Papillary thyroid microcarcinoma: optimal management versus overtreatment

Incidental Thyroid Malignancy in Surgical Patients With Benign Thyroid Disease

INTRODUCTION

The rate of incidental thyroid malignancy (ITM) has increased in recent decades. However, the factors associated with ITM remain uncertain. This study analyzes the rate of ITM in patients after surgical resection for benign thyroid disease (BTD) without preoperative suspicion of thyroid malignancy and its associated sociodemographic factors.

MATERIALS AND METHODS

A retrospective study of prospectively collected data reviewed data from 2528 patients who underwent initial thyroidectomy for BTD at a tertiary academic medical hospital between 2011 and 2022. Patients were excluded if they had a known history of thyroid cancer, radiation exposure, suspicious thyroid ultrasound features, and/or fine needle aspiration results. ITM rate was analyzed along with patient demographics, body mass index (BMI), tumor size, and invasive features.

RESULTS

Among 345 patients with BTD (mean 53.6 y, SD = 14.5), 22.9% (79/345) had ITM on final histopathology. Most patients were women (87.0%), White (87.0%), and Hispanic (56.8%), with an average BMI of 29.6 (SD = 6.56). BTD type was associated with ITM (P < 0.001), with nontoxic multinodular goiter exhibiting the highest incidence (36.0%). Higher BMI emerged as a predictor of higher rate of ITM (OR = 1.057, P = 0.007). Other sociodemographic variables did not show significant associations.

CONCLUSIONS

The study identified a higher rate of ITM than previously reported as well as an association between higher BMI and increased rate of ITM. This highlights a potential link between obesity and ITM not previously identified. Patients with higher BMI and BTD may benefit from further surveillance.

Papillary Thyroid Microcarcinoma: Differences between Lesions in Incidental and Nonincidental Settings-Considerations on These Clinical Entities and Personal Experience

Papillary thyroid microcarcinoma (PTMC) represents 35-40% of all papillary cancers; it is defined as a nodule ≤ 10 mm at the time of histological diagnosis. The clinical significance of PTMC is still controversial, and it may be discovered in two settings: incidental PTMC (iPTMC), in which it is identified postoperatively upon histological examination of thyroid specimens following thyroid surgery for benign disease, and nonincidental PTMC (niPTMC), in which it is diagnosed before surgery. While iPTMC appears to be related to mild behavior and favorable clinical outcomes, niPTMC may exhibit markers of aggressiveness. We retrospectively review our experience, selecting 54 PTMCs: 28 classified as niPTMC (52%) and 26 classified as iPTMC (48%). Patients with niPTMC showed significant differences, such as younger age at diagnosis (p < 0.001); a lower male/female ratio (p < 0.01); a larger mean nodule diameter (p < 0.001); and a higher rate of aggressive pathological findings, such as multifocality, capsular invasion and/or lymphovascular invasion (p = 0.035). Other differences found in the niPTMC subgroup included a higher preoperative serum TSH level, higher hospital morbidity and a greater need for postoperative iodine ablation therapy (p < 0.05), while disease-free long-term survival did not differ between subgroups (p = 0.331) after a mean follow-up (FU) of 87 months, with one nodal recurrence among niPTMCs. The differences between iPTMC and niPTMC were consistent: patients operated on for total thyroidectomy and showing iPTMC can be considered healed after surgery, and follow-up should be designed to properly calibrate hormonal supplementation; conversely, niPTMC may sometimes exhibit aggressive behavior, and so the FU regimen should be closer and aimed at early detection of cancer recurrence.

The Preferred Route for the Diagnosis and Management of Thyroid Carcinoma Among the General Population in Saudi Arabia

BACKGROUND

 Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Papillary thyroid microcarcinoma (PTMC) is a specific subgroup of PTC. Given their small size, PTMCs are often asymptomatic and behave benignly. This puts physicians in a challenging situation about how to prevent overdiagnosis and overtreatment of PTMC. This study aimed to assess the preferences regarding the route of PTMC diagnosis and treatment among Saudi Arabia's general population.

METHODS

 This is a cross-sectional questionnaire-based-study conducted among the general population in Saudi Arabia. The target subjects were the general population of Saudi Arabia both genders and different age groups from various regions of Saudi Arabia (Western, Central, Eastern, Southern, and North). Participants who did not complete the questionnaire or did not agree to participate were excluded. A self-administered questionnaire was distributed on different social media platforms to collect data from different regions. Data analysis was conducted by using Statistical Package for the Social Sciences (SPSS) 24.0 version (IBM Inc., Chicago, USA) statistical software. A Chi-square test was used to compare categorical variables.

RESULTS

 A total of 1,428 participants were included. The majority of them were females (64.4%), and most of them were aged between 19 and 25 years. Moreover, we found that 4.8% of the study population had a medical history of thyroid cancer. Our results revealed that more than half of respondents (54.6%) would select surgical operation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which turns out to be a PTC. The vast majority of participants (90.1%) would prefer to do cytologic confirmation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which has suspicious characteristics of PTC in neck ultrasound examination. Regarding PTMC operation, 59.8% of responders were more concerned about complications than recurrences. We found that neither age nor gender significantly affects decision-making for management or operative extent for PTC. There was a significant difference between age and decision-making for the diagnosis of suspicious thyroid nodules (p value = 0.041).

CONCLUSION

 Our results concluded that most of the participants preferred to select immediate surgery and cytologic confirmation regarding the management and diagnosis of PTC. More research is advised. The need to inform patients about their disease state and treatment options should be highlighted more.

Diagnostic Performance of Various Ultrasound Risk Stratification Systems for Benign and Malignant Thyroid Nodules: A Meta-Analysis

BACKGROUND

To evaluate the diagnostic performance of ultrasound risk-stratification systems for the discrimination of benign and malignant thyroid nodules and to determine the optimal cutoff values of individual risk-stratification systems.

METHODS

PubMed, Embase, SCOPUS, Web of Science, and Cochrane library databases were searched up to August 2022. Sensitivity and specificity data were collected along with the characteristics of each study related to ultrasound risk stratification systems.

RESULTS

Sixty-seven studies involving 76,512 thyroid nodules were included in this research. The sensitivity, specificity, diagnostic odds ratios, and area under the curves by K-TIRADS (4), ACR-TIRADS (TR5), ATA (high suspicion), EU-TIRADS (5), and Kwak-TIRADS (4b) for malignancy risk stratification of thyroid nodules were 92.5%, 63.5%, 69.8%, 70.6%, and 95.8%, respectively; 62.8%, 89.6%, 87.2%, 83.9%, and 63.8%, respectively; 20.7111, 16.8442, 15.7398, 12.2986, and 38.0578, respectively; and 0.792, 0.882, 0.859, 0.843, and 0.929, respectively.

CONCLUSION

All ultrasound-based risk-stratification systems had good diagnostic performance. Although this study determined the best cutoff values in individual risk-stratification systems based on statistical assessment, clinicians could adjust or alter cutoff values based on the clinical purpose of the ultrasound and the reciprocal changes in sensitivity and specificity.

Meta-Analysis of the Application Effect of Different Modalities of Thermal Ablation and Surgical Treatment in Papillary Thyroid Microcarcinoma

Background

Papillary thyroid microcarcinoma (PTMC) refers to papillary thyroid carcinoma (PTC) with a maximum diameter of 10 mm. Thermal ablation, including radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA), has been applied in the treatment of benign thyroid nodules and captured extensive attention. At present, the application of thermal ablation in PTMC has been extensively reported, but outcomes such as volume reduction rate (VRR), complete remission rate (CRR), and adverse reaction rate (ARR) vary considerably. Therefore, this meta-analysis was performed to evaluate the safety and efficacy of different treatment methods of PTMC.

Methods

We did a systematic review and network meta-analysis. We searched PubMed, EMBase, and Cochrane-Library from the date of inception to January 10, 2022, to retrieve the VRR, CRR, and ARR of MWA, RFA, LA and surgical treatment of PTMC, and a meta-analysis was performed using the R meta-package. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and sensitivity analyses, cumulative meta-analyses, and publication bias were also performed. Relevant literature was retrieved with keywords; the eligible cohort studies were screened based on the established inclusion and exclusion criteria.

Results

A total of 1515 patients were included in the 12-month follow-up. The overall VRR was 86.25% (95% CI: 77.89, 94.60), and the VRR was RFA > WMA > LA, but the differences were not significant. A total of 1483 patients were included in the last follow-up. The overall VRR was 99.41% (95% CI: 99.11, 99.72), and the VRR was RFA > WMA > LA, but the differences were not significant. A total of 1622 patients showed complete remission at the last follow-up, and the overall CRR was 0.63 (95% CI: 0.46, 0.79). The CRR was RFA > LA > WMA, but the differences were not significant. A total of 1883 patients had adverse reactions at the last follow-up, and the overall ARR was 0.06 (95% CI: 0.03, 0.08). The ARR at the last follow-up was RFA = Surg < LA < WMA. The ARR of the RFA and Surg subgroups was significantly lower than that of the WMA subgroup.

Conclusions

Similar good efficacy and safety profiles were observed in WMA, RFA, LA, and surgical treatment in PTMC, among which RFA showed the best volume reduction, complete remission rate, and adverse reaction reduction. However, there is a slight bias in the limited literature included in this study, and we did not conduct or refer to mechanistic studies to confirm its specific mechanism of action. Clinicians are advised to use their discretion in the choice of treatment.

Predictive features of central lymph node metastasis in papillary thyroid microcarcinoma: Roles of active surveillance in over-treatment

Background

Low-risk papillary thyroid microcarcinoma (PTMC) without clinically evident lymph nodes, extrathyroidal expansions, and distant metastases may be candidates for active monitoring.

Objective

The purpose of this research is to identify risk factors for papillary thyroid microcarcinoma (PTMC) metastasis to central cervical lymph nodes (CLNM) and to discuss the viability of an active surveillance strategy to minimize unnecessary therapy for patients.

Methods

This single-center retrospective study was conducted on the data and medical records of the patients who were diagnosed with PTMC and underwent surgery at the Baotou Cancer Hospital, China, between January 1, 2018, and December 31, 2019. Both lobectomy and complete thyroid resections were performed, and central lymph node dissections (CLND) were used in all patients. Comparisons and analyses were conducted on the preoperative ultrasound (US) characteristics, the post-operation pathological results, and lymph node metastasis.

Results

We analyzed 172 patients with PTMC with average age 48.32 ± 10.59 years old, with 31 males and 142 females. US testing showed 74 (43.0%) patients had suspicious lymph nodes; 31 (41.9%) had capsular invasion and 52 (30.2%) patients were confirmed to have CLNM. Based on logistic regression analysis, central lymph node metastasis was shown to be more common in individuals with PTMC who were older than 45 years old, male, and had tumors that lacked micro-calcification on US imaging. Postoperative pathology assessments suggested that 58 cases (33.7%) were more suitable candidates for active surveillance cohorts.

Conclusions

While active surveillance might benefit many PTMC patients, treatments for the patients should also encompass occult lymph node metastasis, especially in patients with over 45 years old, male, tumor without micro-calcification in the US imaging. Furthermore, the prediction of lymph nodes in the central cervical via the preoperative US and the PTMC risk stratification accuracy need to be improved. Our findings showed about 30% of the patients with PTMC had no active surveillance high-risk factors but required surgical treatment. Fear of cancer in the PTMC patients, although informed of the details, is still the main reason for choosing surgical treatment over active surveillance.

Less-Intensive Management Options for Low-Risk Thyroid Cancer

The incidence of thyroid cancer is increasing, whereas mortality remains relatively stable. An increasing body of research supports the use of less-intensive treatment for low-risk thyroid cancer, as the overall prognosis is excellent. Although total thyroidectomy was the gold standard for many years, the options of lobectomy alone, active surveillance, and other ablative modalities are increasingly being used. The clinicohistologic features of any thyroid cancer are important to help determine the optimal management for a given tumor. However, the patient's own desires and goals in their cancer treatment must be evaluated.

Assessment of Radiofrequency Ablation for Papillary Microcarcinoma of the Thyroid: A Systematic Review and Meta-analysis

IMPORTANCE

Papillary microcarcinomas of the thyroid (mPTCs) account for an increasing proportion of thyroid cancers in past decades. The use of radiofrequency ablation (RFA) has been investigated as an alternative to surgery. The effectiveness and safety of RFA has yet to be determined.

OBJECTIVE

To evaluate the effectiveness and safety of RFA for low-risk mPTC.

DATA SOURCES

Embase, MEDLINE via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched from inception to May 28, 2021.

STUDY SELECTION

Articles reporting on adult patients with mPTC treated with RFA were included. Studies that involved patients with pre-ablation lymph node or distant metastases, recurrence of disease, or extrathyroidal extension were excluded. Final article selection was conducted by multiple reviewers based on consensus. The proportion of eligible articles was 1%.

DATA EXTRACTION AND SYNTHESIS

This meta-analysis was conducted in accordance with the MOOSE guidelines. Random and fixed-effect models were applied to obtain pooled proportions and 95% CIs.

MAIN OUTCOMES AND MEASURES

The primary outcome was the complete disappearance rate of mPTC. Secondary outcomes were tumor progression and complications.

RESULTS

Fifteen studies were included in this meta-analysis. A total of 1770 patients (1379 women [77.9%]; mean [SD] age, 45.4 [11.4] years; age range, 42.5-66.0 years) with 1822 tumors were treated with RFA; 49 tumors underwent 1 additional RFA session and 1 tumor underwent 2 additional RFA sessions. Mean (SD) follow-up time was 33.0 (11.4) months (range, 6-131 months). The pooled complete disappearance rate at the end of follow-up was 79% (95% CI, 65%-94%). The overall tumor progression rate was 1.5% (n = 26 patients), local residual mPTC in the ablation area was found in 7 tumors (0.4%), new mPTC in the thyroid was found in 15 patients (0.9%), and 4 patients (0.2%) developed lymph node metastases during follow-up. No distant metastases were detected. Three major complications occurred (2 voice changes lasting >2 months and 1 cardiac arrhythmia). Minor complications were described in 45 patients.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that RFA is a safe and efficient method to treat selected low-risk mPTCs. Radiofrequency ablation could be envisioned as step-up treatment after local tumor growth under active surveillance for an mPTC or initial treatment in patients with mPTCs with anxiety about active surveillance.

Trends in the Management of Localized Papillary Thyroid Carcinoma in the United States (2000-2018)

Background: In response to evidence of overdiagnosis and overtreatment of papillary thyroid carcinoma (PTC), the 2009 and 2015 American Thyroid Association (ATA) adult guidelines recommended less extensive surgery (lobectomy vs. total thyroidectomy) and more restricted use of postsurgical radioactive iodine (RAI) in management of PTC at low risk of recurrence. In 2015, active surveillance was suggested as a viable option for some <1-cm PTCs, or microcarcinomas. The 2015 ATA pediatric guidelines similarly shifted toward more restricted use of RAI for low-risk PTCs. The impact of these recommendations on low-risk adult and pediatric PTC management remains unclear, particularly after 2015. Methods: Using data from 18 Surveillance, Epidemiology, and End Results (SEER) U.S. registries (2000-2018), we described time trends in reported first-course treatment (total thyroidectomy alone, total thyroidectomy+RAI, lobectomy, no surgery, and other/unknown) for 105,483 patients diagnosed with first primary localized PTC (without nodal/distant metastases), overall and by demographic and tumor characteristics. Results: The declining use of RAI represented the most pronounced change in management of PTCs <4 cm (44-18% during the period 2006-2018), including microcarcinomas (26-6% during the period 2007-2018). In parallel, an increasing proportion of PTCs were managed with total thyroidectomy alone (35-54% during the period 2000-2018), while more subtle changes were observed for lobectomy (declining from 23% to 17% during the period 2000-2006, stabilizing, and then rising from 17% to 24% during the period 2015-2018). Use of nonsurgical management did not meaningfully change over time, impacting <1% of microcarcinomas annually during the period 2000-2018. Similar treatment trends were observed by sex, age, race/ethnicity, metropolitan vs. nonmetropolitan residence, and insurance status. For pediatric patients (<20 years), use of RAI peaked in 2009 (59%), then decreased markedly to 11% (2018), while use of total thyroidectomy alone and, to a lesser extent, lobectomy increased. No changing treatment trends were observed for ≥4-cm PTCs. Conclusions: The declining use of RAI in management of low-risk adult and pediatric PTC is consistent with changing recommendations from the ATA practice guidelines. Post-2015 trends in use of lobectomy and nonsurgical management of low-risk PTCs, particularly microcarcinomas, were more subtle than expected; however, these trends may change as evidence regarding their safety continues to emerge.

TERT Promoter Mutations Are an Independent Predictor of Distant Metastasis in Middle Eastern Papillary Thyroid Microcarcinoma

BACKGROUND

Papillary thyroid microcarcinomas (PTMCs) have been attributed to the recent increased incidence of thyroid cancer. Although indolent, a subset of PTMC could potentially develop distant metastasis (DM). This study aimed to evaluate the clinico-pathological features and molecular characteristics of PTMC and identify the risk factors for DM in PTMC patients from Middle Eastern ethnicity.

METHODS

We retrospectively analyzed 210 patients with histologically confirmed PTMC. Clinico-pathological associations for DM, BRAF mutation and TERT mutation were analyzed successfully in 184 patients. Multivariate analysis was performed using Cox proportional hazards model and logistic regression analysis.

RESULTS

Among the PTMC patients included in this cohort, DM was noted in 6.0% (11/184), whereas tumor relapse occurred in 29/184 (15.8%). Of the 11 cases with DM, lung metastasis occurred in 8 cases, bone metastasis in 2 cases and brain metastasis in 1 case. Presence of extrathyroidal extension and male sex were significantly associated with DM. Molecular analysis showed BRAF V600E mutations to be the most frequent, being detected in 45.7% (84/184). TERT promoter mutations were detected in 16 (8.7%) cases and were significantly associated with DM and shorter metastasis-free survival in multivariate analysis.

CONCLUSIONS

Our study indicates a surprisingly high frequency of TERT promoter mutation in Saudi patients with PTMC. Identifying TERT promoter mutations as an independent predictor of DM in patients with microcarcinoma could explain the inherent aggressive nature of PTMC from Middle Eastern ethnicity and magnify its role in patient risk stratification, which might help in improving therapeutic strategy for these patients.

Risk Factor Analysis for Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

Purpose

Although the prognosis of papillary thyroid microcarcinoma (PTMC) is excellent, cervical lymph node metastasis (CLNM) is commonly observed in PTMC. This study aimed to investigate the incidence and risk factors for CLNM in PTMC.

Patients and Methods

Altogether, 687 patients with PTMC who initially underwent unilateral thyroidectomy with unilateral central lymph node dissection or bilateral thyroidectomy with bilateral central lymph node dissection between January 2014 and June 2018 at our hospital were included. The patients were divided into two groups: PTMC with CLNM and PTMC with no CLNM. The clinicopathologic characteristics and ultrasound features were compared between the groups. Univariate and multivariate logistic regression analyses were used to identify the risk factors for CLNM.

Results

CLNM was observed in 121/687 (17.6%) patients with PTMC. PTMC patients aged <55 years exhibited a greater incidence of CLNM (87.6% vs 12.4%) than those aged ≥55 years. PTMC patients with CLNM were more likely to have capsular extension (24.0% vs 15.4%) and extension to the adjacent structures (9.9% vs 4.2%). Patients with microcalcification on ultrasound images were more likely to have CLNM (66.1% vs 47.9%). Multivariate logistic regression analysis revealed that microcalcification (odds ratio [OR]: 2.066, 95% confidence interval [CI]: 1.361-3.135, P<0.001), age <55 years (OR: 2.341, 95% CI: 1.309-4.187, P=0.004), capsular invasion (OR: 1.772, 95% CI: 1.082-2.879, P=0.023), and invasion of the adjacent tissues (OR: 2.872, 95% CI: 1.355-4.187, P=0.004) were significant risk factors for CLNM.

Conclusion

Microcalcification, age <55 years, capsular invasion, and invasion of the adjacent tissues were significant risk factors for CLNM in PTMC.

A practical approach for the management of small thyroid nodules referred for biopsy

OBJECTIVE

Current guidelines recommend against routine ultrasound (US) guided fine-needle aspiration biopsy (FNAB) of small (<1 cm) thyroid nodules and suggest follow-up of ≥5 mm small nodules only if they are TI-RADS-5. This study aims to determine the best suspicious ultrasound features related to cytology results in patients referred for FNAB of small thyroid nodules and construct an algorithm for declining unnecessary biopsies and selection of patients to be followed up.

METHODS

This prospective observational study enrolled patients referred for US-guided biopsy of ≤1 cm thyroid nodules. Ultrasound features including composition, echogenicity, shape, margin, echogenic focus, hypoechoic rim, vascularity were assessed. The cytology results were dichotomised as either benign or malignant/high risk. The features with excellent interobserver reliability and more than 90% sensitivity were selected.

RESULTS

Overall, 95 patients [82 (86.3%) females, mean age 48.5 ± 11.9 years] with 95 small (≤1 cm) thyroid nodules were biopsied. Cytology revealed 15 (15.8%) malignant nodules. Pure solid composition, hypoechogenicity, taller than wide shape and irregular margin of the nodules were significantly associated with malignancy. Hypoechogenicity (100%) and pure solid composition (93%) had very high sensitivity and excellent interobserver agreement (Cohen's Kappa 0.83, P = .003 for both) for predicting high risk/malignant nodule. In the absence of these two features, 48 (50.5%) nodules either would not require FNAB or follow-up.

CONCLUSION

The presence of cyst or iso/hyperechogenicity within a small thyroid nodule in patients already referred for invasive sampling safely allows for declining a decision of FNAB or follow-up without the concern of missing malignancy.

Papillary thyroid microcarcinomas: does subtyping predict aggressive clinical behavior?

The most common malignant neoplasm affecting the thyroid gland is papillary thyroid carcinoma (PTC). PTC can demonstrate a number of morphologic variants including, but not limited to, classic, follicular, and tall cell. Each of these morphologic subtypes carry distinct clinical characteristics such that certain variants, like tall cell, behave more aggressively than others. PTCs measuring less than or equal to 1.0 cm are classified as microcarcinomas. Although these lesions are thought to be clinically indolent, we hypothesized that, like their larger counterparts, certain histologic variants may lead to worse patient outcomes. To test our hypothesis, we analyzed our pathology archives between the years 2009 and 2020 for papillary thyroid microcarcinomas and assessed whether different morphologic features correlated with more aggressive clinical behavior. Our findings suggest that certain variants exhibit features that portend a more worrisome clinical course and thus papillary thyroid microcarcinomas should be subtyped to help predict patient outcome.

Incidence and Mortality Risk Spectrum Across Aggressive Variants of Papillary Thyroid Carcinoma

Importance

While well-differentiated papillary thyroid carcinoma (WDPTC) outcomes have been well characterized, the prognostic implications of more aggressive variants are far less defined. The rarity of these subtypes has led to their consolidation as intermediate risk for what are in fact likely heterogeneous diseases.

Objective

To analyze incidence, clinicopathologic characteristics, and outcomes for aggressive variants of papillary thyroid carcinoma (PTC).

Design, Setting, and Participants

This cohort study used data from 2000 to 2016 from hospital-based and population-based US cancer registries to analyze aggressive PTC variants, including diffuse sclerosing (DSV), tall-cell (TCV), insular, and poorly differentiated (PDTC) subtypes. These variants were compared against WDPTC and anaplastic cases. Data analysis was conducted from January 2019 to October 2019.

Main Outcomes and Measures

Age-adjusted incidence was calculated via annual percentage change (APC) using the weighted least-squares method. Overall survival and disease-specific survival were analyzed via Cox regression. Propensity-score matching was used to adjust survival analyses for clinical and demographic covariates.

Results

Collectively, 5447 aggressive PTC variants were identified (including 415 DSV, 3339 TCV, 362 insular, and 1331 PDTC cases), as well as 35 812 WDPTC and 2249 anaplastic cases. Over the study period, a substantial increase in aggressive variant incidence was observed (APC, 9.1 [95% CI, 7.33-10.89]; P < .001), surpassing the relative increases observed in WDPTC (APC, 5.1 [95% CI, 3.98-6.12]; P < .001) and anaplastic cases (APC, 1.9 [95% CI, 0.75-3.05]; P = .003; parallelism P < .007). Survival varied markedly based on histologic subtype, with a wide spectrum of mortality risk noted; 10-year overall survival was 85.4% (95% CI, 84.6%-86.3%) in WDPTC, 79.2% (95% CI, 73.6%-85.3%) in DSV, 71.9% (95% CI, 68.4%-75.6%) in TCV, 45.1% (95% CI, 40.2%-50.6%) in PDTC, 27.9% (95% CI, 20.0%-38.9%) in the insular variant, and 8.9% (95% CI, 7.5%-10.6%) in anaplastic cases (P < .001). These differences largely persisted even after adjusting for inherent differences in baseline characteristics by multivariable Cox regression and propensity-score matching.

Conclusions and Relevance

An upsurge in aggressive PTC incidence was observed at a rate beyond that seen in WDPTC or anaplastic thyroid carcinoma. Moreover, long-term survival outcomes for aggressive PTC subgroups exhibit heterogeneous clinical behavior and a wide range of mortality risk, suggesting that treatment should be tailored to specific histologic subtypes. Given increasing prevalence and disparate outcomes, further investigation to identify optimal therapeutic strategies is needed in these diverse, understudied populations.

Prognostic Impact of Histologic Grade for Papillary Thyroid Carcinoma

BACKGROUND

While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade.

METHODS

We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed.

RESULTS

Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01).

CONCLUSIONS

Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.