Clinical features of recently diagnosed papillary thyroid carcinoma in elderly patients aged 65 and older based on 10 years of sonographic experience at a single institution in Korea

Comprehensive evaluation of risk factors for lymph node metastasis in patients with papillary thyroid carcinoma

With the increasing incidence of papillary thyroid cancer (PTC), it is important to risk-stratify patients who may have a more aggressive tumor biology. The present study aimed to evaluate the risk factors for lymph node metastasis (LNM) in patients with PTC, which may provide a significant reference for clinical diagnosis and treatment. In total, 1,045 patients with PTC [313 with PT microcarcinoma (PTMC) and 732 with non-PTMC] between August 2016 and August 2019 were investigated. The B-type Raf kinase (BRAF) V600E mutation was tested in all samples. The clinical data (sex, age, tumor location, sample type and pathological features) were retrospectively analyzed. Logistic regression analysis was performed to evaluate independent risk factors for LNM. A total of 181/313 (57.8%) PTMC cases and 145/732 (19.8%) non-PTMC cases had a BRAF V600E mutation. In the PTMC cases, significant differences in sex and sample type were identified (BRAF V600E mutation vs. wild-type). In the non-PTMC cases, significant differences in sex and age were identified (BRAF V600E mutation vs. wild-type). Female sex and tumor diameter ≤1 cm were significant independent predictors of LNM in PTC. In PTMC, female sex was a significant independent predictor of LNM. A bilateral tumor was an independent protective factor for LNM in PTC, PTMC and non-PTMC. The BRAF V600E mutation rate of ultrasound-guided fine-needle aspiration cytology was higher compared with FFPE in PTMC (P=0.018). In contrast to previous studies, the results of the present study suggested that being female and having a tumor of diameter ≤1 cm were risk factors for LNM, and that the BRAF wild-type of PTMC may be more aggressive than other types. Notably, the position of the tumor in the bilateral thyroid was also an independent protective factor for LNM. Therefore, ultrasound-guided fine-needle aspiration should be recommended for gene analysis (BRAF V600E) in PTMC. In addition, clinicians should consider an individualized treatment according to gene mutations, sex, age, tumor size and the location of the tumor, in order to achieve an improved therapeutic efficacy.

The age threshold of the 8th edition AJCC classification is useful for indicating patients with aggressive papillary thyroid cancer in clinical practice

BACKGROUND

Papillary thyroid cancer (PTC) is unique among cancers in that patient age is a consideration in staging. One of the most important modifications in the 8th Edition of the American Joint Committee on Cancer (AJCC) classification is to increase the age cut off for risk stratification in PTC from 45 to 55 years. However, whether this cut off is useful in clinical practice remains controversial. In the present study, we assessed how well this new age threshold stratifies patients with aggressive PTC.

METHODS

We retrospectively analyzed the clinicopathological features and overall survival rate of patients with PTC admitted to and surgically treated at a single surgical center. The study protocol was divided into two series. In each series all patients (n = 523) were divided in 2 groups according to age cut off. In the first series (cut off 45) patients < 45 (n = 193) vs. ≥45 (n = 330) were compared, and in the second series (cut off 55) patients < 55 (n = 306) vs. ≥55 (n = 217) were compared.

RESULTS

The rate of the prevalence of locally advanced disease (pT3 and pT4) was significantly higher in the patients above 55 years old than in those below 55 years old (p = 0.013). No significant differences were found for this parameter in series with cut off point 45 years old. A significantly higher risk of locally advanced disease T3 + T4 (OR = 4.87) and presence of LNM (N1) (OR = 3.78) was observed in ≥45 years old group (p = 0.021 and p < 0.0001, respectively). More expressive results were found for the patients ≥55 years old group, where the risk of locally advanced disease (T3 + T4) was higher (OR = 5.21) and LNM presence was OR = 4.76 (p < 0.001 and p < 0.0001, respectively). None of the patients below 55 years old showed distant metastasis, but 19 patients above 55 years old showed M1 (p < 0.0001). In older patients group (≥55 years old) we observed deaths related thyroid cancer in 11 individuals.

CONCLUSIONS

The age cut off of 55 years old for risk stratification proposed by the 8th Edition of AJCC effectively stratifies PTC patients with a poor prognosis, indicating it is likely to be useful in clinical practice.

The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study

BACKGROUND

Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population.

METHODS

A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old.

RESULTS

Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B).

CONCLUSIONS

The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Persistent/Recurrent Differentiated Thyroid Cancer: Clinical and Radiological Characteristics of Persistent Disease and Clinical Recurrence Based on Computed Tomography Analysis

BACKGROUND

The natural course of persistent/recurrent differentiated thyroid cancer (DTC) has not been fully elucidated. The purpose of this study was to assess the relative incidence and clinico-radiological characteristics of persistent disease and clinical recurrence based on computed tomography (CT) analysis in patients with persistent/recurrent DTC.

METHODS

From January 2005 to December 2016, this retrospective study included 107 patients (M:F = 28:79; M_age = 53.5 years) with surgically proven cervical locoregional recurrence of DTC. Two neck CT examinations (median interval 1.92 years; range 0.17-7.58 years) before the last thyroid cancer surgery within the study period were reevaluated. Based on the presence of the lesion on the first CT and its progression on the second CT, the locoregional recurrence was classified into the following categories: stable persistence (decrease, no change, or increase by <2 mm in short dimension on the second CT), progressive persistence (increase by ≥2 mm), and clinical recurrence (newly appeared on the second CT). Clinical and radiological characteristics of the three groups were compared using univariate and multivariate logistic regression analyses.

RESULTS

The relative incidences of stable persistence, progressive persistence, and clinical recurrence were 56.1% (60/107), 15.0% (16/107), and 29.0% (31/107), respectively. Multivariate analysis between the clinical recurrence (29.0%) and persistence (71.0%) groups revealed various independent factors for prediction of clinical recurrence. These included longer interval between the two CT examinations (median 2.67 vs. 1.79 years; p = 0.021), a smaller number of thyroid surgeries (1.16 ± 0.45 vs. 1.55 ± 0.81; p = 0.002), and a history of neck dissection at the location of the largest locoregional recurrence (70.0% vs. 31.4%; p < 0.001). There was no significant independent factor for differentiation between the stable persistence (78.9%; 60/76) and progressive persistence (21.1%; 16/76) groups. The results may have been influenced by selection bias because this study included only surgically proven cases.

CONCLUSIONS

With regard to cervical locoregional recurrence of DTC, active surveillance may be favored because more than a half of the cases are structurally persistent and stable. However, meticulous evaluation is necessary to detect progressive persistence and clinical recurrence, considering various clinical factors.