Predictors of Neck Reoperation and Mortality After Initial Total Thyroidectomy for Differentiated Thyroid Cancer

TIPARP as a prognostic biomarker and potential immunotherapeutic target in male papillary thyroid carcinoma

BACKGROUND

Male patients with papillary thyroid carcinoma (PTC) tend to have poorer prognosis compared to females, partially attributable to a higher rate of lymph node metastasis (LNM). Developing a precise predictive model for LNM occurrence in male PTC patients is imperative. While preliminary predictive models exist, there is room to improve accuracy. Further research is needed to create optimized prognostic models specific to LNM prediction in male PTC cases.

METHODS

We conducted a comprehensive search of publicly available microarray datasets to identify candidate genes continuously upregulated or downregulated during PTC progression in male patients only. Univariate Cox analysis and lasso regression were utilized to construct an 11-gene signature predictive of LNM. TIPARP emerged as a key candidate gene, which we validated at the protein level using immunohistochemical staining. A prognostic nomogram incorporating the signature and clinical factors was developed based on the TCGA cohort.

RESULTS

The 11-gene signature demonstrated good discriminative performance for LNM prediction in training and validation datasets. High TIPARP expression associated with advanced stage, high T stage, and presence of LNM. A prognostic nomogram integrating the signature and clinical variables reliably stratified male PTC patients into high and low recurrence risk groups.

CONCLUSIONS

We identified a robust 11-gene signature and prognostic nomogram for predicting LNM occurrence in male PTC patients. We propose TIPARP as a potential contributor to inferior outcomes in males, warranting further exploration as a prognostic biomarker and immunotherapeutic target. Our study provides insights into the molecular basis for gender disparities in PTC.

Surgical resection of recurrent differentiated thyroid cancer: patterns, detection, staging, and treatment of 683 patients

Background

Despite improvements in overall survival, the recurrence of differentiated thyroid cancer (DTC) is becoming more common and remains a challenge necessitating accurate reappraisal of the patient. This study aimed to describe the characteristics, reasons, morbidity, and strategies of second operations for DTC.

Methods

This was a retrospective observational study of patients with DTC who underwent a second surgery between June 2008 and June 2021 in the Department of Thyroid Surgery at China-Japanese Union Hospital, Jilin University, P.R. China. All clinical characteristics were recorded, and the analysis was estimated using SPSS.

Results

Second surgeries were detected in 683 patients. The proportion of second operations changed with the update of international guidelines from 2015 (P < 0.001). The true recurrence rate progressively increased from 21.3% to 61.5%. The rate of an "absence of preoperative FNA" or an "absence of intraoperative pathology at first surgery" decreased from 49.8% to 12.7%, while that of a "misdiagnosis of preoperative FNA at second surgery" decreased from 10% to 1.8%. The most common tumor location during the second surgery was the lateral lymph nodes (n = 104, 36.5%), with a median time to relapse of 36 months. Completion of thyroidectomy and lymph node dissection correlated with the second operation.

Conclusion

After 2015, second surgeries were more standardized, the incidence of complications decreased, and real recurrence became the most common reason for a second DTC surgery.

Effect of Waiting Time for Radioactive Iodine Therapy on Outcome in N1 Stage Papillary Thyroid Cancer

CONTEXT

The waiting time for radioactive iodine therapy (WRAIT) after total thyroidectomy (TT) in patients with papillary thyroid cancer (PTC) and lymph node metastases (N1) has not been sufficiently investigated for risk of adverse outcomes.

OBJECTIVE

This work aimed to estimate the effect of WRAIT on the outcomes of disease persistence and recurrence among patients with N1 PTC and investigate factors predictive of delayed radioactive iodine therapy (RAIT).

METHODS

This retrospective cohort study was conducted in a university hospital. A total of 909 patients with N1 PTC were referred for RAIT between 2014 and 2018. WRAIT is the duration between TT and initial RAIT. The optimal WRAIT threshold determined using recursive partitioning analysis was used to define early and delayed RAIT. The primary end point was tumor persistence/recurrence. We compared the outcomes of patients with early and delayed RAIT using inverse probability weighting based on the propensity score.

RESULTS

The WRAIT threshold that optimally differentiated worse long-term remission/excellent response outcomes was greater than 88 days (51% of our cohort; n = 464). WRAIT exceeding 88 days was associated with an augmented risk of disease persistence/recurrence (odds ratio, 2.47; 95% CI, 1.60-3.82) after adjustment. Predictors of delayed RAIT included residence in lower-income areas, reoperation before the initial RAIT, TT at a nonuniversity-affiliated hospital, multifocality, extrathyroidal extension, N1b disease, and pre-RAIT-stimulated thyroglobulin level less than 1 ng/mL.

CONCLUSION

Delayed RAIT beyond 88 days after TT in patients with N1 PTC independently increased the risk of disease persistence/recurrence. Evaluation of the predictive determinants of prolonged WRAIT may help target at-risk patients and facilitate interventions.

Influence of Socioeconomic Status on Incident Medical Conditions in Two-Year Survivors of Adolescent or Young Adult Differentiated Thyroid Cancer

Purpose: We sought to enumerate secondary medical conditions from hospitalization records in adolescent and young adult (AYA) differentiated thyroid cancer (DTC) survivors and identify characteristics of patients with increased likelihood of subsequent medical diagnoses. Methods: Using data from the California Cancer Registry and statewide hospitalization data, we examined incident oncologic, endocrine, pulmonary, hematologic, and cardiovascular diagnoses in 12,312 AYA (aged 15-39) patients diagnosed with DTC in 1996-2012 and surviving >2 years after diagnosis with follow-up through 2014. We calculated the cumulative incidence of each condition accounting for the competing risk of death and used multivariable Cox proportional hazards regression to evaluate sociodemographic and clinical characteristics associated with each incident condition. Results: The 10-year cumulative incidences of multiple medical conditions were particularly high in blacks and Hispanics. Asian/Pacific Islander survivors were most likely to develop subsequent cancers. Men had higher rates of cardiovascular and diabetes diagnoses than women, but lower rates of asthma and cytopenias. Low socioeconomic status and/or public or no insurance were associated with a higher risk of several diagnoses. More extensive disease stage and thyroid surgery increased the risk of calcium and phosphorus metabolism disorders. Neck reoperation associated with the risk of cytopenias, as well as subsequent endocrine, cardiovascular, and respiratory diagnoses. Conclusions: The incidence of medical conditions after thyroid cancer diagnosis and treatment differ among racial/ethnic groups and sexes. Those residing in lower socioeconomic neighborhoods, those with public or no insurance, and those who require further neck surgery have substantially higher burdens of subsequent medical diagnoses.

Severe Hypocalcemia After Thyroidectomy: An Analysis of 7366 Patients

OBJECTIVE

The aim of the study was to determine severe hypocalcemia rate following thyroidectomy and factors associated with its occurrence.

BACKGROUND

Hypocalcemia is the most common complication after thyroidectomy. Severe post-thyroidectomy hypocalcemia can be life-threatening; data on this specific complication are scarce.

METHODS

Patients who underwent thyroidectomy in the American College of Surgeons-National Surgical Quality Improvement Program thyroidectomy-targeted database (2016-2017) were abstracted. A severe hypocalcemic event was defined as hypocalcemia requiring intravenous calcium, emergent clinic/hospital visit, or a readmission for hypocalcemia. Multivariable regression was used to identify factors independently associated with occurrence of severe hypocalcemia.

RESULTS

Severe hypocalcemia occurred in 5.8% (n = 428) of 7366 thyroidectomy patients, with 83.2% necessitating intravenous calcium treatment. Rate of severe hypocalcemia varied by diagnosis and procedure (0.5% for subtotal thyroidectomy to 12.5% for thyroidectomy involving neck dissections). Overall, 38.3% of severe hypocalcemic events occurred after discharge; in this subset, 59.1% experienced severe hypocalcemia despite being discharged with calcium and vitamin D. Severe hypocalcemia patients had higher rates of recurrent laryngeal nerve injury (13.4% vs 6.6%), unplanned reoperations (4.4% vs 1.3%), and longer hospital stay (30.4% vs 6.2% ≥3 days (all P < 0.01). After multivariate adjustment, severe hypocalcemia was associated with multiple factors including Graves disease [odds ratio (OR) = 2.06], lateral neck dissections (OR: 3.10), and unexpected reoperations (OR = 3.55); all P values less than 0.01.

CONCLUSIONS

Severe hypocalcemia and suboptimal hypocalcemia management after thyroidectomy are common. Patients who experienced severe hypocalcemia had higher rates of nerve injury and unexpected reoperations, indicating surgical complexity and provider inexperience. More biochemical surveillance particularly a parathyroid hormone-based protocol, fine-tuned supplementation, and selective referral could reduce occurrence of this morbid complication.

The Current Histologic Classification of Thyroid Cancer

Thyroid cancers of follicular cell derivation provide excellent phenotype-genotype correlations. Current morphologic classifications are complex and require simplification. Benign adenomas have follicular or papillary architecture and bland cytology. Well-differentiated thyroid carcinomas exhibit follicular architecture, expansile growth, and variable cytologic atypia and invasiveness; low-risk tumors have excellent prognosis after surgical resection whereas widely-invasive and angioinvasive tumors warrant total thyroidectomy and radioablation. Papillary carcinoma is less differentiated; indolent microcarcinomas can be managed by active surveillance, whereas clinical lesions with local or distant spread require therapy. Progression gives rise to poorly differentiated and anaplastic carcinomas that are less common but far more aggressive.