a larger size, higher LN ratio (LNR), and more extranodal extension. The analyses based on the NCCN guidelines showed similar findings, but more completion TT was required compared with our criteria. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the frozen analyses were 94.6%, 100%, 100%, and 96.1%, respectively.

CONCLUSIONS

Elective CCND with intraoperative frozen analyses is a highly reliable procedure that detects occult nodal metastasis in unilateral node-negative PTC patients. Our nodal criteria yielded significant aggressive nodal characteristics in the TT group while yielding less TTs compared with the NCCN guidelines. The concept and clinical significance of small-volume nodal metastasis in PTC should be further investigated.

Clinical course and outcome of differentiated thyroid cancer patients with pregnancy after diagnosis of distant metastasis

PURPOSE

There is no sufficient data about the clinical course and outcome in thyroid cancer patients who become pregnant after diagnosis of distant metastasis (DM). The current study was conducted to collect information regarding the clinical and reproductive characteristics, and outcomes in thyroid cancer patients who became pregnant after being diagnosed with DM.

METHODS

Records of 125 differentiated thyroid cancer (DTC) patients with age ≤45 years at DM diagnosis who had visited Ito Hospital from January 2005 to June 2021 were retrospectively reviewed. Among those 125 patients, 28 who became pregnant after DM diagnosis were classified as pregnancy group, and the remained 97 patients were classified as comparator group.

RESULTS

In pregnancy group, the median age at malignancy diagnosis, DM diagnosis, and first pregnancy after DM diagnosis was 25 years (range, 4-41 years), 27 years (range, 11-41 years), and 32 years (range, 25-45 years), respectively. Fifty-five pregnancies and 40 live births were reported. Other pregnancy outcomes were miscarriage (n = 14) and induced abortion (n = 1). The 10-year progression-free survival (PFS) rates of pregnant and comparator group were 92.1% and 74.4%, respectively (p = 0.018). The multivariate analysis showed that multiple ¹³¹I treatment was independent negative prognostic factor for PFS (p = 0.046).

CONCLUSIONS

DTC patients with age ≤45 years at DM diagnosis had good survival even though they became pregnant. Our results add to the information required for counseling thyroid cancer patients who have concerns about their fertility in the future.

Cutoff Age Between Pediatric and Adult Thyroid Differentiated Cancer: Is 18 Years Old Appropriate?

Background: The characteristics of pediatric differentiated thyroid cancer (DTC) are substantially different from those of adult DTC. This study investigated whether the cutoff age of 18 years, as recommended by the American Thyroid Association (ATA) management guidelines for pediatric DTC, is appropriate based on clinical characteristics and outcomes. Methods: The medical records of 288 patients aged <21 years with DTC, who underwent initial surgery between 1979 and 2014, were retrospectively reviewed. Disease-free survival (DFS) rates and distant metastasis-free survival (DMFS) rates were calculated using the Kaplan-Meier method. As per the International Incidence of Childhood Cancer Report and the ATA management guidelines, cutoff ages of 14 and 18 years were analyzed in this study. Results: The age distributions of the subjects were as follows: 53 patients were aged <15 years (18.4%), 118 patients were aged 15-18 years (41%), and 117 patients were aged 19-20 years (40.6%). The DMFS rates were significantly different between the two cutoff ages. The DMFS was also significantly different between patients aged >15 years and patients aged 15-18 years; however, no significant difference was observed between patients aged 15-18 and 19-20 years. Multivariate analyses showed that clinically apparent lymph node metastasis (cN1) and gross extrathyroidal extension were significant factors related to DFS and DMFS. Although age as a continuous variant was not a significant factor related to either DFS or DMFS, when the cutoff age was set as 14 years rather than 18 years, differences in patient characteristics related to DMFS and DFS stood out. Conclusions: This study found that age was not significantly related to clinical outcome. However, in the younger patient group, more patients had factors that related to DFS and DMFS. Due to the indolent biological behavior of DTC, age at presentation or thyroidectomy does not always represent the age at occurrence, but patients aged <15 years had distinct clinical manifestations. Age <15 years rather than <19 years may therefore be a more suitable cutoff age in pediatric DTC.

Trends for In- and Outpatient Thyroid Cancer Surgery in Older Adults in New York State, 2007-2017

BACKGROUND

In view of the 2013 American Thyroid Association consensus statement on outpatient thyroidectomy, the present study assessed the trends and factors associated with thyroid cancer surgery setting in older adults, using the New York Statewide Planning and Research Cooperative System database.

MATERIALS AND METHODS

There were 14,495 patients with surgically treated thyroid cancer in New York State between 2007 and 2017. Trends were plotted over time and stratified by surgery type. Significance of the trend was assessed using the Mann-Kendall test. Multivariable logistic regression was used to assess independent associations with surgical setting.

RESULTS

The overall outpatient surgery rate significantly increased over time (correlation coefficient 0.82; P < 0.001), for both total thyroidectomy (P < 0.001) and lobectomy (P < 0.001). Factors associated with increased odds of inpatient surgery were medium- and high-volume hospitalization (adjusted odds ratio [OR_adj] 2.12, 95% confidence interval [CI] 1.93-2.32; OR_adj 1.69, 95% CI 1.55-1.85, respectively) versus low volume, undergoing total thyroidectomy (OR_adj 1.75, 95% CI 1.61-1.90), as well as having Medicare insurance (OR_adj 1.13, 95% CI 1.02-1.24) versus private insurance.

CONCLUSIONS

The present study shows that outpatient thyroidectomy is increasingly favored over inpatient thyroidectomy over time in an older patient population. A clear changepoint following 2011 preceded the publication of the American Thyroid Association statement on outpatient thyroidectomy in 2013 and was likely associated with multiple publications reporting safety of outpatient thyroid surgery and clear economic benefits.

Concepts of Pathological Staging and Prognosis in Papillary Thyroid Carcinoma

American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (AJCC/UICC) staging and American Thyroid Association (ATA) risk predication system are the best predicators of mortality and cancer recurrence, respectively, in patients with differentiated thyroid carcinoma, including papillary thyroid carcinoma. In ATA risk stratification of differentiated thyroid carcinomas, clinical features, nodal features, and pathological features are assessed. Many of the features are also assessed in pathological staging. The prognostic stage grouping of papillary thyroid carcinoma in AJCC/UICC depends on the age of the patients as well as the standard parameters-extent of tumor (T), lymph node status (N), and presence of distant metastasis (M). Major changes noted in the current pathological staging protocol include the cut-off age from 45-year to 55-year in grouping of patients, use of gross invasion of strap muscles instead of minimal microscopic extrathyroidal extensions as T3b and downstage of many prognostic groups such as those with lymph node metastases (without distant metastases) from Stage III to Stage II. The staging protocol have moved many patients with papillary thyroid carcinoma into good prognostic groups for better predication of patients' survival rates and to avoid unnecessary treatment. This new approach has been verified by different groups globally, although modifications could be expected in the future for better prognostic assessment in patients with papillary thyroid carcinoma.

An Integrative Multi-Omics Analysis of The Molecular Links between Aging and Aggressiveness in Thyroid Cancers

Aging modifies risk in all cancers, but age is used as a clinical staging criterion uniquely in thyroid cancer (TC). The molecular drivers of age-dependent TC onset and aggressiveness remain poorly understood. We applied an integrative, multi-omics data analysis approach to characterize these signatures. Our analysis reveals that aging, independent of BRAF^V600E mutational status, drives a significant accumulation of aggressiveness-related markers and poorer survival outcomes, most noticeably at age 55 and over. We identified that chromosomal alterations in loci 1p/1q as aging-associated drivers of aggressiveness, and that depleted infiltration with tumor surveillant CD8+T and follicular helper T cells, dysregulation of proteostasis- and senescence-related processes, and ERK1/2 signaling cascade are key features of the aging thyroid and TC onset/progression and aggressiveness in aging patients but not in young individuals. A panel of 23 genes, including those related to cell division such as CENPF, ERCC6L, and the kinases MELK and NEK2, were identified and rigorously characterized as aging-dependent and aggressiveness-specific markers. These genes effectively stratified patients into aggressive clusters with distinct phenotypic enrichment and genomic/transcriptomic profiles. This panel also showed excellent performance in predicting metastasis stage, BRAF^V600E, TERT promoter mutation, and survival outcomes and was superior to the American Thyroid Association (ATA) methodology in predicting aggressiveness risk. Our analysis established clinically relevant biomarkers for TC aggressiveness factoring in aging as an important component.

Clinical implications of age and excellent response to therapy in patients with high-risk differentiated thyroid carcinoma

BACKGROUND

Patients with American Thyroid Association (ATA) high-risk differentiated thyroid carcinoma (DTC) have poor clinical outcomes. This study aimed to evaluate the clinical implications of age and response to therapy classification in patients with ATA high-risk DTC.

DESIGN AND PATIENTS

This study included 222 patients with high-risk DTC who initially underwent therapy between 2000 and 2010 in a single tertiary center in Korea. We evaluated the prognostic parameters associated with progression-free survival (PFS) and disease-specific survival (DSS) with a focus on age and achieving an excellent response (ER).

RESULTS

During the median follow-up period of 11.3 years, disease progression was detected in 77 patients (34.7%), and disease-specific mortality was reported in 31 patients (14.0%). Older age (≥55 years) and not achieving ER (not-ER) were independent risk factors associated with PFS (age, p < .001; not-ER, p < .001) and DSS (age, p < .001; not-ER, p = .015). Of the 74 patients in the ER group, 7 (9.5%) displayed disease progression and 1 (1.4%) died from DTC. There were no significant differences in PFS and DSS according to age in the ER group. However, older patients had significantly worse PFS and DSS than younger patients in the not-ER group (p = .002 and p < .001, respectively).

CONCLUSIONS

Response to therapy classification is important for predicting PFS and DSS in patients with high-risk DTC. Patients in the ER group had a relatively good prognosis, but disease progression occurred in 9.5% of patients. Age was a key predictor of both PFS and DSS in high-risk patients who did not achieve ER.

Overall survival is improved with total thyroidectomy and radiation for male patients and patients older than 55 with T2N0M0 Stage 1 classic papillary thyroid cancer

BACKGROUND

We examine whether surgery extent and radiation administration affect overall survival for cT2N0M0 classic papillary thyroid cancer according to age and sex.

METHODS

Patients with cT2N0M0 classic papillary thyroid cancer tumors in the National Cancer Data Base (2004-2016) were selected. Multivariable Cox regression analysis compared patients (combined male + female cohorts) having lobectomy to those having total thyroidectomy with or without radiation (primarily radioactive iodine) for ages: 18 to 45, 46 to 55, and >55 years. In addition, 1:1 propensity score matching and Kaplan-Meier curves with 10-year overall survival estimates, and log-rank test were stratified by age and sex.

RESULTS

Lobectomy had equivalent overall survival to total thyroidectomy without and with radiation for patients (combined male + female cohorts) aged 18 to 45 and 46 to 55 years on multivariable analysis. On propensity score matching there was overall survival advantage for total thyroidectomy with radiation over both lobectomy and total thyroidectomy for men (ages 18-90+ combined) and overall survival advantage in patients (combined male + female cohort) aged >55 years having total thyroidectomy with radiation versus lobectomy. On propensity score matching there were no overall survival differences in women (ages 18-90+ combined) or patients (combined male + female cohort) aged 18 to 45 and 46 to 55 years having either lobectomy, total thyroidectomy, or total thyroidectomy with radiation.

CONCLUSION

For cT2N0M0 classic papillary thyroid cancer, total thyroidectomy with radiation improves 10-year overall survival for patients (combined male + female cohort) aged >55 years and men (ages 18-90+ combined).

Can Age at Diagnosis and Sex Improve the Performance of the American Thyroid Association Risk Stratification System for Prediction of Structural Persistent and Recurrent Disease in Patients With Differentiated Thyroid Carcinoma? A Multicenter Study

OBJECTIVE

Although the age at diagnosis has been suggested as a major determinant of disease-specific survival in the recent TNM staging system, it is not included in the recent American Thyroid Association (ATA) guidelines to estimate the risk of recurrence. Nevertheless, the effect of sex on differentiated thyroid carcinoma (DTC) recurrence is controversial. Therefore, this multicenter study was conducted to assess whether age at diagnosis and sex can improve the performance of the ATA 3-tiered risk stratification system in patients with DTC with at least 5 years of follow-up.

METHODS

In this study, the computer-recorded data of the patients diagnosed with DTC between January 1985 and January 2016 were analyzed. Only patients with proven structural persistent/recurrent disease were selected for comparisons.

RESULTS

This study consisted of 1691 patients (female, 1367) with DTC. In Kaplan-Meier analysis, disease-free survival (DFS) was markedly longer in females only in the ATA low-risk category (P = .045). Nevertheless, a markedly longer DFS was observed in patients aged <45 years in the ATA low- and intermediate-risk categories (P = .004 and P = .009, respectively), whereas in patients aged <55 years, DFS was markedly longer only in the ATA low-risk category (P < .001). In the Cox proportional hazards model, ages of ≥45 and ≥55 years at diagnosis and the ATA risk stratification system were all independent predictors of persistent/recurrent disease.

CONCLUSION

Applying the age cutoff of 45 years in the ATA intermediate- and low-risk categories may identify patients at a higher risk of persistence/recurrence and may improve the performance of the ATA risk stratification system, whereas sex may improve the performance of only the ATA low-risk category.

How to identify indolent thyroid tumors unlikely to recur and cause cancer death immediately after surgery-Risk stratification of papillary thyroid carcinoma in young patients

Current histopathological diagnosis methods cannot distinguish the two types of thyroid carcinoma: clinically significant carcinomas with a potential risk of recurrence, metastasis, and cancer death, and clinically insignificant carcinomas with a slow growth rate. Both thyroid tumors are diagnosed as "carcinoma" in current pathology practice. The clinician usually recommends surgery to the patient and the patient often accepts it because of cancer terminology. The treatment for these clinically insignificant carcinomas does not benefit the patient and negatively impacts society. The author proposed risk stratification of thyroid tumors using the growth rate (Ki-67 labeling index), which accurately differentiates four prognostically relevant risk groups based on the Ki-67 labeling index, ≥30%, ≥10 and <30%, >5 and <10%, and ≤5%. Indolent thyroid tumors with an excellent prognosis have the following four features: young age, early-stage (T1-2 M0), curatively treated, and low proliferation index (Ki-67 labeling index of ≤5%), and are unlikely to recur, metastasize, or cause cancer death. Accurate identification of these indolent tumors helps clinicians select more conservative treatments to avoid unnecessary aggressive (total thyroidectomy followed by radio-active iodine) treatments. Clinicians can alleviate the fears of patients by confirming these four features, including the low proliferation rate, in a pathology report immediately after surgery when patients are most concerned.

A Three-Domain Scoring System to Customize the Risk of Relapse of Differentiated Thyroid Carcinoma

PURPOSE

the validation of a new scoring model considering the principal risk factors of differentiated thyroid cancer (DTC) relapse.

METHODS

we evaluated all DTC patients treated with thyroidectomy and radioactive iodine (RAI) therapy. Three domains were considered: the demographic domain (age and gender), the surgical domain (histology and the American Thyroid Association risk categories), and the RAI-related domain (pre-RAI thyroglobulin and post-therapeutic ¹³¹I whole-body scan). The progression-free survival was assessed. The patients' sample was randomly split into a training and validation set. The three-domain score was calculated as the weighted sum of the levels of each significant factor, then scaled to an integer range (0-100) and, finally, stratified into terciles: mild risk 0-33, moderate risk 34-66, and severe risk 67-100.

RESULTS

907 DTC patients were included. The RAI-related domain was the most relevant factor in the score calculation. The tercile stratification identified significantly different survival curves: patients within the two upper terciles showed approximately 6 to 30 times more progressive risk than patients at mild risk.

CONCLUSION

we have validated a three-domain scoring system and the principal impact on this score is provided by the peri-RAI findings, whose prognostic role seems to be essential in risk identification.

Development and validation of a nomogram based on stromal score to predict progression-free survival of patients with papillary thyroid carcinoma

Background

Growing evidence has proved that stromal cells, as the critical component of tumor microenvironment (TME), are closely associated with tumor's progression. However, the model based on stromal score to predict progression‐free survival (PFS) in papillary thyroid carcinoma (PTC) has not been developed. The study aimed at exploring the relation between stromal score and prognosis, then establishing a nomogram to predict PFS of patients with PTC.

Method

We obtained the stromal score and clinicopathological characteristics of PTC patients from The Cancer Genome Atlas (TCGA) database. Cox regression analysis assisted in selecting prognosis‐related factors. A stromal score‐based nomogram was built and verified in the training and validation cohorts, respectively. The calibration curve, concordance index (C‐index), decision curve analysis (DCA) as well as receiver operating characteristic (ROC) curve assisted in measuring the performance exhibited by the nomogram.

Results

We divided 381 PTC patients into the training cohort (n = 269) and the validation cohort (n = 112) randomly. Compared with patients who had a low stromal score, patients with a high stromal score appeared with significantly better PFS [Hazard ratio (HR) and 95% confidence interval (CI): 0.294, 0.130–0.664]. The C‐index of the PFS nomogram was 0.764 (0.662–0.866) in the training cohort and 0.717 (0.603–0.831) in the validation cohort. The calibration curves for PFS prediction in the nomogram were remarkably consistent with the actual observation. DCA indicated superior performance of the nomogram to predict PFS than the American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) staging system. The ROC curves showed the favorable sensitivity and specificity of the novel nomogram.

Conclusion

High stromal score was significantly associated with improved PFS in patients with PTC. The nomogram based on the stromal score and clinicopathological patterns yielded a reliable performance to predict the prognosis of PTC.

Finding the Optimal Age Cutoff for the UICC/AJCC TNM Staging System in Patients with Papillary or Follicular Thyroid Cancer

Background: Differentiated thyroid cancer (DTC) is the only cancer entity for which the UICC/AJCC (Union for International Cancer Control and American Joint Committee on Cancer) TNM (tumor-node-metastasis) staging system involves an age cutoff as a prognostic criterion. However, the optimal age cutoff has not yet been determined in detail. The aim of our study was therefore to investigate the optimal age cutoff for the TNM staging system to predict disease-specific survival (DSS) with a focus on differences between patients with papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC). Methods: We retrospectively studied two large well-described cohorts of adult DTC patients from a Dutch and a German university hospital. DSS was analyzed for DTC overall, and for PTC and FTC separately, using several age cutoffs (per 5-year increment between 20 and 85 years and subsequently 1-year increments between 35 and 55 years), employing the histopathological criteria from the TNM staging system, eighth edition. Results: We included 3074 DTC patients (77% PTC and 23% FTC; mean age at diagnosis was 49 years). Median follow-up was seven years. For DTC and for PTC and FTC separately, the majority of the age cutoffs had a better statistical model performance than a model with no age cutoff. For DTC overall and for PTC, an age cutoff of 50 years had the best statistical model performance, while it was 40 years for FTC. Conclusions: In this large European population of DTC patients, when employing the histopathological criteria of the TNM system (eighth edition), the optimal age cutoff to predict DSS is 50 years rather than the 55 years currently in use. With the optimal age cutoff being 50 years for PTC and 40 years for FTC, there was a substantial difference in age cutoff for the respective histological entities. Therefore, implementation of different age cutoffs for PTC and FTC could improve the predictive value of the TNM staging system.

Proposal of a New Prognostic Model for Differentiated Thyroid Cancer with TERT Promoter Mutations

The role of telomerase reverse transcriptase (TERT) promoter mutations as an independent poor prognostic factor in differentiated thyroid cancer (DTC) patients is well known, but there is no prognostic system that combines the TERT promoter mutation status with tumor-node-metastasis (TNM) stage to predict cancer-specific survival (CSS). A total of 393 patients with pathologically confirmed DTC after thyroidectomy were enrolled. After incorporating wild-type TERT and mutant TERT with stages I, II, and III/IV of the AJCC TNM system 8th edition (TNM-8), we generated six combinations and calculated 10-year and 15-year CSS and adjusted hazard ratios (HRs) for cancer-related death using Cox regression. Then, a new mortality prediction model termed TNM-8T was derived based on the CSS and HR of each combination in the four groups. Of the 393 patients, there were 27 (6.9%) thyroid cancer-related deaths during a median follow-up of 14 years. Patients with a more advanced stage had a lower survival rate (10-year CSS for TNM-8T stage 1, 2, 3, and 4: 98.7%, 93.5%, 77.3%, and 63.0%, respectively; p < 0.001). TNM-8T showed a better spread of CSS (p < 0.001) than TNM-8 (p = 0.002) in the adjusted survival curves. The C-index for mortality risk predictability was 0.880 (95% CI, 0.665-0.957) in TNM-8T and 0.827 (95% CI, 0.622-0.930) in TNM-8 (p < 0.001). TNM-8T, a new prognostic system that incorporates the TERT mutational status into TNM-8, showed superior predictability to TNM-8 in the long-term survival of DTC patients.

Reduction of overtreatment without reduction of overdiagnosis in patients with differentiated thyroid cancer: mission impossible

PURPOSE

Lateral neck nodal metastases are common in patients with differentiated thyroid cancer (DTC) and usually have an indolent nature. They may be detected via neck palpation or preoperative ultrasound (US) of the neck. We hypothesized that preoperative neck metastases detected with US did not affect regional recurrence or long-term survival.

METHODS

A retrospective analysis of patients' records treated for DTC at our institution between January 2006 and December 2016 was performed. Information about preoperative US of the neck, treatment, demographics, staging, and histopathology was obtained. The endpoints for the study were nodal recurrence and survival. Differences in survival were analyzed between three groups of patients divided by presence or lack of preoperative US and/or palpable cervical lymph nodes (PLN). Furthermore, the prognostic value of multiple variables was tested by univariate and multivariate analysis.

RESULTS

There were 1108 patients with DTC, 221 males and 887 females. The median age was 48.3 years (range 3 to 86), the median time of observation was 68 months (range 0 to 142). Eight hundred sixty-two patients without PLN or preoperative US represented group 1, 112 patients with PLN were in group 2, and 134 patients without PLN and with preoperative US were in group 3. Only five patients had a regional recurrence, one died due to distant metastases. There was no statistically significant difference in survival between the groups (p = 0.841) and neck US was not significantly associated with overall survival neither in univariate nor in multivariate analysis.

CONCLUSION

In patients with DTC, the benefits of preoperative US of cervical lymph nodes are probably limited and "less is more" approach is advised.

Application of competing risk model in the prognostic prediction study of patients with follicular thyroid carcinoma

BACKGROUND

Follicular thyroid carcinoma (FTC) is an indolent carcinoma. The cumulative incidence of death from patients with FTC and the nomogram built based on the competing risks model have not been described.

METHODS

The data from patients diagnosed with primary FTC were identified and extracted from the surveillance, epidemiology, and end results (SEER) program (1988-2015). The cumulative incidence function was utilized to calculate the likelihood of death resulting from thyroid cancer and other causes, respectively. Gray's test was used to examine the difference in the cumulative incidence of death between the groups. A tenfold cross-validation was applied to assess the discrimination and calibration of the model.

RESULTS

A total of 9210 patients diagnosed with primary FTC were included. The median follow-up time was 92 months (1-347 months). The 5-year, 10-year, and 20-year probabilities of death from FTC were 2.84%, 5.23%, and 8.61%, respectively. The age at diagnosis, sex, tumor size, pathological subtypes, tumor extension, lymph node involvement, as well as surgical and radiotherapy methods used, were related to the cumulative incidence of death. Multivariate analysis identified several risk factors for patient survival. The model behaved well in terms of performance. A nomogram based on the model allowed the prediction of the probability of death among patients with FTC.

CONCLUSIONS

The prognosis of FTC is excellent. The likelihood of death caused by thyroid cancer increases with age. Male sex, tumors larger than 4 cm, invasion, extrathyroidal extension, lymph node involvement, and distant metastases increase the risk of dying of thyroid carcinoma. The nomogram constructed on the basis of the model is potentially useful for both clinicians and patients.

Nomograms for Differentiated Thyroid Carcinoma Patients Based on the Eighth AJCC Staging and Competing Risks Model

Background

Differentiated thyroid carcinoma (DTC) patients have a long survival period and good prognosis, so they are easily affected by competing risk events. The purpose of this study was to use the competing risks model to identify prognostic factors for cause-specific death (CSD) and death due to other causes (DOC) in patients with DTC.

Methods

Our screening process identified 34 585 DTC patients in the Surveillance, Epidemiology, and End Results database and randomly divided them into a training cohort and a validation cohort. We used the Fine and Gray subdistribution hazards model to establish the CSD and DOC nomograms. The distinguishing ability and consistency of the nomograms were evaluated using the consistency indexes and calibration plots.

Results

Our analysis of a competing risks model revealed that pathological grade, tumor size, histological type, American Joint Committee on Cancer (AJCC)-8 stage, surgery status, adjuvant radiotherapy status, adjuvant chemotherapy status, and log odds of positive lymph nodes are prognostic factors for CSD, and age at diagnosis, year of diagnosis, sex, pathological grade, tumor size, AJCC-8 stage, surgery status, adjuvant radiotherapy status, and lymph node ratio are prognostic factors for DOC. The 1-year, 3-year, and 5-year concordance indexes in the validation cohorts were 0.942, 0.931, and 0.913 for the CSD nomogram and 0.813, 0.746, and 0.776 for the DOC nomogram. The calibration plots showed good consistency in both nomograms.

Conclusions

Our nomograms can be used as a tool to help clinicians individually predict the probability of CSD and DOC in DTC patients at 1 year, 3 years, and 5 years, which has certain guiding value in clinical applications.

Survival in differentiated thyroid carcinoma: Comparison between the 7th and 8th editions of the AJCC/UICC TNM staging system and the ATA initial risk stratification system

BACKGROUND

The AJCC/UICC TNM staging system evaluates the risk of death from cancer. Its 8th edition aimed to increase its accuracy. In turn, the American Thyroid Association proposed an initial risk stratification system (IRSS) focusing on the risk of recurrence in differentiated thyroid carcinoma. The present study intended to analyze their prediction abilities.

METHODS

Six hundred and eighty-five consecutive surgical patients (mean follow-up 71.6 months) were staged. Correlations with disease-free survival (DFS) and overall survival (OS) were carried out.

RESULTS

IRSS was discriminative for DFS but not for OS. Applying TNM 8th, 36.9% of the cohort was downstaged. Their DFS was shorter, compared with other patients in the same stage, but with no impact on OS. However, all those who died of the disease had been downstaged.

CONCLUSIONS

IRSS was more effective to predict DFS, but not OS. TNM 8th was more appropriate for OS analysis than TNM 7th and IRSS.

Thyroid cancer, recent advances in diagnosis and therapy

Over the past several decades, the approach to the diagnosis and management of patients with follicular cell-derived thyroid cancer has evolved based on improved classification of patients better matching clinical outcomes, as well as advances in imaging, laboratory, molecular technologies and knowledge. While thyroid surgery, radioactive iodine therapy and TSH suppression remain the mainstays of treatment, this expansion of knowledge has enabled de-escalation of therapy for individuals diagnosed with low-risk well-differentiated thyroid cancer; better definition of treatment choices for patients with more aggressive disease; and improved ability to optimize treatments for patients with persistent and/or progressive disease. Most recently, the advancement of knowledge regarding the molecular aspects of thyroid cancer has improved thyroid cancer diagnosis and has enabled individualized therapeutic options for selected patients with the most aggressive forms of the disease. Guidelines from multiple societies across the world reflect these changes, which focus on taking a more individualized approach to clinical management. In this review, we discuss the current more personalized approach to patients with follicular cell-derived thyroid cancer and point toward areas of future research still needed in the field.