Impact of Extent of Surgery on Tumor Recurrence and Survival for Papillary Thyroid Cancer Patients

Impact of fellowship training for specialists on thyroidectomy outcomes of patients with thyroid cancer

We aimed to evaluate the impact of fellowship training (FT) for thyroid specialists on the outcomes of patients with thyroid cancer. We reviewed surgeries performed for thyroid cancer before (non-FT group) and after (FT group) fellowship training and compared several variables, including length of stay of patients, tumor diameter, surgical method, lymph node dissection, parathyroid implantation, surgical duration, intraoperative blood loss, and postoperative complications. Compared with the non-FT group, the FT group had a shorter hospital stay, more adequate fine needle aspiration biopsy of the thyroid, less intraoperative blood loss, higher rate of parathyroid implantation, higher lymph node dissection rate, and lower nerve injury and hypoparathyroidism rates. When the surgical duration was < 200 min and/or only central lymph node dissection was performed, the FT group had a lower incidence of postoperative complications than the non-FT group. When, the incidence of postoperative complications, including postoperative nerve injury and hypoparathyroidism. In conclusion, FT for thyroid specialists is beneficial for patients with thyroid cancer and may allow a shorter hospital stay and reduced incidence of postoperative complication. Accordingly, FT may facilitate a more appropriate surgical approach with a preoperative pathological diagnosis.

Surgical management of low-risk papillary thyroid cancer in real life in Spain: a nationwide survey of endocrine neck surgeons and endocrinologists

BACKGROUND

The extent of surgery in patients with papillary thyroid cancer (PTC) is a subject of ongoing debate. We aimed to explore the attitude of Spanish specialists (endocrinologists, surgeons, and otolaryngologists) in real life on the surgical management of low-risk PTC.

METHODS

We designed an anonymous, web-based survey to inquire information regarding the preferences of interviewees for hemithyroidectomy (Hem), total thyroidectomy (TT) and prophylactic central neck dissection (pCND) in one standard patient with PTC and six clinical variants. We differentiated between small (1.1-2.5 cm) and large (2.6-4.0 cm) tumors.

RESULTS

A total of 278 valid responses were received and divided into two groups: group END (n = 135) and group SUR (n = 143, 101 general surgeons and 42 otolaryngologists). The preference for Hem was low in the standard patient and similar between both groups (40.6 vs 49.0%, NS). This preference decreased for tumors measuring 2.6-4.0 cm, multifocal, with risk location, family history of thyroid cancer, or history of irradiation, and increased in patients older than 65 years or with comorbidity. Preference for pCND ranged from 12.6-71.1% in the group END and from 22.4-65.0% in the group SUR, with few differences between the two. In multivariate analysis, being a high-volume specialist was associated with a lower preference for Hem, while having private practice was associated with a more favorable opinion of Hem.

CONCLUSION

The real clinical practice of Spanish specialists is far from what is recommended by the clinical guidelines in patients with low-risk PTC, especially among high-volume professionals.

Racial and Ethnic Disparities in Appropriate Thyroid Cancer Treatment, Before and After the Release of the 2015 American Thyroid Association Guidelines

BACKGROUND

The 2015 American Thyroid Association (ATA) guidelines reduced the recommended extent of therapy for low-risk thyroid cancers. Little is known about the impact of these changes on overall treatment patterns and on previously described racial/ethnic disparities in guideline-concordant care. This study aimed to assess trends in thyroid cancer care before and after release of the 2015 guidelines, with particular attention to racial/ethnic disparities.

METHODS

Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2018). An interrupted time series design was used to assess trends in treatment before and after the 2015 guidelines. Appropriateness of surgical and radioactive iodine (RAI) treatment was determined based on the ATA guidelines, and the likelihood of receiving guideline-concordant treatment was compared between racial/ethnic groups.

RESULTS

The study identified 309,367 patients (White 74%, Black 8%, Hispanic 9%, Asian 6%). Between 2010 and 2015, the adjusted probability of appropriate surgery was lower for Black (- 2.1%; p < 0.001), Hispanic (- 1.0%; p < 0.001), and Asian (- 2.1%; p < 0.001) patients than for White patients. After 2015, only Hispanic patients had a lower probability of undergoing appropriate surgical therapy (- 2.6%; p = 0.040). Similarly, between 2010 and 2015, the adjusted probability of receiving appropriate RAI therapy was lower for the Hispanic (- 3.6%; p < 0.001) and Asian (- 2.4%; p < 0.001) patients than for White patients. After 2015, the probability of appropriate RAI therapy did not differ between groups.

CONCLUSIONS

Between 2010 and 2015, patients from racial/ethnic minority backgrounds were less likely than White patients to receive appropriate surgical and RAI therapy for thyroid cancer. After the 2015 guidelines, racial/ethnic disparities in treatment improved.

The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer

BACKGROUND

The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations.

METHODS

A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test.

RESULTS

Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy.

CONCLUSION

Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.

Survey of Korean head and neck surgeons and endocrinologists for the surgical extent of 1.5 and 2.5 cm papillary thyroid carcinoma

Background

The surgical extent of 1-4 cm papillary thyroid carcinoma (PTC) is controversial. We aimed to determine the current trend in the extent of thyroidectomy and prophylactic central neck dissection (pCND) for 1.5 and 2.5 cm PTC, which are the most clinically controversial sizes.

Methods

The questionnaire was sent to 342 Korean Society of Head and Neck Surgery and 160 one branch of Korean Endocrine Society members from June to July 2021 by e-mail. A questionnaire included extent of thyroidectomy [hemithyroidectomy (Hemi) vs. total thyroidectomy (TT)] and pCND according to the tumor location and degree of extrathyroidal extension (ETE) at 1.5 or 2.5 cm PTC. We compared the proportion of respondents' preference for each scenario.

Results

Fifty-seven of 342 surgeons and twenty-seven of 160 endocrinologists responded to the questionnaire. At 1.5 and 2.5 cm PTC without ETE, both groups preferred Hemi, and there was no difference between the groups. When 1.5 or 2.5 cm PTC with anterior minimal ETE was suspected, the preference for Hemi by endocrinologists was significantly lower than that by surgeons (P<0.05). When anterior and posterior gross ETE were suspected, TT was preferred in both groups. When anterior gross ETE was suspected, the preference for Hemi by endocrinologists was significantly lower than that by surgeons (P<0.05). There was no difference between the groups in the posterior gross ETE. Surgeons preferred Hemi and endocrinologists preferred TT for a 1.5 cm PTC located in the isthmus. The pCND showed a similar pattern in both groups according to the size and location of the tumor and the degree of ETE. The proportion of Hemi did not differ between high-experience and low-experience endocrinologists. Also, there was no significant difference in preference for surgical extent between low-volume and high-volume surgeons.

Conclusions

TT was frequently preferred in tumors with a large size or gross ETE, and pCND was frequently preferred in cases of suspected gross ETE. This study shows as the extent of thyroid surgery may differ between endocrinologists and surgeons and this could be confusing to patient and affect the patient outcomes. Therefore, multidisciplinary approach considering the extent of surgery for thyroid cancer is recommended.

Clinicopathological and surgical comparisons of differentiated thyroid cancer between China and the USA: A multicentered hospital-based study

Background

Thyroid cancer (TC), was the fastest-rising tumor of all malignancies in the world and China, predominantly differentiated thyroid cancer (DTC). However, evidence on TC stage distribution and influencing factors of late-stage were limited in China.

Methods

We carried out a retrospective study and enrolled TC patients who were first diagnosed and hospitalized in 8 hospitals in China in 2017. Logistic regression was used to evaluate associations between influencing factors and DTC stage. We extracted eligible primary DTC records newly diagnosed in 2017 from the USA's Surveillance, Epidemiology, and End Results (SEER) database. We compared clinicopathological features and surgical treatment between our DTC records and those from the SEER database.

Results

A total of 1970 eligible patients were included, with 1861 DTC patients with known stage. Among patients ≥45 years old, males (OR = 1.76, 95%CI 1.17-2.65) and those with new rural cooperative medical scheme insurance (NCMS) (OR = 1.99, 95%CI 1.38-2.88) had higher risks of late-stage DTC (stage III-IV). Compared with SEER database, over-diagnosis is more common in China [more DTC patients with onset age< 45 years old (50.3 vs. 40.7%, P < 0.001), with early-stage (81.2 vs. 76.0%, P < 0.001), and with tumors<2cm (74.9 vs. 63.7%, P < 0.001)]. Compared with the USA, TC treatment is more conservative in China. The proportion of lobectomy in our database was significantly higher than that in the SEER database (41.3 vs. 17.0%, P < 0.001).

Conclusions

Unique risk factors are found to be associated with late-stage DTC in China. The differences in the aspect of clinicopathological features and surgical approaches between China and the USA indicate that potential over-diagnosis and over-surgery exist, and disparities on surgery extent may need further consideration. The findings provided references for other countries with similar patterns.

Long-Term Health-Related Quality of Life Outcomes Following Thyroid Surgery for Malignant or Benign Disease: Deficits Persist in Cancer Survivors Beyond Five Years

BACKGROUND

Thyroid cancer diagnoses are increasing and treatment can lead to significant morbidity. Long-term health-related quality of life (HRQoL) in thyroid cancer is understudied and lacks reference populations. This study compares long-term HRQoL between patients with thyroid cancer or benign disease, following thyroid surgery.

METHODS

Patients undergoing thyroidectomy between 2000 and 2017 were identified from a pathology database. 696 participants (278 malignant, 418 benign) were invited to complete a validated disease-specific HRQoL tool, City of Hope-Thyroid Version. Propensity scores were used to adjust for demographic and clinical differences between cohorts.

RESULTS

206 patients (102 malignant, 104 benign), 71% female, returned surveys a median of 6.5 (range 1-19) years after thyroidectomy. Of the cancer cohort, 95% had differentiated thyroid cancer and 83% remained disease-free. There were no significant differences in overall HRQoL scores between groups. In comparison to the benign cohort, cancer patients showed a significant detriment in the social subdomain score (OR 0.10-0.96, p = 0.017) but not in other subdomains (physical, psychological, spiritual). Female gender, increasing BMI and cancer recurrence were significantly associated with decreased overall HRQoL. Compared to the benign cohort, cancer patients reported more personal and family distress associated with diagnosis and treatment, increased future uncertainty, poorer concentration and greater financial burden.

CONCLUSION

Although no difference in overall HRQoL was found between patients undergoing thyroidectomy for benign or malignant disease, detriments in social well-being may persist many years after surgery. Thyroid cancer patients and their families may benefit from increased supports around the time of diagnosis and treatment.

Impact of Endocrinologist and Surgeon Density on Well-Differentiated Thyroid Cancer Survival

BACKGROUND

The influence of provider density and access on well-differentiated thyroid cancer (DTC) survival is uncertain.

METHODS

We used the SEER18 database to study DTC patients undergoing surgery from 2000-2012. County-level endocrinologist and surgeon density were calculated. We evaluated the relationship between provider density and cause-specific survival controlling for demographic, socioeconomic, and treatment characteristics.

RESULTS

Median endocrinologist density was 1.4/100 000 residents, with 15.5% of patients living in a county with no endocrinologist. Survival increased by 11% for each endocrinologist/100,000 people (P = .007). Median surgeon density was 14.8/100 000 residents, with only 1.7% of patients living in a county with no general surgeon or otolaryngologist. No significant association between surgeon density and survival was identified (P = .06). Rural residence was independently associated with lower survival (P = .009).

CONCLUSIONS

County-level endocrinologist density is associated with improved DTC survival. Results may reflect endocrinologist expertise, earlier diagnosis, or represent surrogacy for higher county-level access to specialized care.

Association of Total Thyroidectomy or Thyroid Lobectomy With the Quality of Life in Patients With Differentiated Thyroid Cancer With Low to Intermediate Risk of Recurrence

IMPORTANCE

Owing to the good prognosis of differentiated thyroid cancer (DTC), guidelines recommend total thyroidectomy (TT) or thyroid lobectomy (TL) as surgical treatment for DTC with low to intermediate risk of recurrence. However, the association of these surgeries with the health-related quality of life (HRQOL) of patients with DTC with low to intermediate risk of recurrence is unclear.

OBJECTIVE

To longitudinally compare the HRQOL of patients with DTC undergoing different surgeries.

DESIGN, SETTING, AND PARTICIPANTS

This prospective observational longitudinal cohort study enrolled patients diagnosed with DTC with low to intermediate risk of recurrence at the First Affiliated Hospital, Sun Yat-sen University, China, from October 1, 2018, to September 31, 2019. Eligible patients were categorized into TL and TT groups according to the surgery they underwent. They were evaluated preoperatively and followed up at 1, 3, 6, and 12 months postoperatively using 3 HRQOL-related questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, version 3.0; Hospital Anxiety and Depression Scale; and Thyroid Cancer-Specific Quality of Life Questionnaire); serum thyrotropin levels, complications, and patient satisfaction were also monitored. Data were analyzed to compare the HRQOL of patients undergoing different surgeries at different time points.

EXPOSURES

Total thyroidectomy or TL.

MAIN OUTCOMES AND MEASURES

The primary end point was HRQOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, version 3.0; Hospital Anxiety and Depression Scale; and Thyroid Cancer-Specific Quality of Life Questionnaire) at different time points, and the secondary end points were postoperative complications, thyrotropin level, and patient satisfaction.

RESULTS

Of the 1060 eligible patients, 563 underwent TL (438 women [77.8%]; median [IQR] age, 38 [31-45] years), and 497 underwent TT (390 women [78.5%]; median [IQR] age, 38 [32-48] years). Compared with the TL group, including the 1- to 4-cm tumor subgroup, the TT group experienced more postoperative HRQOL problems at 1 and 3 months postoperatively. However, nearly all the differences disappeared at 6 and 12 months postoperatively.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that HRQOL of patients with DTC with low to intermediate risk of recurrence is not associated with the extent of surgery, and HRQOL may not be an important consideration when making surgical decisions. If better HRQOL is requested in the short term, TL may be preferred.

A Prognostic Model of Differentiated Thyroid Cancer Based on Up-Regulated Glycolysis-Related Genes

OBJECTIVE

This study aims to identify reliable prognostic biomarkers for differentiated thyroid cancer (DTC) based on glycolysis-related genes (GRGs), and to construct a glycolysis-related gene model for predicting the prognosis of DTC patients.

METHODS

We retrospectively analyzed the transcriptomic profiles and clinical parameters of 838 thyroid cancer patients from 6 public datasets. Single factor Cox proportional risk regression analysis and Least Absolute Shrinkage and Selection Operator (LASSO) were applied to screen genes related to prognosis based on 2528 GRGs. Then, an optimal prognostic model was developed as well as evaluated by Kaplan-Meier and ROC curves. In addition, the underlying molecular mechanisms in different risk subgroups were also explored via The Cancer Genome Atlas (TCGA) Pan-Cancer study.

RESULTS

The glycolysis risk score (GRS) outperformed conventional clinicopathological features for recurrence-free survival prediction. The GRS model identified four candidate genes (ADM, MKI67, CD44 and TYMS), and an accurate predictive model of relapse in DTC patients was established that was highly correlated with prognosis (AUC of 0.767). In vitro assays revealed that high expression of those genes increased DTC cancer cell viability and invasion. Functional enrichment analysis indicated that these signature GRGs are involved in remodelling the tumour microenvironment, which has been demonstrated in pan-cancers. Finally, we generated an integrated decision tree and nomogram based on the GRS model and clinicopathological features to optimize risk stratification (AUC of the composite model was 0.815).

CONCLUSIONS

The GRG signature-based predictive model may help clinicians provide a prognosis for DTC patients with a high risk of recurrence after surgery and provide further personalized treatment to decrease the chance of relapse.

Adverse Histological Features of Differentiated Thyroid Cancer Are Commonly Found in Autopsy Studies: Implications for Treatment Guidelines

Background: While the popularity of lobectomy for differentiated thyroid cancer (DTC) has increased since the 2015 ATA (American Thyroid Association) guidelines, recent studies reported that adverse histological features (minimal extrathyroidal extension [mETE], multifocality, vascular invasion, and lymph node [LN] metastases) may be found in 30-60% of lobectomy specimens, questioning the validity of this approach. Aim: To assess the prevalence adverse histological features in occult DTC detected in autopsy studies. Methods: Meta-analysis of autopsy studies of the thyroid in subjects without known history of thyroid cancer. Results: Twenty-nine studies including 8750 subjects fulfilled the inclusion criteria, with incidentally discovered DTC in 740 autopsies (8.5%). Age was reported in 17 studies, with a median age of 61 years (range 41-68 years). Multifocality was reported in 27 studies with a calculated event rate of 28.2% ([CI 23.1-33.8], I² = 46.3%), with bilateral involvement in 18% [CI 12.6-25.1]. mETE was reported in 5 studies, with an event rate of 24.5% ([CI 9.3-50.7], I² = 88.5%), and the presence of LN metastases were reported in 13 studies with an event rate of 11% ([CI 6.1-19.1], I² = 69.5%). Vascular invasion was reported in seven studies with an event rate of 16% ([CI 4-47], I² = 86.8%). Of 25 studies with whole body autopsies (722 subjects), 3 cases of distant metastases were reported, of which 2 had fatal metastatic disease (where thyroid origin was not diagnosed before death), and 1 had occult disease. Conclusions: Adverse histological features including mETE, LN metastases, multifocality, and vascular invasion are common in occult DTC. When minimal in size, these adverse histological features do not seem to be markers of aggressive disease and may not be an indication for completion thyroidectomy or radioiodine therapy.

Benefits and harms of hemithyroidectomy, total or near-total thyroidectomy in 1-4 cm differentiated thyroid cancer

OBJECTIVE

For 1-4 cm differentiated thyroid cancer (DTC), current ATA guideline recommended hemithyroidectomy (HT) as an acceptable alternative initial procedure to total or near-total thyroidectomy (TT). The aim of this study was to evaluate benefits and harms of HT, TT in 1-4 cm DTC.

DESIGN

Retrospective cohort study.

PATIENTS

DTC patients aged 18 years or older who underwent initial thyroidectomy in a tertiary medical centre were included from January 2008 to July 2018.

MEASUREMENTS

The structural persistent/recurrent disease, reoperation rates and surgical complications were compared using Cox proportional regression and logistic regression. Propensity score matching was performed to adjust for related clinicopathological variables.

RESULTS

Among 1824 DTC patients, 795 patients sized 1-4 cm were included. A total of 286 patients underwent HT and 509 patients underwent TT. In the matched analysis, no significant difference in disease-free survival (DFS) between HT and TT was observed during the median follow-up period of 56.5 months (hazard ratio [HR] 0.86; 95% CI, 0.37-2.00; p = .733). The difference in DFS between two groups was consistent regardless of age, sex, tumour size, follow-up duration. Meanwhile, HT was associated with a decreased risk of surgical complications (odds ratio [OR] 0.47, 95% CI 0.31-0.71, p < .001), as well as lower proportion of levothyroxine replacement (p = .007). Two cases in HT group received reoperation. Further multivariate analysis showed surgical procedure was not associated with structural persistence/recurrence (HR 0.68; 95%CI, 0.29-1.58, p = .367).

CONCLUSIONS

For patients with 1-4 cm DTC without clinical evidence of lymph node metastasis or extrathyroidal extension, HT was associated with lower risk of surgical complications than TT while provided similar benefits as TT.

Patient-reported outcomes following total thyroidectomy and lobectomy in thyroid cancer survivors: an analysis of the PROFILES Registry data

PURPOSE

Patient-reported outcomes are important in the surgical decision-making process for low-risk, differentiated thyroid cancer. Current study aimed to assess patient-reported outcomes in thyroid cancer survivors comparing total thyroidectomy (TT) and lobectomy (LT) using the Patient Reported Outcomes Following Initial treatment and Long term Evaluation of Survivorship (PROFILES) registry.

METHODS

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scales, illness perception questions, Beliefs about Medicines Questionnaire (BMQ) scales and questions about thyroid surgery-related medication use were compared between thyroid cancer patients who underwent TT versus LT using descriptive analyses.

RESULTS

In total, 58 thyroid cancer patients who underwent TT or LT were included in this study. None of the EORTC QLQ-C30 scales or questions regarding illness perception were significantly different between the surgical groups. Patients in the TT group had significantly higher belief in the necessity of their medication (21.0 vs 15.4; p = 0.003) and greater concerns about taking their medicines (14.7 vs 11.1; p = 0.008) versus patients in the LT group.

CONCLUSION

Concerns about post-surgical medication use specifically in the TT group may indicate that clinicians should consider LT in patients with low-risk, differentiated thyroid cancer when LT and TT are viable surgical options. Clinicians should be aware of the impact of post-surgical medication use in particular following TT and use this knowledge to align goals of treatment with the extent of surgery, allowing for a better-informed decision-making process.

Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: A National Survey of Low- and High-Volume Surgeons

BACKGROUND

The 2015 American Thyroid Association guidelines endorsed lobectomy for patients with low-risk papillary thyroid cancer (PTC) measuring 1-4 cm. Attitudes about the use of lobectomy for these patients are lacking, particularly from low-volume surgeons who perform the majority of thyroidectomies in the US.

METHODS

A survey was mailed to 1000 surgeons stratified by specialty (500 general surgeons and 500 otolaryngologists) registered with the American Medical Association, to evaluate beliefs and practices about the extent of surgery for low-risk PTC. Comparisons examined differences by surgeon volume.

RESULTS

Of 320 respondents who have performed thyroidectomy since 2015 (150 general surgeons, 170 otolaryngologists), 206 (64.4%) were low volume (< 26 thyroidectomies/year). The proportion of surgeons recommending lobectomy for low-risk PTC measuring 1.1 to < 4 cm ranged from 43.1 to 2.6%. High-volume surgeons recommended lobectomy more frequently for PTC measuring 1.1-3 cm, although this was not statistically significant. Thirty-three percent of respondents believed lobectomy is underused for low-risk PTC, while 10.0% believed it is overused. Additionally, 19.6% of respondents believed recurrence is more likely after lobectomy than total thyroidectomy, and 3.3% believed mortality is higher. Few believed quality of life is better after lobectomy (12.3%). Low-volume surgeons were less likely to be aware guidelines support lobectomy for low-risk PTC 1-4 cm (p < 0.001) and less likely to use clinical practice guidelines (p = 0.004).

CONCLUSIONS

Most surgeons do not support lobectomy for patients with low-risk PTC > 1 cm. Awareness of guidelines and concerns about increased risk of recurrence after lobectomy may drive surgeons' preference for total thyroidectomy.

Factors associated with health-related quality of life in papillary thyroid microcarcinoma patients undergoing radiofrequency ablation: a cross-sectional prevalence study

PURPOSE

To explore the association of demographic characteristics, clinical symptoms and the fear of the disease progression factors with the physical and mental summary components of the health-related of life (HRQoL) of the papillary thyroid microcarcinoma (PTMC) patients undergoing radiofrequency ablation (RFA).

METHODS

123 PTMC survivors undergoing RFA were enrolled in this study from October 2019 to March 2020. Demographic, clinical symptoms and the fear of the disease progression data were collected. SF-36, THYCA-QoL and FoP-Q-SF were used to evaluate the HRQoL of patients, clinical symptoms and the fear of disease progression. A multivariate regression model was performed to evaluate the association between the independent variable and the HRQoL variable.

RESULTS

The average self-reported HRQoL score was 81.17 ± 15.48 for the PCS and 73.40 ± 18.03 for the MCS. The multivariate linear regression model shows that the factors related to a poorer PCS were dependent for the female patients, the symptoms of neuromuscular and the throat/mouth, the fear of disease progression; the psychological disorder, symptoms of throat/mouth, inability to concentrate were related to worse scores for the MCS. The condition that was most strongly related to a poorer HRQoL (in both PCS and MCS) was the fear of their physical health.

CONCLUSIONS

The factors related to significantly worse HRQoL scores across PCS and MCS for PTMC survivors include the female gender, the symptoms of neuromuscular and the throat/mouth, the psychological disorder, inability to concentrate, and the fear of their own physical health. Identification, management, and prevention of these factors are critical to improving the HRQoL of patients.

Preoperative ultrasound characteristics in determining the likelihood of cytologically confirmed (Bethesda VI), 1-4 cm papillary thyroid tumours requiring completion thyroidectomy

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most commonly diagnosed differentiated thyroid carcinoma. There is controversy about performing upfront lobectomy vs thyroidectomy for smaller well differentiated thyroid carcinoma.

METHODS

A retrospective study from 2015 to 2020 was conducted consisting of consecutive patients with a preoperative malignant (Bethesda VI) cytology on fine needle aspirate (FNA) consistent with PTC. Specific ultrasonographic features such as taller than wide, hypoechogenicity, irregular margins, internal vascularity and microcalcifications were recorded. Criteria for exclusion was the presence of positive lymph nodes, extrathyroidal extension, familial thyroid carcinoma and bilateral disease detected preoperatively. Outcome was defined as a lobectomy being adequate treatment or a completion thyroidectomy recommended based on current 2015 ATA guidelines.

RESULTS

Preoperative malignant cytological nodules (Bethesda VI) with irregular margins on sonography were significantly (p = 0.025) at increased risk (OR = 2.48) of requiring a completion thyroidectomy. There was also no statistically significant difference between groups when stratified by size with 50% of tumours between 1 and 2 cm requiring a completion thyroidectomy.

CONCLUSIONS

The presence of irregular margins on ultrasound predicts an increased risk of requiring a completion thyroidectomy. Specific consideration of this sonographic finding should be made when counselling patients who have cytologically confirmed papillary thyroid carcinoma regarding the best choice of thyroid operation.

Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis

BACKGROUND

Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC.

METHODS

The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival.

RESULTS

There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry).

CONCLUSIONS

This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.

Patients' Reaction to Diagnosis with Thyroid Cancer or an Indeterminate Thyroid Nodule

Introduction: Little is known about the experiences and concerns of patients recently diagnosed with thyroid cancer or an indeterminate thyroid nodule. This study sought to explore patients' reactions to diagnosis with papillary thyroid cancer (PTC) or indeterminate cytology on fine needle aspiration. Methods: We conducted semistructured interviews with 85 patients with recently diagnosed PTC or an indeterminate thyroid nodule before undergoing thyroidectomy. We included adults with nodules ≥1 cm and Bethesda III, IV, V, and VI cytology. The analysis utilized grounded theory methodology to create a conceptual model of patient reactions. Results: After diagnosis, participants experienced shock, anxiety, fear, and a strong need to "get it out" because "it's cancer!" This response was frequently followed by a sense of urgency to "get it done," which made waiting for surgery difficult. These reactions occurred regardless of whether participants had confirmed PTC or indeterminate cytology. Participants described the wait between diagnosis and surgery as difficult, because the cancer or nodule was "still sitting there" and "could be spreading." Participants often viewed surgery and getting the cancer out as a "fix" that would resolve their fears and worries, returning them to normalcy. The need to "get it out" also led some participants to minimize the risk of complications or adverse outcomes. Education about the slow-growing nature of PTC reassured some, but not all patients. Conclusions: After diagnosis with PTC or an indeterminate thyroid nodule, many patients have strong emotional reactions and an impulse to "get it out" elicited by the word "cancer." This reaction can persist even after receiving education about the excellent prognosis. Understanding patients' response to diagnosis is critical, because their emotional reactions likely pose a barrier to implementing guidelines recommending less extensive management for PTC.

Margin Positivity and Survival Outcomes: A Review of 14,471 Patients with 1-cm to 4-cm Papillary Thyroid Carcinoma

BACKGROUND

Papillary thyroid carcinoma (PTC) comprises the majority of thyroid malignancy, but it is associated with excellent long-term survival. Highly prevalent, with increasing incidence, the optimal operative management for patients with 1- to 4-cm PTC remains unclear. This study determined factors that affect clinical outcomes, including survival, in this patient population.

STUDY DESIGN

Patients with 1- to 4-cm PTC, who underwent thyroidectomy between 2004 and 2016, were identified in the National Cancer Database (NCDB). Factors affecting survival, including margin status, extent of resection, operative volume, and institution type, were studied. Outcomes were estimated by Kaplan-Meier and log rank tests. Cox proportional hazard and binary logistic regression analyses identified factors affecting survival as well as margin positivity.

RESULTS

Of 14,471 patients with 1- to 4-cm PTC, 2,269 (15.7%) exhibited lymphovascular invasion, 6,925 (47.9%) had multifocality, 14,235 (98.3%) underwent total thyroidectomy, and 2,212 (15.3%) had microscopic margin positivity, which conferred lower survival (hazard ratio [HR] 1.464, p < 0.05), with 30-day and 90-day mortality of 0.1% and 0.2%, respectively. Operative volume (odds ratio [OR] 0.979, p < 0.01) and thyroid surgery at an academic center (OR 0.623, p < 0.001) were associated with lower odds of margin positivity.

CONCLUSIONS

In patients with 1- to 4-cm PTC, margin positivity confers lower survival. Factors associated with lower rate of margin positivity are higher operative volume and referral for treatment at academic center. Because margin positivity is a modifiable risk factor, referral of patients with aggressive features of PTC to high volume academic centers may improve survival.

The extent of surgery for low-risk 1-4 cm papillary thyroid carcinoma: a catch-22 situation. A retrospective analysis of 497 patients based on the 2015 ATA Guidelines recommendation 35

PURPOSE

The adequate extent of surgery for 1-4 cm low-risk papillary thyroid carcinoma (PTC) is unclear. Our objective was to analyze the applicability of the 2015 ATA Guidelines recommendation 35B (R35) for the management low-risk PTC.

METHODS

This multicentre study included patients with low-risk PTC who had undergone total thyroidectomy (TT). Retrospectively we selected those who met the R35 criteria for the performance of a thyroid lobectomy (TL). The aim was to identify the proportion of low-risk PTC patients treated using TT who would have required reintervention had they had a TL in accordance with R35.

RESULTS

We identified 497 patients (400 female; 80.5%). Median tumor size (mm): 21.2 (11-40). A tumor size ≥2 cm was found in 252 (50.7%). Most of them, 320 (64.4%), were in Stage I (AJCC 7th Edition). Following R35, 286 (57.5%) would have needed TT. Thus, they would have required a second surgery had they undergone TL. The indications for reintervention would have included lymph node involvement (35%), extrathyroidal extension (22.9%), aggressive subtype (8%), or vascular invasion (22.5%). No presurgical clinical data predict TT.

CONCLUSIONS

The appropriate management of low-risk PTC is unclear. Adherence to ATA R35 could lead to a huge increase in reinterventions when a TL is performed, though the need for them would be questionable. In our sample, more than half of patients (57.5%) who may undergo a TL for a seemingly low-risk PTC would have required a second operation to satisfy international guidelines, until better preoperative diagnostic tools become available.

The impact of surgery refusal on thyroid cancer survival: a SEER-based analysis

PURPOSE

In the current era of de-escalation of surgical treatment for low-risk thyroid cancer, it is important to ensure that the natural history of thyroid cancer is as benign as has been suggested previously. We therefore compared the impact of surgery refusal and surgery on disease-specific survival (DSS) in patients with local or regional, papillary thyroid cancer (PTC).

METHODS

Local and regional stage PTC patients in the Surveillance, Epidemiology, and End Results Program (1988-2015) were included. Cox proportional hazard modeling and propensity score matching were conducted to evaluate DSS.

RESULTS

There were 45,136 patients who received surgery and 146 patients who had surgery recommended but refused. Adjusted analysis showed a significantly better DSS for the surgery group compared with the refusal group (HR_adj: 3.07 (95% CI: 1.54-6.11). After stratification for stage, no statistically significant difference in DSS was found (HR_adj: 3.03 (0.89-10.35) when including only local stage PTC. Propensity matching showed a 10-year DSS of 94.0% (95% CI: 87.7-97.1%) and 96.4% (95% CI: 93.2-98.1%) for the refusal and surgery group (p = 0.060). Propensity matching of local stage PTC showed a 10-year DSS of 96.7% (95% CI: 89.9-98.9%) and 100%, respectively (p = 0.002).

CONCLUSION

Although no significant difference in survival was found between surgery and no surgery in local stage PTC, a 3.3% improvement of 10-year DSS was found in the surgery group. Overall, these results suggest that local stage PTC has a benign natural history, and that conservative management strategies such as active surveillance may be appropriate.

New paradigms in the treatment of low-risk thyroid cancer

INTRODUCTION

Thyroid cancer is the most common endocrine malignancy. Multiple different staging systems have been introduced and used for differentiated thyroid carcinoma (DTC).

AREAS COVERED

In this literature review we provide an overview of the standard options for management of patients with low risk differentiated thyroid cancer.

EXPERT OPINION

Surgery is considered the first and most important step in managing DTC with goal to remove all the malignant foci in order to achieve cure and increase the survival with least chance of recurrence. Many studies have been conducted to determine the best surgical approaches and how aggressive surgeries should be in order to achieve the best outcomes regarding efficacy as well as safety. Radioactive iodine (RAI) therapy has also been a part of the treatment regimen and is used for different purposes with three main goals: post-surgical ablation, adjuvant therapy and persisted/recurrent disease treatment. Radiation therapy, on the other hand, is still not recommended to be used routinely in DTC because of the conflicting data of its benefit.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Assessing non-aggressiveness of untreated, local and regional, papillary thyroid cancer

OBJECTIVES

With a steadily increasing thyroid cancer incidence, information regarding cancer aggressiveness is essential to determine which patients may be suitable for active surveillance. This study assessed the extent of non-aggressiveness of untreated, local and regional stage, papillary thyroid cancer.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) registry and included 1423 local stage and 337 regional stage papillary thyroid cancer cases. Thyroid cancer specific survival was estimated conditional on the absence of death due to competing causes using competing risk methods. Stratified analyses were done to determine non-aggressiveness among different patient and tumor characteristics.

RESULTS

The overall rate of non-aggressiveness for local stage thyroid cancer was 99.34% (95% CI: 99.33-99.35%), with a rate of non-aggressiveness of 98.85% (95% CI: 98.77-98.93%) for males and 99.48% (95% CI: 99.46-99.49%) for females (p = 0.055). Rate of non-aggressiveness was significantly lower in patients >60 years compared to patients ≤60 years (p < 0.001). Although the rate of non-aggressiveness was the same for tumors ≤10 mm and tumors of 11-20 mm, tumors measuring >20 mm had a significantly lower rate of non-aggressiveness (p = 0.002). The overall rate of non-aggressiveness for regional stage thyroid cancer was 72.58% (95% CI: 70.61-74.56%).

CONCLUSION

We found high rates of non-aggressiveness in untreated, local stage, papillary thyroid cancer, particularly in younger patients with small (≤2 cm) thyroid cancer, suggesting that these patients may be good candidates for active surveillance.

ANGPTL4 Promotes the Proliferation of Papillary Thyroid Cancer via AKT Pathway

Purpose

Although papillary thyroid carcinoma (PTC) is associated with a generally favorable prognosis, about 15% of patients present recurrence and distant metastasis in the next decade leading to death. Angiopoietin-like 4 (ANGPTL4) is secreted to circulation and belongs to the angiopoietin-like proteins. The expression of ANGPTL4 was increased in several solid tumor tissues compared to corresponding paracancerous tissues. ANGPTL4 was identified as pro-tumorigenic protein, including stimulating tumor cell growth, promoting tumor metastasis. However, the clinical significance and biological function of ANGPTL4 in PTC is still unclear. Hence, the purpose of this study was to evaluate the role of ANGPTL4 in PTC, investigating the possibility of whether ANGPTL4 could become a novel target for PTC therapy.

Methods

We investigated the expression level of ANGPTL4 and pAKT in PTC and paracancerous tissue by immunohistochemistry. We determined the effect of ANGPTL4 in PTC cell proliferation through cell counting kit-8 (CCK-8) and cell cycle by flow cytometry analysis. Furthermore, the correlation between ANGPTL4 expression levels and PTC cell proliferation from the TCGA data set was analyzed by GSEA. We explored the role of ANGPTL4 on the phosphorylation of AKT and proliferation in PTC cells via overexpression or knockdown assays and AKT inhibitor assay.

Results

In the present study, we found that ANGPTL4 was highly expressed in both protein and mRNA level in PTC compared with adjacent noncancerous tissues or benign nodule. ANGPTL4 expression increased according to thyroid tumor progression. ANGPTL4 level was positively correlated with the size of PTC. ANGPTL4 increased cell proliferation and decreased cell cycle arrest of PTC. Knockdown of ANGPTL4 inhibited the phosphorylation of AKT. ANGPTL4 regulated PTC cell proliferation through AKT signaling pathway.

Conclusion

Our findings suggested that ANGPTL4 was increased in PTC compared with adjacent noncancerous tissues, and ANGPTL4 increased cell proliferation and inhibited cell cycle arrest in PTC cells via promoting AKT phosphorylation. The study may provide fundamental information to suggest its suitability as a target for the treatment of PTC.

Total thyroidectomy versus lobectomy for papillary thyroid cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis collected data for evaluating the effect of surgical extent on overall survival (OS) and recurrence-free survival (RFS) in patients with papillary thyroid cancer (PTC).

METHODS

We searched the PubMed, Embase, and Cochrane Library databases. The included studies compared two groups of patients with PTC: the total thyroidectomy (TT) group and the lobectomy (LT) group. The combined hazard ratio (HR) was calculated.

RESULTS

Thirteen studies were included in the present study. The TT and LT groups had similar OS results (HR = 1.04; 95% CI: 0.90-1.21; P = .60). In the subgroup analysis, the combined HR of the ≤1 cm group and the 1.0 to 2.0 cm group showed that TT had no advantage with regard to OS compared to LT. In the 2.0 to 4.0 cm group, TT provided better OS than LT (HR = 0.88; 95% CI: 0.79-0.99; P = .03). Patients who underwent TT had a better RFS outcome than those who underwent LT (HR = 0.56; 95% CI: 0.41-0.77; P < .0001). In the subgroup analysis, both the ≤1 cm group and >1 cm group that underwent TT were associated with better RFS.

CONCLUSIONS

Our meta-analysis suggested that LT increased the risk of recurrence in PTC patients with tumors ≤1.0 cm and in PTC patients with tumors >1.0 cm. More importantly, LT was associated with higher mortality in PTC patients with 2.0 to 4.0 cm tumors. Caution is warranted when LT is performed in this group of patients.

Systematic Review of Recurrence Rate after Hemithyroidectomy for Low-Risk Well-Differentiated Thyroid Cancer

BACKGROUND

Surgical extent in the management of well-differentiated thyroid cancer (DTC) remains a recurrent subject of debate. This is especially relevant in low-risk DTC of 1-4 cm, which represent the majority of new thyroid cancer diagnoses. With trends towards treatment de-escalation and recent guidelines from the American Thyroid Association and British Thyroid Association endorsing hemithyroidectomy (HT) alone for low-risk DTC of 1-4 cm, we sought to systematically appraise the literature to examine recurrence rate outcomes after HT in this low-risk group.

SUMMARY

Searching PubMed, Cochrane Library, and Ovid MEDLINE, we conducted a systematic review to assess the survival and recurrence rate data presented in all published studies that had a cohort of patients treated with HT for the treatment of DTC. Pooled 10-year survival and recurrence rates, odds ratios, and 95% confidence intervals were calculated for meta-analysis. We identified 31 studies (with a total of 228,746 patients (HT: 36,129, total thyroidectomy, TT: 192,617), which had published recurrence and/or survival data for patients having had HT for DTC. We discovered a pooled recurrence rate of 9.0% for HT, which is significantly higher than in previously published reports. Further, this rate is maintained when examining patients within low-risk cohorts established with recognised risk classifications. We also discovered that of those patients who develop recurrent disease, 48% recur outside the central neck.

KEY MESSAGES

Our study provides a comprehensive systematic review of evidence aimed primarily at defining the recurrence rate in DTC after HT, and more specifically within the low-risk subgroup. We describe pooled recurrence and 10-year survival rates from a larger, broader, and more contemporary patient population than has been previously reported. Our findings indicate that there is a small but significantly higher recurrence rate after HT than TT, but the evidence base is heterogenous and subject to confounding factors and would ultimately benefit from prospective randomised trials to overcome these deficiencies.

A comparative study of short-term efficacy and safety for thyroid micropapillary carcinoma patients after microwave ablation or surgery

Background: Although papillary thyroid microcarcinoma (PTMC) has a high incidence and excellent clinical outcome, debate continues as to the therapeutic approach that would be most appropriate after confirming the diagnosis. Methods: We retrospectively analyzed the medical records of 311 patients with T1aN0M0 PTMC between January 2013 and September 2018. In all, 168 underwent microwave ablation (MWA), and 143 underwent surgery. MWA was performed using extensive ablation with hydrodissection. The surgery comprised thyroid lobectomy (TL) with unilateral central lymph node dissection (CND). We examined clinical outcomes during mean follow-up periods of 824 ± 452 days for the TL group and 753 ± 520 days for the MWA group. Results: Postprocedural follow-up revealed that, in the MWA group, the tumors had completely disappeared in 34 patients, and the remainder were reduced to necrotic or carbonized tissue. The incidence of transient hypoparathyroidism was significantly lower in the MWA group than in the TL group (p < .001). In addition, during the follow-up, we found no statistically significant differences between the two groups (TL vs MWA) for PTMC recurrence (1 vs 2 cases), lymph node metastasis (5 vs 5 cases), or disease-free survival [2001 days (5.5 years) vs 1702 days (4.7 years)] (p = .659, p = .795, and p = .974, respectively). Conclusions: If low-risk thyroid carcinoma (i.e., T1N0M0 PTMC) is accurately diagnosed early, MWA could be a minimally invasive alternative to surgery based on our short-term follow-up regarding recurrence and the low rates of complications and disease-free survival.

Quality of Life in Papillary Thyroid Microcarcinoma Patients Undergoing Radiofrequency Ablation or Surgery: A Comparative Study

Objective: Papillary thyroid microcarcinoma (PTMC) has a good prognosis and a long survival time. Health-related quality of life (HRQoL) is vital for PTMC patients during their survivorship. Ultrasound (US)-guided radiofrequency ablation (RFA), which has high efficacy and safety, is recommended as an alternative treatment to surgery for the patients with low-risk PTMC. However, the assessment of QoL of patients with PTMC has not been specially reported. The purpose of our study was to compare the HRQoL of patients with PTMC who underwent RFA and those who underwent surgery. Methods: From October 2019 to December 2019, 88 PTMC patients were enrolled in our study, including 54 in RFA group and 34 in surgery group. We used three questionnaires which included the 36-item short form health survey (SF-36), thyroid cancer-specific quality of life (THYCA-QOL), and Fear of Progression Questionnaire-Short Form (FoP-Q-SF) for each patient to evaluate their scores of HRQoL. The scores were compared after adjusting for age, sex, medical expense, and follow-up time. Results: According to the SF-36, the scores of the domain for the role limitation due to physical problems and emotional problems (RP, RE) as well as Physical Component Summary (PCS) showed a significant negative linear association between the RFA group and surgery group: RP coefficient [coef]-22.613 [confidence interval (CI) -33.504 to -11.723], p < 0.001, RE (coef: -21.901 [CI -36.737 to -7.064], p = 0.004), and PCS (coef: -8.312 [CI -13.694 to -2.930], p = 0.003). The THYCA-QOL showed that the scores of the surgery group were higher than that of the RFA group regarding scars (coef: 10.246 [CI 1.330 to 19.162], p = 0.025 according to the multivariate analysis), suggesting a higher level of complaint in the surgery group. There was no statistically significant difference in the scores of FoP-Q-SF between the two groups. Conclusions: In patients with PTMC, US-guided RFA offers advantage over surgery in terms of HRQoL, which supports the role of RFA as an alternative strategy to surgery.

Suspicious ultrasound characteristics correlate with multiple factors that predict central lymph node metastasis of papillary thyroid carcinoma: Significant role of HBME-1

PURPOSE

Papillary thyroid carcinoma (PTC) is frequently associated with central lymph node metastasis (CLNM). In the present study, we aimed to identify possible risk factors for CLNM in PTC, including suspicious ultrasound (US) features coexisting with thyroid diseases, immunohistochemical markers, and BRAF_V600E. These were used to establish a model to predict the risk of CLNM.

METHODS

From January 2016 to March 2018, we identified a cohort of patients with classic PTC who underwent cervical US and were diagnosed by postoperative pathology. Fine-needle aspiration biopsies were analyzed for the presence ofBRAF_V600E, and immunohistochemistry was used to detect tumor markers. US imaging was performed in accordance with a standardized protocol. A model to determine the risk of CLNM was established using the outcomes of univariate and multivariate analyses.

RESULTS

Age of ≥45 years, male sex, mean tumor diameter of ≥1.0 cm, taller-than-wide tumor shape, multiple PTCs, capsule contact, and HBME-1 expression were significant independent risk predictors of CLNM. Hashimoto's thyroiditis, nodular goiter, andBRAF_V600E were not significantly associated with CLNM. The cutoff value (area under the curve = 0.760) for predicting risk was determined from receiver operating characteristic curves (sensitivity, 75.6 %; specificity, 60.7 %).

CONCLUSIONS

Male sex, age of ≥45 years, mean tumor diameter of ≥1.0 cm, taller-than-wide shape, multiple tumors, capsule contact, and HBME-1 expression were independent predictors of the risk of CLNM in patients with PTC. The risk model may be useful for evaluating patients' prognoses and selecting optimal surgical strategies.

Clinical-pathological issues in thyroid pathology: study on the routine application of NIFTP diagnostic criteria

In 2017, the WHO classification of tumours of the endocrine organs established the criteria for a NIFTP diagnosis. The present paper considers some aspects that are still debated or unresolved: the real incidence and clinical meaning of multifocal/multinodular lesions, the biological behaviour of micro-NIFTP, the sprinkling phenomenon and the corresponding modifications to the FNA reporting systems based on changes to the ROM. Moreover, the paper suggests possible scenarios for the clinical-pathological management of this entity. From the initial 1470 cases, a group of 68 NIFTPs was recruited in a 9 year-long period. The average age at diagnosis was 55 years. The average diameter of the lesion was 1.7 cm (0.1 cm–10 cm). In 41 cases (60.1%), the lesion was inserted in the context of a multinodular background. In 12 cases, the diagnosis was incidental and the pre- operative FNA was performed on a different target. In 10 out of 68 cases, there was a multifocal NIFTP; in 14.7% of patients, PTC-like nuclear features showed sprinkling phenomenon. The cytological revision allocated 21 cases (49%) to the SIAPEC TIR3 indeterminate class and a nuclear score 2 or 3 were identified in 25 smears. Multifocality is part of the spectrum of NIFTPs, that can arise in a multinodular background with variable sizes from microscopic lesions to very large ones. Cytopathological criteria such as an evaluation of the nuclear score may help the pathologists in promoting a NIFTP diagnosis in the preoperative setting.

Extent of Surgery for Low-Risk Differentiated Thyroid Cancer

Although the incidence of thyroid cancer is increasing, survival remains unchanged. Due to concern for overtreatment, surgical management of thyroid cancer has evolved. Papillary thyroid microcarcinoma measuring 1 cm or smaller are considered very low risk and can be managed with either thyroid lobectomy or active surveillance. Total thyroidectomy is no longer recommended for these cancers unless there is evidence of metastasis, local invasion, or aggressive disease. Recommendations for low-risk differentiated thyroid cancer measuring 1 cm to 4 cm remain controversial. This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer.

Is hemi-thyroidectomy adequate in low risk differentiated thyroid cancer?

In low-risk differentiated thyroid carcinoma (LRDTC), appropriate surgical procedure in terms of hemi/total thyroidectomy (TT) has been an area of debate. The aim was to determine whether in LRDTC patients, hemithyroidectomy would be an adequate treatment, determine incidence of disease in contralateral lobe and evaluate the effect of radioactive iodine ablation (RAIA). Retrospective study was done from 2008 to 2014 at a single institution. Preoperative ultrasound (USG) and histopathology reports of all LRDTC patients following total/completion thyroidectomy were recorded. Details of postthyroidectomy, thyroid whole body scan, and stimulated serum thyroglobulin (sTg) levels were also documented and results analyzed. A total of 114/562 patients met inclusion criteria. Of these, 25/114 (22%) underwent hemithyroidectomy followed by a completion thyroidectomy while remaining 89/114 (78%) underwent TT initially. Preoperative USG detected single-lobe involvement in 44 patients; however, among them, histopathology revealed bilateral lobe disease in 17 (38.6%). There was a significant fall of sTg level following RAIA as compared to that before RAIA in T1b-T2 (P = 0.009 and 0.012, respectively). Median follow-up was 2 years (range: 1–7 years) with no distant metastasis or deaths recorded till 2017, except for one local recurrence 4 years after RAIA. In conclusion, the role of TT in LRDTC patients is important as 46% of patients were found to have tumor in contralateral lobe as well. Significant fall in sTg levels following RAIA justifies RAIA of remnant lobe even in LRDTC (T > 1a). It facilitates early detection of recurrence when sTg alone is used for follow-up.

Differentiated Thyroid Cancer, From Active Surveillance to Advanced Therapy: Toward a Personalized Medicine

Differentiated thyroid cancer (DTC) is the most frequent endocrine malignancy and represents the most rapidly increasing cancer diagnosis worldwide. In the last 20 years, this increase has been mostly due to a higher detection of small papillary thyroid cancers, with doubtful effects on patients' outcome. In fact, despite this growth, cancer-related death remained stable over the years. The growing detection of microcarcinomas associated to the indolent behavior of these cancers led to the development of strategies of active surveillance in selected centers of different countries. Moreover, toward a more personalized approach in the management of DTC patients, surgical treatments became more conservative, favoring less extensive options in patients at low risk of recurrence. The rise in lobectomy in low-risk cases and the need to avoid further therapies, with controversial impact on recurrences and cancer-related death in selected intermediate risk cases, led to reconsider the use of radioiodine treatment, too. Since clinicians aim to treat different patients with different modalities, the cornerstone of DTC follow-up (i.e., thyroglobulin, thyroglobulin autoantibodies, and neck ultrasound) should be interpreted consistently with this change of paradigm. The introduction of novel molecular target therapies (i.e., tyrosine kinase inhibitors), as well as a better understanding of the mechanisms of immune checkpoint inhibitor therapies, is radically changing the management of patients with advanced DTC, in whom no treatment option was available. The aim of this review is to analyze the most recent developments of the management of DTC, focusing on several key issues: active surveillance strategies, initial treatment, dynamic risk re-stratification, and therapeutic options in advanced DTC.