Approach to the patient with incidental papillary microcarcinoma

Decoding the past and future of distant metastasis from papillary thyroid carcinoma: a bibliometric analysis from 2004 to 2023

Background

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy, and its distant metastasis (PTCDM), although uncommon, seriously affects the survival rate and quality of life of patients. With the rapid development of science and technology, research in the field of PTCDM has accumulated rapidly, presenting a complex knowledge structure and development trend.

Methods

In this study, bibliometric analysis was used to collect 479 PTCDM-related papers published between 2004 and 2023 through the Web of Science (WoS) Core Collection (WoSCC) database. Keyword clustering analysis was performed using VOSviewer and citespace, as well as dual-map overlay analysis, to explore knowledge flows and interconnections between different disciplines.

Results

The analysis indicated that China, the United States, and South Korea were the most active countries in conducting research activities. Italy's research was notable due to its higher average citation count. Keyword analysis revealed that "cancer," "papillary thyroid carcinoma," and "metastasis" were the most frequently used terms in these studies. The journal co-citation analysis underscored the dominant roles of molecular biology, immunology, and clinical medicine, as well as the growing importance of computer science in research.

Conclusion

This study identified the main trends and scientific structure of PTCDM research, highlighting the importance of interdisciplinary approaches and the crucial role of top academic journals in promoting high-quality research. The findings not only provide valuable information for basic and clinical research on thyroid cancer but also offer guidance for future research directions.

Predictors of lateral lymph node metastasis and skip metastasis in patients with papillary thyroid microcarcinoma

Background

Papillary thyroid microcarcinoma (PTMC) is characterized by its favorable prognosis and potential for active surveillance (AS) as a management option. However, the presence of cervical lymph node (LN) metastasis, especially lateral LN metastasis, significantly impacts management and prognosis. Previous studies have focused on post-surgery risk factors for cervical LN metastasis. This study aims to identify predictors of lateral LN metastasis by analyzing pre-operative ultrasonographic findings alongside clinicopathological factors.

Methods

A retrospective review of medical records was conducted for patients with PTMC who underwent surgery at Chonnam National University Hwasun Hospital between 2004 and 2013. This is a case-control study that compares patients with lateral LN metastasis (N1b) to age- and sex-matched patients without LN metastasis (N0). Subgroup analysis was performed to evaluate risk factors of skip metastasis.

Results

The study included 90 patients with PTMC with lateral LN metastasis (N1b) and 268 age- and sex-matched patients without LN metastasis (N0). The mean age was 49.3 years, and female patients were dominant in both groups. Structural recurrences of 4.4% (4/90) were observed only in the N1b group. The N1b group exhibited a higher frequency of upper lobe tumor location compared to the N0 group (38.9% vs. 16.0%, p < 0.001). There was no significant difference in the locations with the presence of invasion to adjacent organs. A higher proportion of non-parallel shape was observed in the N1b group than the N0 group (80.0% vs. 66.0%, p = 0.013). There were no differences in echogenicity, sonographic feature, margin, and AP diameter of the thyroid gland between the two groups. In multivariate analysis, independent risk factors for lateral LN metastasis included extrathyroidal extension, multiplicity, upper lobe tumor location, and non-parallel shape. Skip metastasis in patients with PTMC was associated with upper lobe tumor location.

Conclusion

Detailed ultrasound examinations, evaluating tumor location, number, orientation, and the presence of ETE, are crucial in accurately predicting lateral LN metastasis especially when primary tumor was in the upper lobe to avoid missing skip metastasis. These evaluations can help guide the decision between AS and immediate surgery in patients with PTMC.

Nomogram for predicting central lymph node metastasis in T1-T2 papillary thyroid cancer with no lateral lymph node metastasis

OBJECTIVE

Whether routine central lymph node dissection (CLND) is necessary for T1-T2 papillary thyroid carcinoma (PTC) patients without certain lateral lymph node metastases (LLNM) remains controversial. This study aims to construct a nomogram that predicts central lymph node metastasis (CLNM) for T1-T2 PTC patients without LLNM.

METHODS

We retrospectively reviewed adult T1-T2 PTC patients with no LLNM retrieved from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. We also collected data from patients treated at the First Hospital of China Medical University between February and April 2021 for external validation. Logistic regression model was used to construct a risk prediction model nomogram. The receiver-operating characteristic (ROC) curve, calibration plot, and decision curve analyses (DCA) were used for assessing the nomogram.

RESULTS

5,094 patients from the SEER database and 300 patients from our department were finally included in this study. Variables such as age, gender, race, tumor size, multifocality, and minimal extrathyroidal extension (mETE) were found to be associated with CLNM and were subsequently incorporated into our nomogram. The C-index of our constructed model was 0.704, while the internal and external validation C-indexes were 0.693 and 0.745, respectively. The nomogram was then evaluated using calibration and decision curve analyses.

CONCLUSION

A visualized nomogram was successfully developed to predict CLNM in T1-T2 PTC patients without LLNM and assist clinicians in making personalized clinical decisions.

Incidentally discovered papillary thyroid microcarcinoma in patients undergoing thyroid surgery for benign disease

INTRODUCTION

The incidence of thyroid carcinoma has grown significantly over the last few decades. A possible explanation is the increased diagnosis of small thyroid microcarcinoma (TMc). TMc reach a maximum diameter of ≤1 cm, identified during histopathology examination following a thyroidectomy performed for reasons not pertaining to malignancy. This study aims to investigate the prevalence of papillary thyroid microcarcinoma (PTMc) according to the benign pathology that refers patients to surgery and its trend evolution.

METHODS

Retrospective cohort analysis of 1815 patients who underwent total thyroidectomy for non-malignant diseases in the 2005-2020 period.

RESULTS

The mean age of the subjects was 53.5 years, with a higher proportion of women (1481, 82.1%). A total of 167 PTMc (9.3%) were incidentally discovered. A multivariate logistic regression analysis was performed, showing no differences in prevalence according to sex or age in patients with PTMc compared to final benign histology. Multinodular goiter increases the risk of PTMc with an odds ratio of 2.2 (p = 0.001) compared to Hashimoto's thyroiditis and Graves' disease (GD). There is a statistically significant increase in the incidence of PTMc in the group operated in the 2017-2020 vs. 2005-2008 period (p = 0.005).

CONCLUSION

The overall prevalence of PTMc in patients who underwent thyroid surgery for the benign disease was 9.3%. Thyroid nodular hyperplasia was the most frequent benign pathology associated with PTMc compared to Hashimoto's or GD. Gender and age were not correlated with the prevalence of TMc. Over the years, surgical findings of PTMc have grown, particularly in the 2017-2020 period.

Prevalence of Central Compartment Lymph Node Metastases in Papillary Thyroid Micro-Carcinoma: A Retrospective Evaluation of Predictive Preoperative Features

Simple Summary

The present study focused on patients affected by stage pT1a papillary thyroid micro-carcinomas that were treated with surgery and central lymph node dissection. In this study, male sex, low age, and sub-capsular carcinoma localization resulted as independent predictive factors for central lymph node metastases.

Abstract

Papillary thyroid micro-carcinomas are considered relatively indolent carcinomas, often occult and incidental, with good prognosis and favorable outcomes. Despite these findings, central lymph node metastases are common, and are related to a poor prognosis for the patient. We performed a retrospective analysis on patients treated with surgery for stage pT1a papillary thyroid micro-carcinomas. One hundred ninety-five patients were included in the analyses. The presence of central lymph node metastases was identified and studied. A multivariate analysis employing binary logistic regression was used to calculate adjusted odds ratios with 95% confidence intervals of possible central lymph node metastases risk factors. In the performed multivariate analysis, male gender, younger age, and histopathological characteristics, such as a tumor sub-capsular localization, were significantly associated with central lymph node metastases in pT1a patients. Central compartment lymph node metastases are present in a non-negligible number of cases in patients with papillary thyroid micro-carcinoma undergoing surgical resection. Studying these factors could be an effective tool for predicting patients’ central lymph node metastases in papillary thyroid micro-carcinomas, defining a tailored surgical treatment in the future.

Treatment strategies and predicting lymph node metastasis in elderly patients with papillary thyroid microcarcinoma

This study aims to explore the prognostic variables for elderly papillary thyroid microcarcinoma (PTMC) patients as well as create a nomogram that could predict the occurrence of cervical lymph node metastasis (CLNM) on the basis of a large population database with high quality.A total of 5165 PTMC patients from Surveillance, Epidemiology, and End Results database database were enrolled in the study. In the meantime, we retrospectively collected 205 PTMC patients who underwent thyroidectomy in our medical center as an external control to test the accuracy of the model. The independent predictors of survival were identified by multivariate Cox regression analysis. Risk factors were selected as nomogram parameters to develop a model to predict CLNM. The C-index and calibration plots were used to evaluate CLNM model discrimination. The predictive nomogram was further validated in the external validation set.76.8% of the enrolled patients underwent thyroidectomy. Overall survival and cancer-specific survival were significantly better in patients who underwent surgery than in those who did not (P < .001). Sex, tumor size, and extent of tumor were included in a multivariable logistic regression model to predict lymph node metastasis. The nomogram had good discrimination with a C-index of 0.71. The calibration curves showed perfect agreement between nomogram predictions and actual observations.Elderly PTMC patients who received a surgical approach without radiotherapy showed survival advantage than those with other treatment strategies. Moreover, a nomogram model was established to predict the risk of CLNM, which will help clinicians in making treatment decisions.

Nomogram for Predicting Central Lymph Node Metastasis in Papillary Thyroid Cancer: A Retrospective Cohort Study of Two Clinical Centers

Purpose

Central lymph node metastasis (CNM) are highly prevalent but hard to detect preoperatively in papillary thyroid carcinoma (PTC) patients, while the significance of prophylactic compartment central lymph node dissection (CLND) remains controversial as a treatment option. We aim to establish a nomogram assessing risks of CNM in PTC patients, and explore whether prophylactic CLND should be recommended.

Materials and Methods

One thousand four hundred thirty-eight patients from two clinical centers that underwent thyroidectomy with CLND for PTC within the period 2016–2019 were retrospectively analyzed. Univariate and multivariate analysis were performed to examine risk factors associated with CNM. A nomogram for predicting CNM was established, thereafter internally and externally validated.

Results

Seven variables were found to be significantly associated with CNM and were used to construct the model. These were as follows: thyroid capsular invasion, multifocality, creatinine > 70 μmol/L, age < 40, tumor size > 1 cm, body mass index < 22, and carcinoembryonic antigen > 1 ng/mL. The nomogram had good discrimination with a concordance index of 0.854 (95% confidence interval [CI], 0.843 to 0.867), supported by an external validation point estimate of 0.825 (95% CI, 0.793 to 0.857). A decision curve analysis was made to evaluate nomogram and ultrasonography for predicting CNM.

Conclusion

A validated nomogram utilizing readily available preoperative variables was developed to predict the probability of central lymph node metastases in patients presenting with PTC. This nomogram may help surgeons make appropriate surgical decisions in the management of PTC, especially in terms of whether prophylactic CLND is warranted.

Clinicopathologic factors and preoperative ultrasonographic characteristics for predicting central lymph node metastasis in papillary thyroid microcarcinoma: a single center retrospective study

Introduction

The treatment of papillary thyroid microcarcinoma remains controversial. Central lymph node metastasis is common in papillary thyroid microcarcinoma and it is an important consideration in treatment strategy selection.

Objective

The aim of this study was to investigate clinicopathologic risk factors and thyroid nodule sonographic characteristics for central lymph node metastasis in papillary thyroid microcarcinoma.

Methods

We retrospectively reviewed the data of 599 papillary thyroid microcarcinoma patients who underwent surgery from 2005 to 2017 at a single institution. Univariate and multivariate analyses were used to identify the clinicopathologic factors and preoperative sonographic features of central lymph node metastasis. A receiver-operating characteristic, ROC curve analysis, was performed to identify the efficacy of ultrasonographic features in predicting central lymph node metastasis. A nomogram based on the risk factors was established to predict central lymph node metastasis.

Results

The incidence of central lymph node metastasis was 22.4%. The univariate and multivariate analyses suggested that gender, age, multifocality, extrathyroidal invasion, and lateral lymph node metastasis were independent risk factors for central lymph node metastasis. The univariate and multivariate analyses revealed that nodular shape, margin, and calcification were independently associated with central lymph node metastasis. The ROC curve analysis revealed that the combination of shape, margin and calcification had excellent accuracy in predicting central lymph node metastasis. The nomogram was developed based on the identified risk factors for predicting central lymph node metastasis, and the calibration plot analysis indicated the good performance and clinical utility of the nomogram.

Conclusions

Central lymph node metastasis is associated with male gender, younger age (<45 years), extrathyroidal invasion, multifocality and lateral lymph node metastasis in papillary thyroid microcarcinoma patients. The ultrasongraphic features, such as irregular shape, ill-defined margin and calcification, may improve the efficacy of predicting central lymph node metastasis. Surgeons and radiologists should pay close attention to the patients who have these risk factors. The nomogram may help guide surgical decision making in papillary thyroid microcarcinoma.

Risk Factors for Lymph Node Metastasis in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis

Purpose: To explore the risk factors that may predict the lymph node metastasis potential of these lesions and new prevention strategies in papillary thyroid carcinoma patients. Materials and Methods: In total, 9,369 papillary thyroid carcinoma patients with 37.17% lymph node metastasis were analyzed (Revman 5.3 software) in this study. The PubMed and Embase databases were used for searching works systematically that were published through to January 22, 2020. Results: Several factors were related to the increased risk of lymph node metastasis in patients with papillary thyroid carcinoma: age <45 years (pooled OR = 1.52, 95% CI = 1.14-2.01, p <0.00001); gender = male (pooled OR = 1.68, 95% CI = 1.51-1.87, p <0.00001); multifocality (pooled OR = 2.05, 95% CI = 1.45-2.89, p <0.0001); tumor size ≥1.0 cm (pooled OR = 3.53, 95% CI = 2.62-4.76, p <0.00001); tumor location at the upper pole 1/3 (pooled OR =1.46, 95% CI = 1.04-2.04, p = 0.03); capsular invasion + (pooled OR = 3.48, 95% CI = 1.69-7.54, p = 0.002); and extrathyroidal extension + (pooled OR = 2.03, 95% CI= 1.78-2.31, p <0.00001). However, tumor bilaterality (pooled OR = 0.85, 95% CI = 0.54-1.34, p = 0.49) and Hashimoto's thyroditis (pooled OR = 1.08, 95% CI = 0.79-1.49, p = 0.62) showed no correlation with lymph node metastasis in papillary thyroid carcinoma patients. Conclusion: The systematic review and meta-analysis defined several significant risk factors of lymph node metastasis in papillary thyroid cancer patients: age (<45 years), gender (male), multifocality, tumor size (>1 cm), tumor location (1/3 upper), capsular invasion, and extra thyroidal extension. Bilateral tumors and Hashimoto's thyroiditis were unrelated to lymph node metastasis in patients with papillary thyroid cancer.

Incidentally Discovered Papillary Thyroid Microcarcinomas Are More Frequently Found in Patients with Chronic Lymphocytic Thyroiditis Than with Multinodular Goiter or Graves' Disease

Background: Incidental finding of differentiated thyroid microcarcinomas (DTMc) in patients undergoing thyroid surgery for benign indications has become increasingly common. Even though carcinogenesis might relate to the background disease of the gland, the incidence of DTMc in the setting of various thyroid disorders remains unclear. We designed the present study to address this question. Materials and Methods: We reviewed data from two prospectively collected databases of consecutive patients undergoing thyroid surgery in two high-volume tertiary care referral centers, one in the United States (A) and the other one in Greece (B) over 18 years. We collected data on the preoperative surgical indication, fine-needle aspiration (FNA) cytology, and surgical pathology. We excluded subjects operated for thyroid cancer or with high risk for malignancy (FNA suspicious for thyroid cancer, follicular neoplasm, suspicious for follicular neoplasm, follicular lesion of undetermined significance/atypia of undetermined significance, or preoperative features of malignancy) and those with postsurgical pathology consistent with papillary thyroid cancer (PTC) ≥1 cm in largest diameter. We divided our subjects based on pathology data into those with chronic lymphocytic thyroiditis (CLT), Graves' disease (GD), or multinodular goiter (MNG). Results: We reviewed 6096 cases of thyroid surgery (A: 2711, B: 3385). We included 3909 subjects in the analysis. Overall, 569 (14.6%) PTC subjects were identified (A: 221/2003 [11%], B: 348/1906 [18.3%], odds ratios [OR] = 0.56, p < 0.0001). CLT was present in 617 subjects; PTC sonographic was present in 143 subjects (23.2%) (A: 79/404 [19.6%], B: 64/213 [30%], OR = 0.56, p = 0.003). GD was present in 359 subjects; PTC was present in 37 subjects (10.3%) (A: 12/197 [6.1%], B: 25/162 [15.4%], OR = 0.36, p = 0.004). MNG was present in 2933 subjects; PTC was present in 389 subjects (13.3%) (A: 130/1402 [9.3%], B: 259/1531 [16.9%], OR = 0.50, p < 0.0001). The incidence of PTC was significantly higher in CLT compared with MNG (OR = 1.75, p < 0.0001) or GD (OR = 2.25, p < 0.0001) but not in MNG compared with GD (OR = 1.29, p > 0.05). Conclusions: Incidentally discovered PTC are more commonly identified in surgical specimens from subjects with CLT compared with patients with MNG, while patients with GD present with a lower incidence compared with both groups. These data support previously published findings that euthyroid Hashimoto thyroiditis favors carcinogenesis, while GD may have a protective role.

Should familial disease be considered as a negative prognostic factor in micropapillary thyroid carcinoma?

PURPOSE

An increased aggressiveness of familial papillary thyroid carcinoma (FPTC) compared with sporadic form has been reported. On the contrary, the biological behavior of familial microPTC (FmPTC) is still debated. To assess if familial diseases should be considered as a negative prognostic factor in mPTC, the clinical presentation and outcome of FmPTC and sporadic mPTC (SmPTC) were compared.

METHODS

We retrospectively analyzed 291 mPTC (SmPTC n = 248, FmPTC n = 43) patients followed for a median follow-up of 8.3 years. FmPTC was defined as the presence of PTC in two or more first-degree relatives, after excluding hereditary syndromes associated with PTC.

RESULTS

FmPTC patients had more frequently bilateral tumor (32.6% versus 16.5%, p = 0.01) and lymph node metastases at diagnosis (30.2% versus 14.9%, p = 0.02). At the first follow-up, FmPTC patients had a higher rate of structural disease and a lower rate of remission compared to SmPTC (p = 0.01). Also in a multivariate model, using a "CHAID tree-building algorithm", familial disease correlated with a worse clinical presentation and outcome of mPTC patients. Familial disease was associated with a higher rate of intermediate risk patients in non incidental mPTC and with a higher rate of structural incomplete response in mPTC without lymph node metastases (p = 0.01).

CONCLUSIONS

Like in macroPTC, the familial form of the diseases has been shown to be a negative prognostic factor also in mPTC, therefore, it should be highly regarded in the management of mPTC patients.

Clinicopathological characteristics and recurrence risk of papillary thyroid microcarcinoma in the elderly

Background: The optimal management for elderly patients with papillary thyroid microcarcinoma (PTMC) is not well established. The aim of the present study is to describe the clinicopathological characteristics and identify predictors of recurrence in the elderly PTMC patients.

Methods: We conducted a retrospective study of PTMC patients who underwent thyroidectomy. The clinicopathological characteristics were compared between patients with age ≥65 years and <65 years. The independent predictors of recurrence were identified by multivariate Cox regression analysis.

Results: The patients in elderly group were more likely to exhibit bilaterality (P<0.050), extrathyroidal extension (P < 0.001), and central compartment lymph node metastasis (CLNM) (P<0.010), especially the ratio of CLNM >0.5 (P<0.010), than the patients with age <65 years. The elderly patients had poorer recurrence-free survival (RFS) than those with younger ages (P=0.002). Multivariate analysis indicated tumor size >5 mm (P=0.009) and CLNM ratio >0.5 (P=0.002) were independent risk factors for recurrence of the elderly patients with PTMC.

Conclusions: The elderly PTMC patients have more aggressive biological characteristics and higher recurrence rate. More aggressive treatment and rigorous follow-up could be considered for elderly patients with tumor diameter >5 mm and CLNM ratio >0.5.

Surgical Treatment in Papillary Thyroid Microcarcinoma

Despite the notable increasing incidence of papillary thyroid microcarcinoma (PTMC), the optimal treatment of the patients with PTMC remains controversial. Because of no consensus about its treatment, the suggested treatment varies from active surveillance alone to total thyroidectomy. Although the 2015 revised American Thyroid Association guideline recommends hemithyroidectomy as the first-line treatment, active surveillance has also been discussed and accepted as another approach for the patients with PTMC. However, the same guideline does not recommend fine needle aspiration biopsy for nodules sized <1 cm, even it is suspicious. In such situation, neither active surveillance nor hemithyroidectomy could be discussed, with a lack of objective cytologic data about the nodules sized <1 cm. In this situation, the decision to perform FNAB to the nodules <1 cm in size depends on the performer of the thyroid ultrasonography. In this invited review, we have discussed the diagnosis and prognostic factors for PTMCs. We have also discussed surgical strategies as the accepted the first-line treatment in patients with PTMC.

Disease Burden and Outcome in Children and Young Adults With Concurrent Graves Disease and Differentiated Thyroid Carcinoma

CONTEXT

Adults with differentiated thyroid cancer (DTC) and Graves disease (GD) demonstrate a greater reported disease burden and aggressive DTC behavior. To date, no studies have examined the impact and long-term outcome of concurrent GD and DTC (GD-DTC) in children and young adults.

DESIGN

Single institution, retrospective longitudinal cohort study between 1997 and 2016.

PARTICIPANTS

One hundred thirty-nine children and young adults with DTC, diagnosed at median age 15 (range, 5 to 23) years, compared with 12 patients with GD-DTC, median age 18 (range, 12 to 20) years.

MAJOR OUTCOME MEASURES

Patient demographics, preoperative imaging, fine needle aspiration (FNA) cytology, operative and pathological reports, laboratory studies, treatment, and subsequent 2-year outcomes.

RESULTS

Compared with DTC, patients with GD-DTC were significantly older at the time of DTC diagnosis (P < 0.01). Patients with GD-DTC were more likely to exhibit microcarcinoma (P < 0.01), and 2 of 12 (17%) demonstrated tall cell variant papillary thyroid cancer (PTC) vs 2 of 139 (2%) in patients who had DTC alone (P = 0.03). Although patients with DTC showed greater lymphovascular invasion (60% vs 25%; P = 0.03), no group differences were noted in extrathyroidal extension, regional lymph node, and distant or lung metastasis. There were no group differences in the 2-year outcome for remission, persistent disease, or recurrence.

CONCLUSIONS

Concurrent DTC in pediatric patients with GD is not associated with a greater disease burden at presentation and shows no significant difference in 2-year outcomes compared with DTC alone. Similar to adults, microcarcinoma and tall cell variant PTC is prevalent in pediatric patients with GD-DTC. For patients who have GD-DTC with an identified nodule on ultrasound imaging prior to definitive therapy, FNA biopsy is recommended to guide definitive treatment.

Papillary thyroid microcarcinoma: characteristics at presentation, and evaluation of clinical and histological features associated with a worse prognosis in a Latin American cohort

Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.

Risk factors associated with intrathyroid extension of thyroid microcarcinomas

PURPOSE

The aims of this study were to investigate the rate of intrathyroid extension of papillary thyroid microcarcinoma (PTMC) in patients operated for benign thyroid disease and to identify independent risk factors associated with it.

METHODS

A retrospective study of 301 patients operated for benign thyroid diseases (hyperthyroid diseases, multinodular goitre, Hashimoto thyroiditis and benign thyroid tumours) was performed at a high-volume endocrine surgery unit of a tertiary referral academic hospital, in a 5-year period. These patients had a PTMC incidentally discovered on definite histopathological findings following total or near-total thyroidectomy. Since distinguishing between intrathyroid extension of PTMC as the result of intrathyroid dissemination or as the result of multicentricity is challenging, we observed them together as multifocality. In statistical analysis, we used standard descriptive statistics and univariate and multivariate logistic regression analysis to determine independent risk factors associated with multifocality.

RESULTS

In our study, there were 85.4% females and 14.6% males with a median age of 54 years. A multinodular goitre (32.5%) was the most common indication for an operation. Most patients (68.4%) had a PTMC that was 5 mm or smaller. The most frequent histological variants of PTMC were the follicular variant (52.8%), followed by the papillary variant (22.6%) and the mixed follicular-papillary variant (18.6%). A multifocal PTMC was present in 26.6% of cases. An independent protective factor for multifocality of PTMC was a thyroid gland that weighed more than 38 g (OR 0.55, 95% CI 0.31-0.97, p = 0.039). Size of PTMC greater than 5 mm was an independent risk factor for a multifocal PTMC (OR 3.26, 95% CI 1.85-5.75, p = 0.000). Finally, the mixed follicular-papillary variant of PTMC represents an independent risk factor for a multifocal PTMC (OR 2.42, 95% CI 1.09-5.36, p = 0.030).

CONCLUSIONS

Intrathyroid extension is present in more than a quarter of PTMCs found in patients operated for benign thyroid disease. Independent risk factors for intrathyroid extension are size of PTMC greater than 5 mm and the mixed follicular-papillary variant of PTMC, while a large thyroid gland is an independent protective factor.

Too Much of a Good Thing: Radioactive Iodine Ablation Use for Micropapillary Thyroid Carcinoma

Radioactive iodine (RAI) is not routinely recommended for the adjuvant treatment of micro-papillary thyroid carcinoma (MPTC). We aimed to report on clinical and pathologic factors associated with the use of RAI in these patients. We queried the Surveillance, Epidemiology, and End Results database for patients who underwent surgery for MPTC (tumor size ≤1 cm) from 1988 to 2009. We excluded patients without a biopsy-proven diagnosis, those diagnosed at autopsy, and patients with documented extra-thyroidal extension. Multivariate logistic regression models predicted the use of RAI based on patient, tumor, and treatment-related factors. We identified 24,076 patients with MPTC that were eligible for study inclusion. Of these, 6,172 (25.6%) received RAI. Lymph node metastases were present in 23.8 per cent of those for whom lymph node status was known. On multivariate analysis, an increasing number of positive nodes, increasing tumor size, Asian race, and male gender predicted the use of RAI. RAI use was less likely in those with advancing age, an increasing number of lymph nodes examined and patients that received less than a total thyroidectomy. Among node-negative patients, Asian race and increasing tumor size predicted the use of RAI. Factors predicting decreased use of RAI were an increasing number of lymph nodes examined, unknown race, less than a total thyroidectomy, and advancing age. A significant number of MPTC patients receive potentially unnecessary RAI.

Risk factors stratifying malignancy of nodules in contralateral thyroid lobe in patients with pre-operative ultrasound indicated unilateral papillary thyroid carcinoma: A retrospective analysis from single centre

OBJECTIVE

Papillary thyroid carcinoma (PTC) is the most common thyroid carcinoma with a favourable clinical outcome. For unilateral PTC patients with thyroid nodules in the contralateral lobes, the necessity of total thyroidectomy (TT) is still in doubt. In this study, we aimed to define clinical factors that could be indicators for malignancy in nodules in the contralateral thyroid lobe, which could aid the clinician in selecting the appropriate operation approach.

DESIGN, PATIENTS AND MEASUREMENTS

This is a retrospective study from January 2014 to December 2016 conducted in Shanghai Ruijin Hospital. A total of 1442 cases with unilateral PTC and ultrasonographically benign nodules in the contralateral lobe who underwent TT at a single institution were enrolled. All patients underwent pre-operative ultrasonography (US), and all the cases were confirmed by board-certified pathologists. Clinicopathological features such as age, gender, tumour location, tumour size, TgAb and TPOAb levels, capsular invasion, multifocality, central lymph node metastases and BRAF mutation were examined to evaluate the rate of malignancy in the contralateral thyroid nodules.

RESULTS

In total, 47% of patients (677 cases)were confirmed to have malignancy in the contralateral lobe. Univariant analysis indicated that capsular invasion, Hashimoto's thyroiditis, multifocal loci, central lymph node metastases as well as BRAF mutation predicted a high incidence of occult contralateral carcinoma. Multivariant analysis showed capsular invasion, multifocal ipsilateral thyroid lobe, central lymph node metastases as well as BRAF mutation can serve as independent predictors for malignancy in the contralateral thyroid lobe.

CONCLUSIONS

Malignancy in the contralateral lobe was found in 47% of patients. This finding was associated with multifocal primary carcinomas involvement, capsular invasion, Hashimoto's thyroiditis history, central lymph node metastases and BRAF mutation, which should therefore be taken into consideration when planning therapeutic strategy for the patients.

The surgical approach to nodule Thyr 3-4 after the 2.2014 NCCN and 2015 ATA guidelines

BACKGROUND

The incidence of palpables thyroid nodules in general population is 5% and the prevalence of non -palpable nodules is higher (35-60%) in the endemic goiter area. In the last years the new guidelines and new classification related to thyroid nodule have changed the indication to treat it.

MATERIAL AND METHOD

We analyzed the patients treated from January 2013 to June 2016 for Thyr 3 and Thyr 4 thyroid nodule sec. Bethesda system. We have divided in I and II period related to the 2.2014 and 2015 ATA guidelines and we have evaluated the indication to treat, the type of surgical procedure, the incidence of thyroid carcinoma and the adverse events.

RESULTS

We selected from 909 cases, 252 cases surgically treated with preoperative diagnosis of Thyr 3(80 cases) and Thyr 4(172 cases); carcinoma was found in 21/80 (26.2%) and in 62/172 (26.05%). The period was divided from January 2013 to December 2014 and from January 2015 to june 2016 (first and second period). In II period we found carcinoma in 8/40 Thyr3 and in 26/88 Thyr 4. The incidence of lobectomy in II period was higher than I period (p < 0.0001) sec.guidelines indications. No difference in adverse events. The number of cancer is lower in patients treated with lobectomy than those who underwent total thyroidectomy (12,5%vs 21,8% in Thyr 3; 15,3% vs 32% in Thyr 4).

CONCLUSIONS

The indications to treat related to Thyr 3 and Thyr4 are changed in the two periods. The number of cancer is lower in patients treated with lobectomy. The new guidelines have changed the surgical approach to thyroid nodule.

Survival Analysis of Papillary Thyroid Carcinoma in Relation to Stage and Recurrence Risk: A 20-Year Experience in Pakistan

OBJECTIVE

The aim of this study was to evaluate the overall and progression-free survival of papillary thyroid carcinoma (PTC), comparing the American Thyroid Association (ATA) guideline for risk of recurrence with the TNM staging system with dynamic assessment at 2 years.

PATIENTS AND METHODS

This study is a retrospective analysis of 689 PTC patients over a 20-year period at a single center. Disease-free survival based on the TNM staging and ATA recurrence risk was calculated using Kaplan-Meier curves. Dynamic response assessment during the first 2 years was compared for both systems. Survival was calculated based on age, baseline resectability, and postthyroidectomy serum tumor marker levels.

RESULTS

Six hundred eighty-nine (72.2%) of the total thyroid cancer patients had PTC. Four hundred sixty-nine patients were females, and 220 patients were males. The age range was 6 to 87 years. Five hundred thirty-five patients were resectable, and 56 patients were unresectable. One hundred fifty-one patients were excluded due to insufficient information on recurrence risk. By ATA categorization, 39% had low risk, no disease-related mortality; 44% had intermediate risk, 3 died; and 17% had high risk, 32 died. The 5-year disease-free survival was 54%, 26%, and 5% in low-, intermediate-, and high-risk groups, respectively. The log-rank test showed a significant difference in the percent survival (P < 0.01). TNM stage wise, in terms of survival, 1.3% in stage I, 2.2% in stage II, 0% in stage III, and 37.5% in stage IV died. The 20-year disease-free survival showed the following: stage I, 43%; stage II, 28%; stage III, 18%; and stage IV, 2%. There is significant difference in survival rate (P < 0.01). Both ATA risk classification and TNM staging were significant predictors of disease-free survival. On bivariate analysis, ATA classification (hazards ratio, 2.1; 95% confidence interval, 1.64-2.67; P = 0.001) was better predictive of overall survival versus TNM classification (hazards ratio, 1.3; 95% confidence interval, 1.11-1.43; P = 0.063).

CONCLUSIONS

The ATA risk stratification and continuous reassessment during the first 2 years predicts disease-free survival better than the TNM staging. Age older than 45 years, unresectable disease, and elevated postthyroidectomy thyroglobulin levels dictate a poorer prognosis.

Ultrasound-guided percutaneous laser ablation of unifocal T1N0M0 papillary thyroid microcarcinoma: Preliminary results

OBJECTIVES

To evaluate the efficacy and safety of percutaneous laser ablation (PLA) for unifocal T1N0M0 papillary thyroid microcarcinoma(PTMC).

METHODS

A retrospective study was conducted in 30 patients with single PTMC which was diagnosed by fine-needle aspiration biopsy (FNAB). PLA was performed for proper time to achieve adequate ablation zones. The extent of ablation was assessed by contrast-enhanced ultrasound (CEUS) immediately and 7 days after PLA. Complications were recorded. The size and volume of the ablation area and thyroid hormones were measured, and clinical evaluations were performed at 1, 3, 6 and12 months, and every half year thereafter.

RESULTS

The procedure was well tolerated without serious complications. Of the 30 patients, 29 were treated successfully under local anaesthesia in a single session. Only one incomplete ablation was detected by immediate CEUS after PLA, and a second ablation was performed. At the last follow-up, ten (33.3 %) ablation zones had disappeared, and 20 (66.67 %) ablation zones remained as scar-like lesions. No regrowth of treated tumours, local recurrence or distant metastases were detected.

CONCLUSIONS

During the short-term follow-up period, ultrasound-guided PLA appears to be effective and safe for treating solitary T1N0M0 PTMC in selected patients who are ineligible for surgery.

KEY POINTS

• Ultrasound is a useful tool in percutaneous laser ablation (PLA). • PLA is safe for treating papillary thyroid microcarcinoma. • PLA is effective for single papillary thyroid microcarcinoma.

Surgical Management of Familial Papillary Thyroid Microcarcinoma: A Single Institution Study of 94 Cases

BACKGROUND

Familial papillary thyroid carcinoma (familial PTC) is well known to present with aggressiveness; however, the characteristics and the prognostic outcomes of familial papillary thyroid microcarcinoma (familial micro-PTC) are not well established. The overall aim of this study was to analyze the clinicopathological outcomes of familial micro-PTC.

METHODS

Between 1996 and 2006, 2071 patients underwent thyroid surgery for papillary thyroid carcinoma. The clinicopathological outcomes for familial PTC and sporadic PTC were compared, and familial micro-PTC data were sub-analyzed.

RESULTS

There were significant differences in multifocality, bilaterality, extent of surgery, and recurrence between familial PTC and sporadic PTC (p<0.05). There was no significant difference in the number of affected family members in the familial PTC group. In patients with familial micro-PTC, less aggressiveness was noted in multifocality, extrathyroidal invasion, tumor stage at time of initial surgery, central lymph node metastasis, and recurrence than in those with familial PTC tumors>1 cm in diameter (p<0.05). The multivariate analysis including recurrence showed no significant difference between familial micro-PTC patients and sporadic micro-PTC patients.

CONCLUSION

When familial PTC was compared with sporadic PTC, our results support the recommendation for more invasive familial PTC surgery. However, familial micro-PTC outcomes differed from familial PTC tumors>1.0 cm in diameter. It was similar to sporadic micro-PTC, illustrating that familial micro-PTC is less aggressive and that a less invasive surgical treatment could be considered.

Incidental Papillary Thyroid Microcarcinoma in an Endemic Goiter Area

Clinical and pathological characteristics of incidental papillary thyroid microcancer cases, surgical, medical, and nuclear treatment methods, and patients' outcome were studied during follow-up period of 102 months. We studied 37 patients with incidental papillary thyroid microcancer (I-PTM). The surgical procedure was total thyroidectomy in 29 and hemithyroidectomy in 8 patients. Size, multifocality, and bilateralism of PTM foci, thyroid capsule invasion, and presence of lymphovascular invasion were histopathological parameters. We analysed adjuvant medical and nuclear treatment and patients' outcome during follow-up period of 102 (61-144) months. The prevalence rates of I-PTM were 9.4% in 395 thyroidectomy cases. Histopathological examination reported unifocal disease in 30 and multifocal disease in 7 (18%) patients. Multifocal disease was bilateral in 6 (20.1%) patients. The mean size of the PTM foci was 4.88 mm. The rate of thyroid capsule invasion was 5.4%. All patients received a suppressive dose of LT4 to achieve a low serum TSH level. Adjuvant surgical and nuclear treatment was not performed in our cases. We did not find any negative changes in blood chemistry and ultrasound imaging, and any unfavourable events as locoregional and systemic recurrence. In conclusion, diagnosis of I-PTM is common that multifocality and bilateralism appear as pathologic features. The prognosis is excellent after surgical treatment and TSH suppression. Routine adjuvant nuclear treatment is unnecessary in majority of patients.

BRAF(V⁶⁰⁰E) mutation and its association with clinicopathological features of papillary thyroid microcarcinoma: A meta-analysis

Recent studies have demonstrated that the BRAF(V600E) mutation is associated with aggressive clinicopathological features of papillary thyroid carcinoma (PTC). However, the BRAF mutation as a prognostic biomarker in papillary thyroid microcarcinoma (PTMC) is unclear. A systematic search of the electronic databases, including Medline, Scopus, CNKI and the Cochrane Library was performed up to July 1, 2014. Outcomes of interest included age, gender, concomitant hashimoto thyroiditis or nodular goiter, tumor size, pathological stage, tall cell variant of PTMC (TCVPTMC), multifocality, extrathyroidal extension (ETE) and lymph node metastasis (LNM). A total of 19 studies published from 2008 to 2014 comprising 2253 patients fulfilled the inclusion criteria and were included in the meta-analysis, and 1143 (50.7%) of these patients were BRAF mutation positive. BRAF mutation was associated with larger tumor size (OR: 1.64; 95% CI: 1.16-2.32), multifocality (OR: 1.58; 95% CI: 1.25-2.00), ETE (OR: 2.59; 95% CI: 2.03-3.29), LNM (OR: 1.73; 95% CI: 1.14-2.62), advanced stage (OR: 2.03; 95% CI: 1.14-3.64) and TCVPTMC (OR: 5.07; 95% CI: 1.49-17.27; P=0.009). Additionally, the BRAF mutation was found to be not associated with age, gender, concomitant hashimoto thyroiditis or nodular goiter (P>0.05 for all). This meta-analysis revealed that in patients with PTMC, BRAF mutation is associated with tumor size, multifocality, ETE, LNM, advanced stage and TCVPTMC, and it may be used as a predictive factor for prognosis of PTMC.

Increase of papillary thyroid microcarcinoma and a plea for restrictive treatment: A retrospective study of 1,391 prospective documented patients

BACKGROUND

The incidence of papillary thyroid microcarcinomas (PMCs) has increased sharply and therefore the lack of consensus for treatment has become a clinical dilemma. Our aim was to evaluate a less-radical approach.

METHODS

This study includes 1,391 patients with PMC treated at a single surgical referral center in the endemic goiter area in Austria. Data, including long-term follow-up examinations with a median follow-up time of 7 years, were collected from the institutional surgery database.

RESULTS

Of the 1,391 patients, 947 (68.1%) had a near-total or total thyroidectomy; 1,090 patients (78.3%) had no lymphadenectomy, and 1,136 patients (81.7%) did not receive radioiodine treatment. Twenty-one patients (1.5%) underwent reoperation, 5 because of lymph node recurrence (0.4%), 16 with clinically benign recurrence, including 4 cases of another PMC. There were no recurrences in the thyroid bed and no disease-related deaths. Risk factors for lymph node recurrences were nonincidental finding, nodal metastases at presentation, young age, aggregate tumor size, and subcapsular tumor localization. Multifocality, sex, maximum tumor size, and the extent of surgery were not relevant factors.

CONCLUSION

Nodal recurrence is rare and reoperation cured all patients. Micrometastases are not of clinical relevance. The postoperative findings of most PMCs suggest that, even if multifocal, a limited approach without completion thyroidectomy, lymphadenectomy and radioiodine treatment is sufficient. In case of pre- or intraoperative clinically suspected nodal metastases or postoperatively diagnosed risk factors we propose the standard radical procedure. Routine preoperative cervical lymph node sonography is advisable before any thyroid surgery.

Retrospective Analysis of 255 Papillary Thyroid Carcinomas ≤2 cm: Clinicohistological Features and Prognostic Factors

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer. The widespread use of neck ultrasound (US) and US-guided fine-needle aspiration cytology is triggering an overdiagnosis of PTC.

OBJECTIVE

To evaluate clinical behavior and outcomes of patients with PTCs ≤2 cm, seeking for possible prognostic factors.

METHODS

Clinical records of cases with histological diagnosis of PTC ≤2 cm followed at the Endocrine Department of Instituto Português de Oncologia, Lisbon between 2002 and 2006 were analyzed retrospectively.

RESULTS

We identified 255 PTCs, 111 were microcarcinomas. Most patients underwent near-total thyroidectomy, with lymph node dissections in 55 cases (21.6%). Radioiodine therapy was administered in 184 patients. At the last evaluation, 38 (14.9%) had evidence of disease. Two deaths were attributed to PTC. Median (±SD) follow-up was 74 (±23) months. Multivariate analysis identified vascular invasion, lymph node and systemic metastases significantly associated with recurrence/persistence of disease. In addition, lymph node involvement was significantly associated with extrathyroidal extension and angioinvasion. Median (±SD) disease-free survival (DFS) was estimated as 106 (±3) months and the 5-year DFS rate was 87.5%. Univariate Cox analysis identified some relevant parameters for DFS, but multivariate regression only identified lymph node and systemic metastases as significant independent factors. The median DFS estimated for lymph node and systemic metastases was 75 and 0 months, respectively.

CONCLUSIONS

In the setting of small PTCs, vascular invasion, extrathyroidal extension and lymph node and/or systemic metastases may confer worse prognosis, perhaps justifying more aggressive therapeutic and follow-up approaches in such cases.

Gray-scale ultrasonography combined with elastography imaging for the evaluation of papillary thyroid microcarcinoma: as a prognostic clinicopathology factor

Ultrasonography (US) is the preferred imaging modality for papillary thyroid microcarcinoma (PTMC). The aim of this study was to evaluate the importance of gray-scale ultrasound combined with elastography to predict extrathyroidal extension and cervical lymph node (LN) metastasis in patients with PTMC. We retrospectively evaluated gray-scale ultrasonic and elastographic results from 119 consecutive cases of PTMC with 138 nodules and correlated the histopathological findings. The results indicated that pathological extrathyroidal extension was significantly associated with T staging on US, extrathyroidal extension on US, bilaterality on US, boundary, strain ratio and hard malignancy as measured with the Rago score. Central LN metastasis on pathology was significantly associated with central LN metastasis on US, lateral LN metastasis on US, multifocality on US and bilaterality on US. Lateral LN metastasis on US was significantly associated with lateral LN metastasis on pathology. On multivariate analysis, T staging on US, extrathyroidal extension on US and hard malignancy as measured with the Rago score were significantly associated with pathological extrathyroidal extension. Lateral LN metastasis on US and bilaterality on US were independent factors in predicting central LN metastasis on pathology. Lateral LN metastasis on US was the predictive factor for lateral LN metastasis on pathology. US should be helpful in the diagnosis of PTMC and in the evaluation of possible PTMC recurrence on US in routine clinical practice.

Clinical value of visually identifiable 18F-fluorodeoxyglucose uptake in primary papillary thyroid microcarcinoma

OBJECTIVE

This study evaluates the relationship between visually identifiable (18)F-fluorodeoxyglucose (FDG) uptake in primary papillary thyroid microcarcinoma (PTMC) and tumor aggressiveness.

STUDY DESIGN

Historical cohort study.

SETTING

Tertiary care center.

METHODS

Clinicopathological factors and PET/CT findings of 219 PTMC surgical patients who underwent preoperative (18)F-FDG positron emission tomography/computed tomography (PET/CT) were retrospectively reviewed.

RESULTS

(18)F-FDG uptake was observed in the tumors of 124 (56.6%) patients. Tumor size (odds ratio [OR] = 1.774; 95% confidence interval [CI], 1.416-2.223; P < .0001) and Hashimoto thyroiditis (OR = 2.815; CI, 1.237-6.404; P = .014) independently predicted (18)F-FDG uptake. Tumor size (OR = 1.495; CI, 1.217-1.835; P < .0001) and BRAF(V600E) mutation (OR = 3.320; CI, 1.056-10.432; P = .040) independently predicted extrathyroidal invasion. Multiplicity (OR = 2.375; CI, 1.278-4.415; P = .006) independently predicted central lymph node metastasis.

CONCLUSION

(18)F-FDG uptake in PTMC depends on tumor size and Hashimoto thyroiditis. Therefore, preoperative PET/CT for PTMC may not help in evaluating tumor aggressiveness.

Long-term outcomes of total thyroidectomy versus thyroid lobectomy for papillary thyroid microcarcinoma: comparative analysis after propensity score matching

AIMS

The objectives of this study were to compare long-term outcomes after total thyroidectomy (TT) or thyroid lobectomy (LT) in a large cohort of patients with papillary thyroid microcarcinoma (PTMC), and to determine whether tumor size (≤0.5 cm vs. >0.5 cm) has a significant impact on the extent of surgery.

METHODS

We evaluated 2014 patients with PTMC who underwent TT with central compartment node dissection (CCND; n = 1015) or LT with CCND (n = 999) between March 1986 and December 2006 and for whom complete follow-up data were available for at least 5 years (median 11.8 years, range 5-26 years). Using propensity score matching to reduce the impact of treatment selection bias and potential confounding in an observational study, we compared overall survival and disease-free survival in the overall cohort and in patients with tumors ≤0.5 cm and >0.5 cm in size.

RESULTS

After adjustment for differences in baseline clinicopathologic risk factors, we observed no significant differences between the LT and the TT groups in the risk of death (hazard ratio for the LT group 1.05, 95% confidence interval [CI] 0.71-1.47, p = 0.890) and locoregional recurrence (hazard ratio for the LT group 3.08 [CI 1.99-8.05], p = 0.194) in the overall matched cohort. Similar results were observed when we compared LT and TT in patients with tumors ≤0.5 cm and >0.5 cm.

CONCLUSIONS

The long-term rates of death and locoregional recurrence were similar in patients with PTMC who underwent LT with CCND and those who underwent TT with CCND. Therefore, completion thyroidectomy may not be recommended unless recurrence after LT is definitely detected in low-risk PTMC patients, and close follow-up is adequate in these patients. Moreover, tumor size greater than or less than 0.5 cm was not a significant determinant of the extent of surgery in patients with PTMC.

Radioactive iodine ablation does not prevent recurrences in patients with papillary thyroid microcarcinoma

OBJECTIVE

Although papillary thyroid microcarcinoma (PTMC) has a favourable long-term prognosis, disease recurrence after initial treatment remains a problem and controversy exists regarding the role of radioactive iodine (RAI) ablation in PTMC. We performed this study to evaluate the effect of RAI ablation on disease recurrence in patients with PTMC.

PATIENTS AND METHODS

Between 1994 and 2004, 2579 patients underwent thyroid surgery for thyroid cancer at Samsung Medical Center. Among these patients, 704 patients with PTMC presumed disease-free after initial treatment were followed up for disease recurrence (median, 64 months; range, 1-185 months). Patients with PTMC with microscopic extrathyroidal extension, cervical lymph node metastases or multifocality were considered to be in the intermediate-risk group for recurrence.

RESULTS

Disease recurrence was found in six patients at a median of 29 months (range, 10-70 months) after initial treatment; all six patients with recurrent tumours had received RAI treatment after total thyroidectomy. Disease-related mortality was not observed, even after recurrence. Based on a Cox regression model considering the standardized inverse probability of treatment weight (IPTW) within each propensity score stratum of patients with a similar likelihood of having received RAI ablation, the likelihood ratio for recurrence did not differ between the RAI ablation group and no RAI group (P = 0·17). When we performed a subgroup analysis considering only patients with PTMC at intermediate-risk for recurrence, RAI ablation again did not have a significant effect on recurrence (P = 0·79).

CONCLUSIONS

Radioactive iodine ablation after total thyroidectomy in low- and intermediate-risk patients with PTMC did not prevent recurrent tumours. Future randomized, controlled, multicenter prospective trials involving a larger sample of patients followed-up for a longer duration are warranted to confirm our findings.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors

INTRODUCTION

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

METHODS

The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

RESULTS

The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

CONCLUSION

These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

Immunohistochemical analysis based Ep-ICD subcellular localization index (ESLI) is a novel marker for metastatic papillary thyroid microcarcinoma

Background

Thyroid cancer is among the fastest growing malignancies; almost fifty-percent of these rapidly increasing incidence tumors are less than or equal to 1cm in size, termed papillary thyroid microcarcinoma (PTMC). The management of PTMC remains a controversy due to differing natural history of these patients. Epithelial cell adhesion molecule (EpCAM) is comprised of an extracellular domain (EpEx), a single transmembrane domain and an intracellular domain (Ep-ICD). Our group reported nuclear Ep-ICD correlated with poor prognosis in thyroid cancer (Ralhan et al., BMC Cancer 2010,10:331). Here in, we hypothesized nuclear and cytoplasmic accumulation of Ep-ICD and loss of membranous EpEx may aid in distinguishing metastatic from non-metastatic PTMC, which is an important current clinical challenge. To test our hypothesis, Ep-ICD and EpEx expression levels were analyzed in PTMC and the staining was correlated with metastatic potential of these carcinomas.

Methods

Thirty-six PTMC patients (tumor size 0.5 - 1cm; metastatic 8 cases and non-metastatic 28 cases) who underwent total thyroidectomy were selected. The metastatic group consisted of patients who developed lymph node or distant metastasis at diagnosis or during follow up. The patients’ tissues were stained for Ep-ICD and EpEx using domain specific antibodies by immunohistochemistry and evaluated.

Results

PTMC patients with metastasis had higher scores for nuclear and cytoplasmic Ep-ICD immunostaining than the patients without metastasis (1.96 ± 0.86 vs. 1.22 ± 0.45; p = 0.007 and 5.37 ± 0.33 vs. 4.72 ± 1.07; p = 0.016, respectively). Concomitantly, the former had lower scores for membrane EpEx than the non-metastatic group (4.64 ± 1.08 vs. 5.64 ± 1.51; p = 0.026). An index of aggressiveness, Ep-ICD subcellular localization index (ESLI), was defined as sum of the IHC scores for accumulation of nuclear and cytoplasmic Ep-ICD and loss of membranous EpEx; ESLI = [Ep − ICD_nuc + Ep − ICD_cyt + loss of membranous EpEx]. Notably, ESLI correlated significantly with lymph node metastasis in PTMC (p = 0.008).

Conclusion

Nuclear and cytoplasmic Ep-ICD expression and loss of membranous EpEx were found to correlate positively with metastasis in PTMC patients. In addition, ESLI had the potential to identify metastatic behavior in PTMC which could serve as a valuable tool for solving a current dilemma in clinical practice.

Factors influencing the outcome of patients with incidental papillary thyroid microcarcinoma

Objective. To analyze some factors that could influence the outcome of patients with PTMC. Material and Methods. This is a longitudinal observational study. All patients diagnosed and treated for papillary thyroid microcarcinoma at the University Hospital of Vigo, between January 1994 and December 2003, were included in the present study. Demographic characteristics, tumour characteristics, TNM stage, rate of recurrence, and treatment with ¹³¹I were the study variables. Results. Ninety-one patients (75 females) with an average age of 47.7 ± 13.4 years, range 19–81, were studied. Initial tumour staging was T1 in 90 patients and T4a in 1 case. Initial lymph node involvement was present in 4 cases (4.4%). We only found one case with distant metastases at diagnosis. Postsurgical evaluation of thyroid specimens revealed that 28 (30.7%) tumours were multifocal. The average size of the tumour was 0.44 ± 0.25 cm, range 0.1–1. Univariate analysis reveals a statistically significant association between tumour multifocality and postsurgical ¹³¹I therapy with the recurrence rate. In the multivariate analysis only multifocality (P = 0.037, HR 5.7) was a significant risk factor for the recurrence rate. Conclusions. Our results indicate that tumour multifocality is an independent predictor of relapse but neither the tumour size nor postsurgical ¹³¹I therapy.

Current treatment of papillary thyroid microcarcinoma

PTMC is being diagnosed with increasing frequency and generally has an excellent prognosis with less than 0.5% disease-specific mortality. Better prognostic stratification, especially for high-risk patients, helps to optimize surgical care. Older age, extrathyroidal invasion, lymph node involvement, and distant metastases are usually regarded as the most potent risk factors for patients with PTMC. Total or near-total thyroidectomy is advocated as the initial therapy for most primary PTMCs, whereas neck dissection is only recommended with the presence of cervical lymphadenopathy or T4 tumors. ATA suggests that postoperative RAI ablations be administrated to patients with gross extrathyroidal invasion or distant metastases. RAI ablation may also facilitate the use of serum Tg concentrations for postoperative risk assessment.

Pathological findings of thyroid nodules after percutaneous laser ablation : a series of 22 cases with cyto-histological correlation

Ultrasound (US)-guided percutaneous laser ablation (LA) of benign thyroid nodules may be a potential alternative to surgery in patients with compressive symptoms, at high surgical risk, or in patients who refuse to undergo surgery. We evaluated the morphological effects of LA procedure on 22 patients and compared the cytological findings before and after LA with the histological features on surgical specimens. Twenty-two (4.9%; 19 women, three men, mean age 53.2 years) out of 452 patients treated with LA for benign thyroid nodules in our Hospital underwent surgery after LA procedure, either because nodule regrowth (treatment failure, n = 17) or indeterminate cytology (Thy3) after LA (n = 5). Morphological findings varied according to the time between LA and surgical intervention. Within 2 months, the area was occasionally cavitated and filled in with dark amorphous material. The inflammatory response was abundant and composed of neutrophils, lymphocytes, and macrophages. After 18 months or more since LA, the expected laser-induced histologic changes in thyroid morphology consisted of a well-defined area surrounded by a fibrous capsule and filled in by amorphous material. No significant pathologic features were found in the thyroid tissue adjacent to the treated area. Histological evaluation of thyroid tissues after LA shows that thermal damage is restricted to the ablated area, with no involvement of the nearby parenchyma. Our long-term histopathological findings indicate that LA treatment of benign thyroid nodules is safe, and patients undergoing LA may also be followed up by fine needle aspiration.

Disparities in the initial presentation of differentiated thyroid cancer in a large public hospital and adjoining university teaching hospital

BACKGROUND

Healthcare disparities associated with insurance and socioeconomic status have been well characterized for several malignancies, such as lung cancer. To assess whether there are healthcare disparities in thyroid cancer, this study evaluated the stage on initial presentation of patients with differentiated thyroid cancer (DTC) in a public versus university teaching hospital.

METHODS

A retrospective chart review was performed to identify patients with a new diagnosis of DTC from January 1, 2007, to January 1, 2010, in a large public and adjoining university teaching hospital at a single academic medical center. Medical records were reviewed for demographics, pathology, and American Joint Committee on Cancer tumor-node-metastasis stage at initial presentation.

RESULTS

There were 49 cases of well-DTC (96% papillary and 4% Hürthle) in the public hospital and 370 cases (95% papillary, 2% Hürthle, and 3% follicular) in the university teaching hospital. Median age (years) at presentation was 50 in the public versus 48 in the university teaching hospital (p=0.39). Ninety-six percent of public hospital patients were from ethnic minorities compared with 16% of university teaching hospital patients (p<0.0001). Only 1 (2%) public hospital patient had private insurance compared with 85% of university teaching hospital patients. Tumor status (p=0.002) and stage (p=0.03) were more advanced and extrathyroidal extension (p=0.02) was more prevalent among public hospital patients compared with university teaching hospital patients. In a multivariable analysis, public hospital, male gender, increasing age, advanced tumor status, and the presence of lymphovascular invasion were the best predictors of more advanced disease stage. Public hospital patients were 3.4 times more likely to present with advanced DTC than university teaching hospital patients of the same age, gender, tumor status, and lymphovascular invasion status (95% confidence interval 1.29-8.95).

CONCLUSIONS

In a public hospital, where the patient population is defined primarily by insurance status, patients were more likely to present with advanced-stage DTC than patients presenting to an adjacent university teaching hospital. These results suggest a disparity in the stage on initial presentation of DTC, possibly resulting in a delayed diagnosis of cancer.

The treatment of differentiated thyroid cancer in children: emphasis on surgical approach and radioactive iodine therapy

Pediatric thyroid cancer is a rare disease with an excellent prognosis. Compared with adults, epithelial-derived differentiated thyroid cancer (DTC), which includes papillary and follicular thyroid cancer, presents at more advanced stages in children and is associated with higher rates of recurrence. Because of its uncommon occurrence, randomized trials have not been applied to test best-care options in children. Even in adults that have a 10-fold or higher incidence of thyroid cancer than children, few prospective trials have been executed to compare treatment approaches. We recognize that treatment recommendations have changed over the past few decades and will continue to do so. Respecting the aggressiveness of pediatric thyroid cancer, high recurrence rates, and the problems associated with decades of long-term follow-up, a premium should be placed on treatments that minimize risk of recurrence and the adverse effects of treatments and facilitate follow-up. We recommend that total thyroidectomy and central compartment lymph node dissection is the surgical procedure of choice for children with DTC if it can be performed by a high-volume thyroid surgeon. We recommend radioactive iodine therapy for remnant ablation or residual disease for most children with DTC. We recommend long-term follow-up because disease can recur decades after initial diagnosis and therapy. Considering the complexity of DTC management and the potential complications associated with therapy, it is essential that pediatric DTC be managed by physicians with expertise in this area.

Screening for medullary thyroid carcinoma with serum calcitonin measurements in patients with thyroid nodules in the United States and Canada

BACKGROUND

Medullary thyroid carcinoma (MTC) is a rare thyroid malignancy with the potential for aggressive behavior. Measurement of serum calcitonin (Ct) in the thyroid nodule population is the most sensitive way to detect occult MTC. An important and controversial question is whether all patients with thyroid nodules should undergo Ct measurements to detect occult MTC.

SUMMARY

The prevalence of MTC detected by performing surgery on unselected individuals with thyroid nodules with elevated serum Ct is 0.4%. The central role of pentagastrin (PG) stimulation for triaging patients with minimally elevated serum Ct to prevent unnecessary surgery is reviewed. Data concerning a large reservoir of medullary thyroid microcarcinomas are discussed.

CONCLUSION

Given the unavailability of PG in the United States and Canada, the available data argue against routine Ct measurements in all individuals with thyroid nodules in these countries because of the potential for unnecessary surgery and the uncertain benefit in diagnosing medullary microcarcinoma.

Micropapillary thyroid carcinoma and concomitant ectopic thyroid tissue in the adrenal gland: metastasis or metaplasia?

BACKGROUND

Ectopic thyroid tissue is a rare finding but has been reported in many thoracic and abdominal locations. It is usually an incidental pathologic finding after an unrelated surgical intervention. When thyroid tissue is found outside the thyroid bed, it is important to rule out thyroid cancer metastasis.

PATIENT FINDINGS

We present a case of a 61-year-old African American woman who was incidentally found to have concomitant ectopic thyroid tissue in the adrenal gland and a papillary thyroid microcarcinoma (PTMC) in the right lobe of the thyroid.

SUMMARY

The concurrent finding of ectopic thyroid tissue and PTMC posed the diagnostic dilemma of whether the extrathyroidal tissue was metastasis or metaplasia, with very different treatment implications. Although many of these incidental micropapillary cancers are indolent, some patients do experience local or distant metastasis. Therefore, it is important to delineate which of these microtumors are likely to metastasize. Some tumor markers and gene mutations have been proposed to help differentiate the more benign tumors from the more aggressive tumors, but there is currently no standard method for determination of metastatic potential.

CONCLUSIONS

Here we present the seventh known case of ectopic thyroid tissue in the adrenal gland and the first case of concomitant incidental PTMC in the setting of this ectopic tissue finding. Using this case, we discuss the diagnostic and therapeutic challenges faced and propose the use of biomarkers to help determine the metastatic potential of these tumors.

Ultrasound-guided laser ablation of incidental papillary thyroid microcarcinoma: a potential therapeutic approach in patients at surgical risk

BACKGROUND

Incidental papillary thyroid microcarcinoma (PTMC), a frequent clinical problem, is usually associated with a favorable outcome. During long-term follow-up, only a minority of cases show aggressive behavior with either lymph node or distant metastases. Recently, we had an opportunity to evaluate the efficacy of nonsurgical, ultrasound (US)-guided percutaneous laser ablation (PLA) for local treatment of PTMC in an otherwise inoperable patient.

PATIENT AND METHODS

Neck US examination revealed an incidental, solitary, 8 × 7 × 7 mm hypoechoic nodule with microcalcifications of the right thyroid lobe. The patient suffered from decompensated liver cirrhosis, renal failure, and recent surgery followed by external beam radiation therapy for breast cancer. Cytologic diagnosis showed papillary thyroid carcinoma, but the patient declined surgery because of high risk of thyroid surgery. After local anesthesia with 2% xylocaine, PLA was performed according to the previously reported procedure with an Nd:YAG laser.

SUMMARY

The procedure was well tolerated, without side effects, and the patient required no analgesics. US-guided fine-needle aspiration biopsy and core-needle biopsy were performed at 1 and 12 months after PLA, which demonstrated necrotic material and inflammatory cells with no viable neoplastic cell. At the 24 months US follow-up examination, the area of necrosis further decreased, demonstrating a 4 × 4 mm hypoechoic zone and a small hyperechoic area due to fibrotic changes. A fine-needle aspiration biopsy confirmed the absence of malignant cells.

CONCLUSIONS

Laser-induced thermal ablation was a safe and effective ablative treatment for a patient with PTMC confined to the thyroid gland who was at high surgical risk. This approach should be considered only in elderly patients and/or in those with comorbidities that might expose the patients to an undue high surgical risk and only after the evaluation by neck US, computed tomography, magnetic resonance imaging, or positron emission tomography/computed tomography rules out lymph-node involvement or metastatic disease.

Endocrine incidentalomas--challenges imposed by incidentally discovered lesions

Endocrine glands are among the organs that most frequently harbor incidentally discovered lesions. Pituitary, thyroid, parathyroid and adrenal incidentalomas are increasingly encountered in everyday practice with variable clinical implications. The major concerns are the risks of malignancy and hormonal hypersecretion mostly in the form of subclinically functioning tumors. Pituitary incidentalomas are usually microadenomas and most of the time clinically unimportant; however, incidentally discovered larger lesions require a more careful diagnostic and therapeutic approach. Thyroid incidentalomas are extremely common; exclusion of malignancy is the main concern in this clinical setting. Although parathyroid adenomas are not uncommon, these lesions are frequently missed owing to their small size and due to clinical unawareness. Adrenal incidentalomas carry a small but finite risk of malignancy. An intriguing challenge regarding incidentally discovered adrenal lesions is that a substantial proportion is associated with hormonal alterations, mainly in the form of subtle cortisol excess. Although still largely controversial, evidence is emerging that so-called subclinical hypercortisolism may not be completely harmless. The best biochemical criterion of subtle cortisol excess remains elusive. Surgical intervention in selected cases results in some beneficial effects, but more data are required in order to routinely support surgery in this clinical setting. This Review provides a brief overview of the prevalence, clinical effect and management of endocrine incidentalomas with a focus on data regarding the diagnostic and therapeutic challenges imposed by incidentally discovered adrenal lesions.

The spectrum of papillary thyroid carcinoma variants

Papillary thyroid carcinoma is the most common type of thyroid malignancy. The diagnostic features of these tumors include characteristic nuclear cytology. However, many variants have been reported with different morphology and molecular profiles. Although the vast majority of papillary thyroid carcinomas have an excellent prognosis, some variants of papillary thyroid carcinoma can have a more aggressive course. With this increased attention to papillary thyroid carcinoma variants has come the need to sort out which variants are clinically important and should be recognized by practicing pathologists. The main objectives of this review article are to (1) summarize the gross and histopathologic features of papillary thyroid carcinoma; (2) provide an overview of the subtypes of papillary thyroid carcinoma and their prognosis; (3) discuss established and emerging data on the immunohistochemical findings that are helpful in differential diagnosis; and (4) summarize molecular findings and pathogenesis of these lesions.