Nodal metastases in thyroid cancer: prognostic implications and management

Validation of Diagnostic Utility of Washout CYFRA 21-1 in Lymph Node Metastasis of Thyroid Cancer

PURPOSE

Traditional methods, fine-needle aspiration cytology (FNAC), and washout thyroglobulin (Tg) do not always provide sufficient accuracy for diagnosing lymph node (LN) metastasis in thyroid cancer. This study aimed to validate the diagnostic performance of washout cytokeratin fragment 21-1 (CYFRA 21-1) as a complementary biomarker for diagnosing metastatic LN in thyroid cancer and to explore its relationship with molecular analysis and distant metastasis.

EXPERIMENTAL DESIGN

In this retrospective cohort study involving 230 LN in 224 patients with papillary thyroid carcinoma, FNAC, washout Tg, and washout CYFRA 21-1 levels were measured in suspicious LN. The final LN outcomes were confirmed by surgical histology.

RESULTS

Among the 230 LN, 145 (63.0%) were benign and 85 (37.0%) were metastatic. The optimal cutoff value for washout CYFRA 21-1 was established at 1.12 ng/mL (AUC, 0.959; 95% confidence interval, 0.936-0.982) with sensitivity of 93.4% and specificity of 97.8%. The cutoff value for washout Tg was 12.61 ng/mL (AUC, 0.832; 95% confidence interval, 0.772-0.892). The diagnostic performance of CYFRA 21-1 remained consistent across the preoperative (1.14 ng/mL) and postoperative assessment (1.10 ng/mL). The combination of FNAC and washout CYFRA 21-1 showed higher sensitivity (92.5%), specificity (95.9%), negative predictive value (93.7%), and diagnostic accuracy (95.1%) than the combination of FNAC and washout Tg. The washout CYFRA 21-1 level was associated with TERT mutations (OR, 3.35; P < 0.001), LN metastasis (OR, 5.43; P = 0.019), and distant metastasis (OR, 4.27; P = 0.019).

CONCLUSIONS

Incorporating washout CYFRA 21-1 into the diagnostic process improves the accuracy of metastatic LN detection in thyroid cancer.

Aggressive variants of papillary thyroid carcinoma: characteristics, influencing factors, and effectiveness of radioiodine therapy

PURPOSE

To investigate the pathological characteristics of aggressive variants of papillary thyroid carcinoma (PTC) and evaluate the efficacy of radioiodine (RAI) therapy for these variants.

METHODS

We analysed 129 patients with aggressive variants of PTC and compared them to those of 4460 patients with non-aggressive variants. And we examined the efficacy of RAI therapy in 70 eligible patients with aggressive variants of PTC and 2530 eligible patients with non-aggressive variants of PTC.

RESULTS

Aggressive and non-aggressive variants of PTC demonstrated a greater degree of variability in terms of age, multifocality, capsular invasion, vascular invasion, extrathyroidal invasion, lymph node metastases, disease stage, risk stratification, N stage, comorbid with Hashimoto thyroiditis (HT) and comorbid with nodular goiter (NG). Propensity score matching method showed poor efficacy of RAI treatment in patients with aggressive variants of PTC compared with non-aggressive variants. Multifactorial analysis showed that comorbid NG was an independent risk factor for poor effectiveness of RAI treatment for aggressive PTC variants ((hazard ratio (HR) 3.027; 95% confidence interval (CI), 1.295-7.075).

CONCLUSION

Aggressive variants of PTC demonstrated a higher degree of aggressiveness and poor efficacy of RAI therapy compared to non-aggressive variants, especially comorbid with NG, which may require higher therapeutic 131I dosage.

Survival in Thyroid Cancer in Sweden From 1999 To 2018

Introduction

Thyroid cancer (TC) is diagnosed in several histological types which differ in their clinical characteristics and survival. We aim to describe how they influence TC survival in Sweden.

Methods

Cancer data were obtained from the Swedish cancer registry between years 1999 and 2018, and these were used to analyze relative survival.

Results

Relative survival for all TC improved when analyzed in 10-year periods, and female survival improved more than male survival. Female survival advantage appeared to be present also for specific histological types, although case numbers were low for rare types. Female 5-year relative survival for TC was 100% for follicular, 95.1% for oncocytic, 93.4% for papillary, 89.7% for medullary, and 6.1% for anaplastic cancer. Among the clinical TNM classes, only T4 and M1 stages were associated with decreased survival compared to T1-3 and M0. Anaplastic cancer presented most often at high T and M1 stages, in contrast to other TC. Curiously, the diagnostic age for anaplastic M1 patients was lower than that for M0 patients. Both anaplastic and medullary cancers did not show age-dependent increases in the probability of metastases, in contrast to the main histological types. This could indicate the presence of several types of anaplastic and medullary cancers.

Conclusion

The poor survival for anaplastic TC is an extreme contrast to the excellent survival of differentiated TC. As less than 20% of anaplastic cancer patients survived one year, urgent diagnosis and initiation of treatment are important. Facilitated treatment pathways have been instituted in Denmark resulting in improved survival. Anaplastic cancer should be a target of a major research focus.

The Role of Risk Factors for the Progression of Patients with T1b-T2 Papillary Thyroid Carcinoma (PC) during Long-Term Follow-Up

Background/Objectives: Recurrence prediction for patients with PC and tumor sizes ranging between 1 and 4 cm, classified as T1b and T2, remains a controversial problem. We evaluated which risk factors, identified during the primary tumor surgery, might play a prognostic role in predicting disease progression. Methods: We retrospectively enrolled 363 patients with classic PC who were in follow-up (207 T1b, 156 T2), with tissue risk factors at surgery in 209/363 cases. In all cases, an 131I-whole-body scan, SPECT/CT, and US were employed to detect any metastases during follow-up, and histology was used to confirm lesions. In the absence of surgery, metastases were validated by radioisotopic and radiologic procedures, eventually culminating in a needle biopsy and sequential thyroglobulin changes. Results: Metastases occurred in 61/363 (16.8%) patients (24 T1b, 37 T2). In 50/61 cases, the following risk factors were identified: minimal extrathyroid tumor extension (mETE) alone in 12/50 patients, neck lymph node (LN) metastases in 8/50 cases, and multifocality/multicentricity (M/M) in 6/50 cases. In the remaining 24/50 cases, the risk factors were associated with each other. From a Cox regression multivariate analysis, metastasis development was significantly (p < 0.001) influenced by only mETE and LN metastases, with a shorter disease-free survival (log-rank test). Conclusions: The current study proves that mETE and neck LN metastases are associated with aggressive PC. While LN metastasis' role is known, mETE's role is still being debated, and was removed by the AJCC's eighth edition because it was considered to not be associated with an unfavorable prognosis. However, this interpretation is not supported by the present study and, according to comparable studies, we suggest a revision of the mETE classification be considered in the next AJCC edition.

First-Generation Radiolabeled Cyclic Peptides for Molecular Imaging of Platelet-Derived Growth Factor Receptor α

Occult nodal spread and metastatic disease require longstanding imaging and biochemical assessments for thyroid cancer, a disease that has a propensity for diffuse, small-volume disease. We have developed a 64Cu-labeled platelet-derived growth factor receptor α (PDGFRA) antibody for immuno-PET of PDGFRA in metastatic papillary thyroid cancer (PTC). The present work describes the discovery of small cyclic PDGFRA-targeting peptides, their binding features, and radiolabeling with positron emitter gallium-68 (68Ga) for in vitro and in vivo characterization in thyroid cancer models. Phage-display technology with two separate libraries and seven different cell lines was used through three rounds of biopanning as well as flow cytometry and comparative analysis with recombinant protein to select specific peptide sequences. Phenotypic binding analysis was completed by using phosphorylation and cell migration assays. In vitro protein binding was analyzed with thermophoresis and flow cytometry using the fluorescent-labeled PDGFRA peptide. Peptide candidates were modified with the NOTA chelator for radiolabeling with 68Ga. In vitro cell uptake was studied in various thyroid cancer cell lines. In vivo studies of 68Ga-labeled peptides included metabolic stability and PET imaging. From the original library (1013 compounds), five different peptide groups were identified based on biopanning experiments with and without the α subunit of PDGFR, leading to ∼50 peptides. Subsequent phenotypic screening revealed two core peptide sequences (CP16 and CP18) that demonstrated significant changes in the level of PDGFRA phosphorylation and cell migration. Alanine scan sublibraries were created from these two lead peptide sequences, and peptides were radiolabeled using 68Ga-GaCl3 at pH 4.5, resulting in RCP > 95% within 34-40 min, including SPE purification. Cyclic peptide CP18.5 showed the strongest effects on cell migration, flow cytometry, and binding by visual interference color assay. 68Ga-labeled PDGFRA-targeting peptides showed elevated cell and tumor uptake in models of thyroid cancer, with 68Ga-NOTA-CP18.5 being the lead candidate. However, metabolic stability in vivo was compromised for 68Ga-NOTA-CP18.5 vs 68Ga-NOTA-CP18 but without impacting tumor uptake or clearance profiles. First-generation radiolabeled cyclic peptides have been developed as novel radiotracers, particularly 68Ga-NOTA-CP18.5, for the molecular imaging of PDGFRA in thyroid cancer.

Clinical-Pathological Features of Thyroid Neoplasms in Young Patients Diagnosed in a Single Center

Background and objectives: The aim of this study was to evaluate the clinical-pathological profile in young patients with thyroid cancer. Materials and methods: We realized a retrospective study on patients with thyroid neoplasms who underwent surgery at the "Pius Brinzeu" County Clinical Emergency Hospital in Timisoara, Romania. A comparative analysis of some parameters between two groups, young patients (<45 years) versus patients ≥45 years, was performed. Results: A total of 211 patients met the study inclusion criteria, mostly females (86.26%) with a female/male ratio of 6.81:1. In patients <45 years old (25.64%), papillary thyroid carcinoma was identified in 51.85% of cases; in 53.85% of cases, the tumor was >1 cm; 13.46% had extrathyroidal extension (p = 0.0430); 21.15% capsule invasion (p = 0.1756); 23.08% lympho-vascular invasion (p = 0.0048); and 13.46% of cases locoregional nodal invasion (p = 0.0092). Conclusions: Thyroid cancer in young people was associated with chronic lymphocytic thyroiditis and tumor progression parameters, identifying more cases of extrathyroidal extension, locoregional nodal invasion, lympho-vascular invasion and perineural invasion in young patients compared to older ones. For a better understanding of this pathology and to improve diagnosis and therapeutic management, more studies are needed for these patients.

A nomogram based on clinicopathological and ultrasound characteristics to predict central neck lymph node metastases in papillary thyroid cancer

Purpose

Papillary thyroid cancer (PTC) has grown rapidly in prevalence over the past few decades, and central neck lymph node metastasis (CNLNM) is associated with poor prognoses. However, whether to carry out preventive central neck lymph node dissection (CNLND) is still controversial. We aimed to construct a prediction model of CNLNM to facilitate making clinical surgical regimens.

Methods

A total of 691 patients with PTC between November 2018 and December 2021 were included in our study. Univariate and multivariate analyses were performed on basic information and clinicopathological characteristics, as well as ultrasound characteristics (American College of Radiology (ACR) scores). The prediction model was constructed and performed using a nomogram, and then discriminability, calibrations, and clinical applicability were evaluated.

Results

Five variables, namely, male, age >55 years, clinical lymph node positivity, tumor size ≥1 cm, and ACR scores ≥6, were independent predictors of CNLNM in the multivariate analysis, which were eventually included to construct a nomogram model. The area under the curve (AUC) of the model was 0.717, demonstrating great discriminability. A calibration curve was developed to validate the calibration of the present model by bootstrap resampling, which indicated that the predicted and actual values were in good agreement and had no differentiation from the ideal model. The decision curve analysis (DCA) indicated that the prediction model has good clinical applicability.

Conclusions

Our non-invasive prediction model combines ACR scores with clinicopathological features presented through nomogram and has shown good performance and application prospects for the prediction of CNLNM in PTCs.

Asiaticoside Down-Regulates HIF-1α to Inhibit Proliferation, Migration, and Angiogenesis in Thyroid Cancer Cells

Background

Thyroid cancer (TC), the most prevalent endocrine malignancy, has been subjected to various treatment methods. However, the efficacy of asiaticoside (AC) for treating TC remains uncertain.

Aims

To explore the impact of AC on TC and determine its potential mechanisms of action.

Study Design

In vitro and in vivo cell line study.

Methods

We evaluated the effects of AC on human TC cell lines, namely TPC-1 and FTC-133. Both in vitro and in vivo experimental validations were conducted.

Results

AC significantly diminished the viability and proliferation of TC cells based on the CCK-8 assay and Edu staining findings. Migration and invasion assays revealed that AC effectively curtailed the migration and invasiveness of TC cells. The tube formation assay demonstrated that AC substantially impeded TC cell-induced angiogenesis. Western blot assay revealed that AC significantly reduced the expression levels of TRAF6, HIF-1α, and VEGFA, indicating that AC could potentially exert its anticancer effect by inhibiting the TRAF6/HIF1α pathway. Our in vivo experiments, which involved administering AC to BALB/c nude mice injected with TPC-1 cells, demonstrated significant inhibition of tumor growth and reduction in the expression of Ki-67, TRAF6, HIF-1α, and VEGFA.

Conclusion

Our study highlights the significant inhibitory effect of AC on TC, offering fresh insights and potential drug candidates for TC treatment.

Partial Thyroidectomy With Incidental Metastatic Lymph Nodes

Importance

The need for completion thyroidectomy in patients with incidental metastatic lymph nodes after partial thyroidectomy is unclear.

Objective

To investigate the outcomes of patients with incidental metastatic lymph nodes following partial thyroidectomy.

Design, Setting, and Participants

A retrospective review of a prospectively maintained thyroid cancer database from 1985 to 2015 was carried out at a head and neck surgery practice at a tertiary referral cancer center. A total of 74 patients who underwent thyroid lobectomy or thyroid isthmusectomy between 1985 and 2015 and were found to have incidental metastatic lymph nodes on final pathologic analysis and were selected to be observed without immediate completion thyroidectomy were included. A separate group of additional 11 patients who underwent immediate completion thyroidectomy was also identified and reviewed.

Main Outcome and Measure

Analysis took place from February to May 2022. Recurrence-free survival outcomes of patients found to have incidental metastatic lymph nodes on final pathologic analysis following partial thyroidectomy with no immediate completion thyroidectomy.

Results

A total of 74 patients were observed, with a median (IQR) age of 39 (28-49) years; 44 (59%) were women. Sixty-four patients underwent thyroid lobectomy and 10 patients had isthmusectomy. Classic papillary thyroid carcinoma was the most common histologic type (34 [46%]). Vascular invasion and microscopic extrathyroidal extension were present in 11 patients (16%) and 22 patients (30%), respectively. Positive margins were identified in 5 patients (7.8%). Size of metastatic lymph nodes ranged between 0.07 cm and 1.2 cm. No extranodal extension was reported. A total of 52 patients (70%) were classified as intermediate risk for recurrence based on the American Thyroid Association risk stratification system. The median (IQR) follow up was 48.15 (15.4-86.1) months, during which only 1 patient had a regional recurrence. Another patient underwent delayed completion thyroidectomy for a contralateral lobe malignant abnormality. Recurrence-free survival, disease-specific survival, and overall survival were 97.4%, 100%, and 96.2%, respectively. A separate group of 11 patients who underwent immediate completion thyroidectomy were reviewed. These patients were more likely to have tall-cell papillary thyroid carcinoma (6 [55%] vs 13 [18%]), multifocality (9 [82%] vs 28 [41%]), microscopic extrathyroidal extension (8 [73%] vs 22 [30%]), and positive margins (3 [30%] vs 5 [7.8%]) compared with patients who were under observation only.

Conclusion and Relevance

Completion thyroidectomy may not be necessary in appropriately selected patients who are found to have incidental metastatic lymph nodes (N1a) after partial thyroidectomy for localized well-differentiated thyroid cancer.

A combination of computed tomography scan and ultrasound provides optimal detection of cervical lymph node metastasis in papillary thyroid carcinomas: A systematic review and meta-analysis

BACKGROUND

Lymph node metastasis (LNM) in patients with papillary thyroid carcinoma (PTC) is common. This meta-analysis assesses the diagnostic accuracy of computed tomography (CT), ultrasound (US), and CT + US in detecting central and lateral LNM.

METHODS

A systematic review and meta-analysis was performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The area under the curve (AUC) for summary receiver operating curves (sROC) were compared.

RESULTS

The study population included 7902 patients with a total of 15 014 lymph nodes. Twenty-four studies analyzed the sensitivity of the overall neck region in which dual CT + US imaging (55.9%) had greater sensitivities (p < 0.001) than either US (48.4%) or CT (50.4%) alone. The specificity of US alone (89.0%) was greater (p < 0.001) than CT alone (88.5%) or dual imaging (86.8%). The DOR for dual CT + US imaging was greatest (p < 0.001) at 11.134, while the AUCs of the three imaging modalities were similar (p > 0.05). Twenty-one studies analyzed the sensitivity of the central neck region in which both CT (45.8%) and CT + US imaging (43.4%) had greater sensitivities (p < 0.001) than US alone (35.3%). The specificity of all three modalities was higher than 85%. The DOR for CT (7.985) was greater than US alone (4.723, p < 0.001) or dual CT + US imaging (4.907, p = 0.015). The AUC of both CT + US (0.785) and CT alone (0.785) were significantly greater (p < 0.001) than US alone (0.685). Of the 19 studies that reported lateral LNM, CT + US imaging sensitivity (84.5%) was higher than CT alone (69.2%, p < 0.001) and US alone (79.7%, p = 0.038). The specificity of all imaging techniques was all greater than 80.0%. CT + US imaging DOR (35.573) was greater than CT (20.959, p = 0.024) and US (15.181, p < 0.001) individually. The AUC of independent imaging was high (CT: 0.863, US: 0.858) and improved significantly when combined (CT + US: 0.919, p = 0.024 and p < 0.001, respectively).

CONCLUSIONS

We report an up-to-date analysis elucidating the diagnostic accuracy of LNM detection by either CT, US, or in combination. Our work suggests dual CT + US to be the best for overall detection of LNM and CT to be preferable in detecting central LNM. The use of either CT or US alone may detect lateral LNM with acceptable accuracy, yet dual imaging (CT + US) significantly improved detection rates.

Role of prophylactic central neck lymph node dissection for papillary thyroid carcinoma in the era of de-escalation

Thyroid cancer is the most common endocrine malignancy. While there has been no appreciable increase in the observed mortality of well-differentiated thyroid cancer, there has been an overall rise in its incidence worldwide over the last few decades. Patients with papillary thyroid carcinoma (PTC) and clinical evidence of central (cN1) and/or lateral lymph node metastases require total thyroidectomy plus central and/or lateral neck dissection as the initial surgical treatment. Nodal status in PTC patients plays a crucial role in the prognostic evaluation of the recurrence risk. The 2015 guidelines of the American Thyroid Association (ATA) have more accurately determined the indications for therapeutic central and lateral lymph node dissection. However, prophylactic central neck lymph node dissection (pCND) in negative lymph node (cN0) PTC patients is controversial, as the 2009 ATA guidelines recommended that CND "should be considered" routinely in patients who underwent total thyroidectomy for PTC. Although the current guidelines show clear indications for therapeutic CND, the role of pCND in cN0 patients with PTC is still debated. In small solitary papillary carcinoma (T1, T2), pCND is not recommended unless there are high-risk prediction factors for recurrence and diffuse nodal spread (extrathyroid extension, mutation in the BRAF gene). pCND can be considered in cN0 disease with advanced primary tumors (T3 or T4) or clinical lateral neck disease (cN1b) or for staging and treatment planning purposes. The role of the preoperative evaluation is fund-amental to minimizing the possible detrimental effect of overtreatment of the types of patients who are associated with low disease-related morbidity and mortality. On the other hand, it determines the choice of appropriate treatment and determines if close monitoring of patients at a higher risk is needed. Thus, pCND is currently recommended for T3 and T4 tumors but not for T1 and T2 tumors without high-risk prediction factors of recurrence.

Nomograms for Prediction of High-Volume Lymph Node Metastasis in Papillary Thyroid Carcinoma Patients

OBJECTIVE

The coexistence rate between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) is quite high. Whether CLT influences metastatic lymph nodes remains uncertain. High-volume lymph node metastasis is recommended as an unfavorable pathological feature. We aimed to investigate risk factors for high-volume central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) in PTC patients.

STUDY DESIGN

Retrospective cohort study.

SETTING

Changzhou First People's Hospital.

METHODS

Clinicopathological characteristics of 1094 PTC patients who underwent surgery in our center from January 2019 to November 2021 were analyzed.

RESULTS

The number of metastatic lymph nodes in the central compartment and lateral compartment were lower in the CLT group. We demonstrated that age, BRAF V600E, shape, and the number of foci were risk factors for high-volume CLNM in patients with CLT. For patients without CLT, sex, age, tumor size, number of foci, and margin were risk factors for high-volume CLNM. Tumor size, number of foci, location, and CLNM were all risk factors for high-volume LLNM in patients with or without CLT. Body mass index was only associated with high-volume LLNM in CLT patients. All the above factors were incorporated into nomograms, which showed perfect discriminative ability.

CONCLUSION

Separate predictive systems should be used for CLT and non-CLT patients for a more accurate clinical assessment of lymph node status. Our nomograms of predicting high-volume CLNM and LLNM could facilitate risk-stratified management of PTC recurrence and treatment decisions.

A comparative analysis of treatment efficacy in intermediate-risk thyroid cancer

PURPOSE

This study aimed to evaluate the efficacy of different treatment combinations on patient survival in intermediate-risk differentiated thyroid cancer (DTC).

METHODS

The 2004-2017 National Cancer Database was queried for intermediate-risk papillary (PTC), follicular (FTC), or Hurthle cell (HTC) thyroid cancer patients. Four treatments were analyzed using Kaplan Meier and multivariable Cox regression: surgery, surgery with adjuvant radioiodine ablation (S + RAI), surgery with adjuvant thyroid-stimulating hormone suppression therapy (S + THST), and S + RAI + THST. Kaplan-Meier and multivariable Cox proportional-hazards analyses evaluated treatment-associated overall survival (OS).

RESULTS

Of 65,736 patients, 72.2% were female and the average age was 45.4 ± 15.4 years. The 10-year OS rates for PTC, FTC, and HTC were 93.2%, 85.2%, and 78.5%, respectively. S + RAI + THST exhibited higher OS than surgery alone and S + RAI (all p < 0.05). Compared to surgery alone, S + RAI + THST demonstrated reduced mortality in PTC (Hazard Ratio [HR]: 0.628, p < 0.001), FTC (HR: 0.490, p < 0.001), and HTC (HR: 0.520, p = 0.006). Similarly, adjuvant RAI + THST reduced mortality regardless of lymphovascular invasion (HR: 0.490, p < 0.001), N1a (HR: 0.570, p < 0.001) or N1b metastasis (HR: 0.621, p < 0.001), or positive margin status (HR: 0.572, p < 0.001).

CONCLUSIONS

Treatment combinations demonstrated varying efficacies in intermediate-risk DTC depending on histology and tumor characteristics, with S + RAI + THST exhibiting the greatest treatment response.

Frozen section analysis of central lymph nodes in papillary thyroid cancer: the significance in determining the extent of surgery

BACKGROUND

The indolent feature of papillary thyroid cancer (PTC) has recently led to an increase in less aggressive treatment options instead of total thyroidectomy (TT). We aimed to investigate the clinical significance of elective central compartment neck dissection (CCND) with intraoperative frozen analyses of the central lymph nodes (LNs) to determine the surgical extent of unilateral clinically node-negative PTC.

METHODS

We retrospectively reviewed the medical records of 290 patients with unilateral clinically node-negative PTC who underwent surgery and performed frozen analyses of the central LNs from 2020 to 2021 using our own nodal criteria with cut-off size 5 mm. The patients were divided and investigated according to the surgical extent and the National Comprehensive Cancer Network (NCCN) guidelines; diagnostic accuracy of the frozen analyses was estimated.

RESULTS

TT was performed in 16.2% of patients. The TT group had more metastatic nodes with a larger size, higher LN ratio (LNR), and more extranodal extension. The analyses based on the NCCN guidelines showed similar findings, but more completion TT was required compared with our criteria. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the frozen analyses were 94.6%, 100%, 100%, and 96.1%, respectively.

CONCLUSIONS

Elective CCND with intraoperative frozen analyses is a highly reliable procedure that detects occult nodal metastasis in unilateral node-negative PTC patients. Our nodal criteria yielded significant aggressive nodal characteristics in the TT group while yielding less TTs compared with the NCCN guidelines. The concept and clinical significance of small-volume nodal metastasis in PTC should be further investigated.

Thoracoscopy-assisted treatment for mediastinal metastasis of thyroid cancer: a case report

Advanced thyroid cancer with upper mediastinal lymph node metastasis is not rare in the clinical setting. For patients with severe metastasis, a thoracocervical incision is usually performed for dissection of lymph nodes. However, the difficult operation of three-port thoracoscopy to support performance of a cervical incision in the treatment of upper mediastinal lymph node metastasis has rarely been reported to date. We herein describe a case involving the treatment of thyroid cancer with upper mediastinal lymph node metastasis. The lymph node metastasis was severe, closely adhered to the innominate vein, and fused into a mass. Thoracoscopy with a cervical incision was performed and proved to be a highly difficult surgical maneuver. The patient recovered quickly after the operation. Repeat computed tomography showed no swollen metastatic lymph nodes, indicating that the dissection was thorough. Thoracoscopy with a neck incision is more difficult than conventional longitudinal split sternotomy in the treatment of upper mediastinal lymph node metastasis, but its advantages are less severe trauma and faster recovery. This procedure may be performed by surgeons with proficient skill in cervical surgery and thoracoscopy techniques.

Thyroglobulin in lymph node fine-needle aspiration biopsy washout fluid. A tertiary center experience

Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Most PTC secretes thyroglobulin, a useful marker in monitoring preoperative staging and postoperative progression; in addition to serum thyroglobulin, fine needle aspiration washout thyroglobulin (FNA-Tg) is also used. Our aim was to determine the cut-off value for FNA-Tg in our center and to describe major discrepancies between FNA-Tg, cytology and pathology results of the lymph nodes. Methods: We retrospectively retrieved from the electronic database of our endocrinology center all the FNA-Tg measurements between December 10, 2019 and September 2021. For each measurement we also retrieved the corresponding sex, FNAB results and the pathology reports. FNA-Tg was measured by ECLIA immunoelectro-chemiluminescent method. Results: There were 58 FNAB and FNA-Tg of suspect cervical lymph nodes in 40 patients. There were 17 cytologically benign lymph nodes of which 13 had low and 4 had high FNA-Tg; 3 non-diagnostic cytology results of which one had high FNA-Tg; 38 PTC metastases of which 6 had low and 32 had high FNA-Tg titers. The cut-off value of FNA-Tg in our center is 10 ng/ml, with a sensitivity of 86.6% (in those with pathology reports available after surgery). Conclusions: Washout TG is useful in suspicious lymph nodes and has added value to cytology in selected cases. The cut-off value of FNA-Tg in our center is 10 ng/ml, with a sensitivity of 86.6%. However, we must consider the possible false negative results that may occur in some histological types of PTC.

Predictors of Response to Therapy Among Post Thyroidectomy Adult Filipino Patients with Papillary Thyroid Carcinoma Based on the 2015 American Thyroid Association Guidelines

Objective

To identify factors independently associated with incomplete response to therapy based on the 2015 ATA guidelines in surgically treated Filipino patients with papillary thyroid carcinoma (PTC).

Methodology

This is a retrospective cohort study of adults aged 21-74 years with papillary thyroid carcinoma (PTC) treated with surgery with or without radioactive iodine therapy (RAI) in Makati Medical Center from 2013 to 2017. We collected the following factors through a review of charts: age at diagnosis, gender, family history of thyroid cancer, date of surgery, tumor size, capsular/lymphovascular invasion, lymph node/distant metastases, stage, risk of recurrence, dose of post-surgical RAI therapy, initial post-treatment serum Thyroglobulin (Tg) and anti-Tg antibody levels (Negative Tg level: suppressed non-stimulated Tg <0.2 ng/mL or TSH-stimulated Tg <1 ng/mL; Positive Tg level: suppressed Tg ≥1 ng/mL or a TSH-stimulated Tg ≥10 ng/mL or rising anti-Tg antibody levels), thyroid stimulating hormone suppression, post-operative imaging studies and levothyroxine dose. Response to therapy was checked 6-24 months post-therapy.

Results

We analyzed a total of 115 patients with PTC who underwent thyroidectomy. Patients who had family history of thyroid cancer were less likely to have an incomplete or indeterminate response (p=0.045). None of the patients with excellent response had lymphovascular invasion. Having a positive Tg (p=0.001) and positive anti-Tg post-operatively (p<0.001) were strongly associated with incomplete or indeterminate response.

Conclusion

Patients who were positive for thyroglobulin and anti-thyroglobulin post-operatively were strongly associated with incomplete or indeterminate response to therapy in PTC.

Identification of soluble tissue-derived biomarkers from human thyroid tissue explants maintained on a microfluidic device

Although a large cohort of potential biomarkers for thyroid cancer aggressiveness have been tested in various formats in recent years, to the best of our knowledge, thyroglobulin and calcitonin remain the only two established biomarkers associated with thyroid cancer management. Our group has recently validated a novel means of maintaining live, human ex vivo thyroid tissue within a tissue-on-chip format. The present pilot study aimed to interrogate the tissue effluent, containing all the soluble markers released by the tissue samples maintained within the devices' tissue chamber, for the presence of markers potentially associated with thyroid cancer aggressiveness. Culture effluent from tissue samples harvested from 19 individual patients who had undergone thyroidectomy for the treatment of suspected thyroid cancer was assessed, first using a proteome profiler™ angiogenesis array kit. Patients were subcategorised as 'aggressive' if they possessed a minimum of N1b level metastases, whilst 'non-aggressive' samples were T3 or lower without evidence of multifocality; and contralateral healthy thyroid tissue was harvested for comparative studies. Levels of Serpin-F1, vascular endothelial growth factor, Thrombospondin-1 and chemokine (C-C motif) ligand were significantly altered and, thus, were further investigated using ELISA to allow for quantitative analysis. The concentration of serpin-F1 was significantly increased in the effluent of aggressive thyroid cancer tissue when compared with levels released by both non-aggressive and benign samples. The present study demonstrated the usability of microfluidic technology for the analysis of the ex vivo tissue secretome in order to identify novel biomarkers.

Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma: All Risks, No Reward

BACKGROUND

Central neck dissection (CND) remains a controversial intervention for papillary thyroid carcinoma (PTC) patients with clinically negative nodes (cN0) in the central compartment. Proponents state that CND in cN0 patients prevents locoregional recurrence, while opponents deem that the risks of complications outweigh any potential benefit. Thus, there remains conflicting results amongst studies assessing oncologic and surgical outcomes in cN0 PTC patients who undergo CND. To provide clarity to this controversy, we sought to evaluate the efficacy, safety, and oncologic impact of CND in cN0 PTC patients at our institution.

MATERIALS AND METHODS

Six hundred and ninety-five patients with PTC who underwent thyroidectomy at our institution between 1998 and 2018 were identified using an institutional cancer registry and supplemental electronic medical record queries. Patients were stratified by whether or not they underwent CND; identified as CND(+) or CND(-), respectively. Patients were also stratified by whether or not they received adjuvant radioactive iodine (RAI) therapy. Patient demographics, pathologic results, as well as surgical and oncologic outcomes were reviewed. Standard statistical analyses were performed using ANOVA and/or t-test and chi-squared tests as appropriate.

RESULTS

Among the 695 patients with PTC, 492 (70.8%) had clinically and radiographically node negative disease (cN0). The mean age was 50 ± 1 years old and 368 (74.8%) were female. Of those with cN0 PTC, 61 patients (12.4%) underwent CND. CND(+) patients were found to have higher preoperative thyroid stimulating hormone (TSH) values, 2.8 ± 0.8 versus 1.5 ± 0.2 mU/L (P = 0.028) compared to CND(-) patients. CND did not significantly decrease disease recurrence, development of distant metastatic disease (P = 0.105) or persistence of disease (P = 0.069) at time of mean follow-up of 38 ± 3 months compared to CND(-) patients. However, surgical morbidity rates were significantly higher in CND(+) patients; including transient hypocalcemia (36.1% versus 14.4%; P < 0.001), transient recurrent laryngeal nerve (RLN) injury (19.7% vers us 7.0%; P < 0.001), and permanent RLN injury (3.3% versus 0.7%; P < 0.001).

CONCLUSIONS

The majority of patients at our institution with cN0 PTC did not undergo CND. This data suggests that CND was not associated with improvements in oncologic outcomes during the short-term follow-up period and led to increased postoperative morbidity. Therefore, we conclude that CND should not be routinely performed for patients with cN0 PTC.

Disease-free Survival of Patients with Differentiated Thyroid Cancer: A Study from a Tertiary Center in Oman

Objectives

As with global trends, the prevalence of differentiated thyroid cancer (DTC) has increased in recent years in Oman. However, to the best of our knowledge, no local studies have yet been published evaluating the prognosis of DTC cases in Oman. This study aimed to assess disease-free survival (DFS) and prognostic factors related to DTC among Omani patients attending a tertiary care center.

Methods

This retrospective, observational cohort study was conducted between January 2006 and May 2016 at the National Diabetes and Endocrine Center in Oman. Data related to DFS and prognostic factors were obtained from the electronic medical records of all ≥ 18-year-old patients diagnosed with DTC during the study period.

Results

A total of 346 DTC cases were identified. Overall, 82.7% of patients were disease-free at their last follow-up appointment. Univariate analysis indicated that various tumor characteristics including histological subtype (i.e., papillary carcinoma, Hurthle cell cancer, and minimally invasive follicular thyroid carcinoma), lymph node status, number of lymph node metastases, distant metastasis status, and TNM status (primary tumor (T), regional lymph node (N), distant metastasis (M) stage) were strong prognostic factors for DFS (p < 0.050). According to multivariate regression analysis, lymph node status, extrathyroidal extension, and angiovascular invasion were independent predictors of DFS (p < 0.050).

Conclusions

The overall prognosis of DTC among Omani patients was excellent. Treatment and follow-up strategies for patients with DTC should be tailored based on the individual’s risk factor profile.

Diagnostic Model Incorporating Clinicopathological Characteristics of Delphian Lymph Node Metastasis Risk Profiles in Papillary Thyroid Cancer

The Delphian lymph node (DLN), also known as the prelaryngeal node, is one component of the central lymph node. The DLN has been well studied in laryngeal cancer, although its significance in papillary thyroid cancer (PTC) remains unclear. We retrospectively analyzed 936 patients with PTC who underwent thyroidectomy by a single surgeon in Tianjin Cancer Hospital from 2017 to 2019. Moreover, 250 PTC patients who underwent thyroidectomy by another surgeon in Tianjin Cancer Hospital from January 2019 to April 2019 were used as a validation cohort. Among the 936 patients with PTC, 581 patients (62.1%) had DLNs, of which 177 samples with metastasis (177/581, 30.5%) were verified. DLN metastasis was significantly correlated with sex, age, tumor size, bilateral cancer, multifocality, extrathyroidal extension, lymphovascular invasion and central and lateral neck lymph node metastasis. Multivariate analysis revealed that independent risk factors for DLN metastasis included age, gender, tumor size, extrathyroid extension, lymphovascular invasion and central lymph node metastasis, which determined the nomogram. In particular, tumor size was proven to be one of the most predominant single predictors. The diagnostic model had an area under the curve (AUC) of 0.829 (95% confidence interval, 0.804-0.854). The internal and external validations of the nomogram were 0.819 and 0.745, respectively. Our results demonstrate that DLN metastasis appears to be a critical parameter for predicting metastatic disease of the central compartments. Furthermore, this study provides a precise criterion for assessing DLN metastasis and has great clinical significance for treating PTC.

Decline in radioiodine use but not total thyroidectomy in thyroid cancer patients treated in the United Arab Emirates - A retrospective study

Objectives

To assess the trend of clinicopathological features and treatment modalities in patients with thyroid cancer (TC) in the largest oncology center in the United Arab Emirates (UAE).

Methods

A retrospective analysis of patients with TC presenting to a tertiary care hospital in Al Ain, UAE between September 2008 and December 2018 identified using ICD 9 & 10 codes was performed. Data on demographics, histopathology, surgical extent, and use of Radioiodine (RAI) were extracted. Exact logistic and ordinal logistic regressions were performed to analyze the annual trend in features and management of TC, and logistic regression analysis was performed to identify predictors of total thyroidectomy and RAI use.

Results

A total of 762 patients were included in the analysis (mean age: 39.6 ± 12.6 years, 45 (60%) women). The majority (92.2%) were diagnosed with papillary thyroid cancer (PTC) and 83.9% had tumor size of <4 cm. All patients underwent surgery (93.8% total thyroidectomy, 6.2% lobectomy) and 77.4% received RAI therapy overall with a significant (p < 0.001) decline from 100% in 2008 to 60% in 2018. In multivariate analysis, nationality, and lymph node (LN) involvement were significant predictors of total thyroidectomy, while nationality, LNs, year of diagnosis, and tumor size significantly predicted RAI use.

Conclusion

Most patients in our cohort were diagnosed with localized PTC with no significant change in the extent of surgical approach but a substantial decline in RAI therapy administration over time. Nationality and LN involvement were significant predictors of surgical extent and RAI use.

•

This is the largest study evaluating clinicopathological features and treatment modalities in TC patients in the UAE.

•

Most patients were diagnosed with localized PTC.

•

A substantial decline in RAI therapy administration but not the extent of thyroidectomy was observed during the study period.

•

Nationality and LN involvement were significant predictors of surgical extent and RAI use.

Simultaneous targeting of primary tumor, draining lymph node, and distant metastases through high endothelial venule-targeted delivery

Cancer patients with malignant involvement of tumor-draining lymph nodes (TDLNs) and distant metastases have the poorest prognosis. A drug delivery platform that targets the primary tumor, TDLNs, and metastatic niches simultaneously, remains to be developed. Here, we generated a novel monoclonal antibody (MHA112) against peripheral node addressin (PNAd), a family of glycoproteins expressed on high endothelial venules (HEVs), which are present constitutively in the lymph nodes (LNs) and formed ectopically in the tumor stroma. MHA112 was endocytosed by PNAd-expressing cells, where it passed through the lysosomes. MHA112 conjugated antineoplastic drug Paclitaxel (Taxol) (MHA112-Taxol) delivered Taxol effectively to the HEV-containing tumors, TDLNs, and metastatic lesions. MHA112-Taxol treatment significantly reduced primary tumor size as well as metastatic lesions in a number of mouse and human tumor xenografts tested. These data, for the first time, indicate that human metastatic lesions contain HEVs and provide a platform that permits simultaneous targeted delivery of antineoplastic drugs to the three key sites of primary tumor, TDLNs, and metastases.

Comparison of the diagnostic performances of US-guided fine needle aspiration cytology and thyroglobulin measurement for lymph node metastases in patients with differentiated thyroid carcinoma: a meta-analysis

OBJECTIVES

Ultrasound (US)-guided fine needle aspiration cytology (FNAC) and thyroglobulin measurement (FNA-Tg) are two common methods for confirming lymph node metastases (LNM) in patients with differentiated thyroid carcinoma (DTC). This study aimed at comparing the diagnostic performance of FNAC, FNA-Tg alone, and in combination by means of a meta-analysis.

METHODS

Eligible articles were selected according to predefined criteria, and their quality was evaluated as per the QUADAS-2 checklist. We calculated pooled sensitivity (Se), specificity (Sp), positive/negative likelihood ratio, and diagnostic odds ratio (DOR), and plotted the summary receiver operating characteristic (SROC) curve using the Meta-DiSc1.4 software.

RESULTS

Twenty-one studies pooling 1662 malignant and 1279 benign LNs from 2712 patients with DTC were included. The results showed that FNAC was more specific (pooled Sp, 0.98) while FNA-Tg was more sensitive (pooled Se, 0.94). FNAC and FNAC+FNA-Tg performed better postoperatively than FNA-Tg, while FNA-Tg performed better preoperatively. The combination of FNAC and FNA-Tg could achieve a better diagnostic performance than each alone (DOR 446.00, area under the curve [AUC] 0.9862), no matter preoperatively (DOR 378.14, AUC 0.9879) or postoperatively (DOR 788.72, AUC 0.9930). Besides, the combination of FNAC and FNA-Tg/serum-Tg ratio obtained a higher Sp (0.98) than the combination of FNAC and FNA-Tg.

CONCLUSION

The addition of FNA-Tg, especially the FNA-Tg/serum-Tg ratio, to FNAC could increase the diagnostic performance of LNM in both preoperative and postoperative patients with DTC. Since one test or test combinations could perform differently according to the clinical situation, the best-fitting test should be chosen accordingly.

KEY POINTS

• FNAC is more specific than FNA-Tg while FNA-Tg is more sensitive than FNAC. • The combination of FNAC and FNA-Tg could achieve a better diagnostic performance than either alone, no matter preoperatively or postoperatively. • The combination of FNAC and FNA-Tg/serum-Tg ratio could reach a higher Sp than the combination of FNAC and FNA-Tg.

Ultrasonography for the Prediction of High-Volume Lymph Node Metastases in Papillary Thyroid Carcinoma: Should Surgeons Believe Ultrasound Results?

Background

Lymph node metastasis (LNM) often occurs in papillary thyroid carcinoma (PTC); the efficacy of ultrasound for predicting high-volume lymph node metastases (LNMs) in patients with PTC remains unexplored.

Methods

The medical records of 2073 consecutive PTC patients were reviewed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate the efficacy of ultrasound. Risk factors for LNM/high-volume LNMs and lymph node involvement on ultrasound (usLNM) were identified by univariate and multivariate analyses.

Results

Of all the patients, 936 (45.2%) patients had LNMs, and 254 (12.3%) patients had high-volume LNMs. The sensitivity of ultrasound for detecting LNM/high-volume LNMs was 27.9% and 63.8%, respectively; the specificity was 93.1% and 90.3%, respectively. The NPV for ultrasound in detecting high-volume LNMs was 94.7%. In multivariate analysis, male sex (OR = 2.108, p < 0.001), tumor diameter > 1.0 cm (OR = 2.304, p < 0.001) and usLNM (+) (OR = 12.553, p < 0.001) were independent clinical risk factors for high-volume LNMs. Tumor diameter > 1 cm (OR = 3.036, p < 0.001) and male sex (OR = 1.642, p < 0.001) were independent clinical risk factors for usLNM; a skilled sonographer (OR = 1.121, p = 0.358) was not significantly associated with usLNM.

Conclusions

Lymph node involvement found by ultrasound has great predictive value for high-volume LNMs; the NPV is very high for patients without lymph node involvement on ultrasound. The ultrasound results do not appear to be influenced by the experience of the sonographer.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05755-0) contains supplementary material, which is available to authorized users.

The Benefit of Primary Tumor Surgical Resection in Distant Metastatic Carcinomas of the Thyroid

OBJECTIVES/HYPOTHESIS

Thyroid cancer with distant metastasis (TCDM) at diagnosis has significantly worse survival rates when compared to localized/regional thyroid cancer. This study sought to report on the characteristics of patients presenting with TCDM and the potential survival advantage of surgical resection.

STUDY DESIGN

Data were acquired from the Surveillance, Epidemiology, and End Results (SEER) database with cases from 2004 to 2015.

METHODS

TCDM cases (n = 2,558) were identified from the SEER database. The Bonferroni correction was applied for multivariate analysis. Kaplan-Meier analysis was utilized to obtain disease-specific survival (DSS) rates. Cox regression analysis was utilized to identify independent factors significantly associated with survival.

RESULTS

The average age of diagnosis of TCDM was 62.0 (±17.5) years. Patients were predominantly white (74.6%), female (54.6%), in a relationship (56.0%), and between ages 36 and 80 years (76.4%). Cases consisted of papillary (57.2%), follicular (16.0%), medullary (8.9%), anaplastic (17.9%) TCDM histological variants. Overall 1-, 5-, and 10-year DSS rates were 72.0%, 56.8%, and 43.8%, respectively. Anaplastic and medullary variants had the worst 10-year DSS (0% and 25.5%, respectively). Patients who underwent surgical resection only and surgical resection with radiation were 49% and 59% less likely to die, respectively. Treatment, age, histology, T staging, relationship status, and metastasis site were determined to be significant predictors of survival.

CONCLUSIONS

Surgical resection with radiation was found to be a significant predictor of survival after applying the Bonferroni correction for all thyroid cancer variants except medullary. To increase survival, surgical intervention should be recommended in patients who are deemed to be medically tolerant of surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1026-1034, 2021.

Modified risk stratification based on cervical lymph node metastases following lobectomy for papillary thyroid carcinoma

OBJECTIVE

Evidence for American Thyroid Association (ATA) risk stratification stems largely from studies involving patients undergoing total thyroidectomy. We aimed to assess the risk of recurrence according to the present ATA risk stratification system in patients who underwent lobectomy.

DESIGN

Retrospective cohort study.

PATIENTS

Patients who underwent thyroid lobectomy for 1-4 cm-sized papillary thyroid carcinoma (n = 571).

MEASUREMENTS

Disease-free survival (DFS) was compared according to the ATA risk stratification, and specific lymph node (LN) characteristics were evaluated to modify the ATA criteria with a higher predictability for recurrence.

RESULTS

Based on the ATA risk stratification, 439 patients (61.1%) were classified into intermediate- or high-risk group, and consideration for completion thyroidectomy is suggested by ATA guidelines for these patients. However, no significant differences were found in DFS among the low-, intermediate- and high-risk groups (P = .9). In contrast, when patients were stratified according solely to the LN criteria from the ATA risk stratification, only 127 patients (22.2%) had intermediate risk (intermediate-N1a) and exhibited significantly poorer DFS than those with N0 disease (P = .035). Modifying the intermediate-N1a criteria by adding the extranodal extension (ENE) status and omitting the clinical nodal disease enabled the subclassification of 19 patients (3%) with a high risk for recurrence.

CONCLUSIONS

The present study suggests that risk stratification based solely on LN metastases is more reasonable for predicting structural persistence/recurrence following lobectomy than that based on the overall ATA criteria. Considering the ENE status can assist in selecting patients with a high risk of recurrence to minimize further treatments.

Total thyroidectomy versus thyroid lobectomy in the treatment of papillary carcinoma

Extent of thyroidectomy for papillary thyroid carcinoma is still matter of debate. Indeed, recently, international guidelines endorsed thyroid lobectomy as initial surgical approach for low risk, small medium-sized (T1-T2), N0 papillary thyroid carcinoma in absence of extrathyroidal extension. When dealing with a conservative surgery for oncologic disease is of utmost importance to exclude effectively more advanced disease, which could benefit from a more aggressive initial operation. However, in the setting of surgery for papillary thyroid carcinoma, despite an accurate preoperative work up could led to identify some suspicious characteristics as macroscopic evidence of multifocality or extrathyroidal extension, and/or evidence of lateral neck lymph node metastases, it is difficult to reliably assess the central neck nodal status both pre- and intra-operatively. Frozen section examination of the central neck nodes ipsilateral to the side of the tumor has been proposed in patients scheduled for thyroid lobectomy, in order to modulate the extension of both thyroidectomy and central neck dissection. Future molecular and genetic evidences are needed to establish high-risk patients with small papillary thyroid carcinoma in which thyroid lobectomy could be not and adequate surgical treatment.

miR-3619-3p promotes papillary thyroid carcinoma progression via Wnt/β-catenin pathway

BACKGROUND

It is well known that the dysregulation of microRNAs (miRNAs) has been identified in papillary thyroid carcinoma (PTC), but their roles in the progression and metastasis of PTC remain unclear. MicroRNA-3619-3p (miR-3619-3p) is associated with cancer progression as an oncogene which is predicted to target at the Wnt/β-catenin signaling pathway. Our study aimed to investigate the role of miR-3619-3p on PTC cell migration and invasion, as well as the underlying mechanisms.

METHODS

The expression of miR-3619-3p in 36 PTC tissues and corresponding tumor-adjacent tissues, as well as 3 PTC cell lines (BCPAP, K1, TPC-1) and the normal thyroid epithelial cell line (N-thy-ori 3-1) were detected by quantitative real-time polymerase chain reaction (qRT-PCR). The relationship between miR-3619-3p expression and clinicopathologic status of PTC patients was analyzed. Migration, invasion, and wound healing, were used to evaluate the role of miR-3619-3p in PTC. The activation of β-catenin and the possible molecular pathway were detected by western blotting.

RESULTS

The expression of miR-3619-3p in PTC tissues was significantly higher than the corresponding tumor-adjacent tissues (P<0.01), and its high expression positively correlated with extrathyroidal invasion, multicentricity, and cervical lymph node metastasis. Moreover, the miR-3619-3p was also up-regulated in PTC cell lines when compared to N-thy-ori 3-1. MiR-3619-3p enhanced the capabilities of migration and invasion in PTC cell lines. Furthermore, miR-3619-3p activated Wnt/β-catenin pathway via maintaining the mRNA stability of β-catenin.

CONCLUSIONS

miR-3619-3p promoted PTC cell migration and invasion as an oncogene via activating the Wnt/β-catenin pathway through increasing the stability of β-catenin.

Upregulation of sphingosine kinase 1 is associated with recurrence and poor prognosis in papillary thyroid carcinoma

Sphingosine kinase 1 (SPHK1), an ATP-dependent protein, has previously been demonstrated to be upregulated in several types of human cancer and to play an important role in tumor development and progression. However, the role of SPHK1 in predicting long-term prognosis in patients with papillary thyroid carcinoma (PTC) remains unclear. The purpose of the present study was to assess the significance of SPHK1 expression and its associations with clinicopathological characteristics and prognostic outcome in patients with PTC. Immunohistochemistry staining was retrospectively performed to investigate the expression levels of SPHK1 in 92 PTC tumors. Statistical analyses revealed that high levels of SPHK1 expression were associated with tumor size, lymph node metastasis and the Tumor-Node-Metastasis stage. The disease-free survival (DFS) time of patients that exhibited high levels of SPHK1 expression was shorter, whereas patients with lower levels of SPHK1 expression survived longer. Furthermore, multivariate analysis suggested that upregulated SPHK1 was an independent prognostic factor for predicting DFS of patients with PTC. The results of the Cell Counting Kit-8 and invasion assays demonstrated that SPHK1 overexpression significantly enhanced the proliferation and invasion of a PTC cell line, consistent with clinical findings. The results from the present study provide evidence that elevated expression levels of SPHK1 may be involved in the development and progression of PTC, indicating that this protein may act as a potential prognostic marker for patients with this disease.

Cystic form of cervical lymphadenopathy. Guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery (SFORL). Part 1: Diagnostic procedures for lymphadenopathy in case of cervical mass with cystic aspect

OBJECTIVES

The authors present the guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery Society on diagnostic procedures for lymphadenopathy in case of a cervical mass with cystic aspect.

METHODS

A multidisciplinary work-group was entrusted with a review of the scientific literature on the topic. Guidelines were drawn up, then read over by an editorial group independent of the work-group, and the final version was drawn up. Guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.

RESULTS

In adults presenting a cystic cervical mass, it is recommended to suspect cervical lymphadenopathy: in order of decreasing frequency, cystic metastasis of head and neck squamous cell carcinoma, of undifferentiated nasopharyngeal carcinoma, and of thyroid papillary carcinoma (Grade C). On discovery of a cystic cervical mass on ultrasound, architectural elements indicating a lymph node and a thyroid nodule with signs of malignancy should be screened for, especially if the mass is located in levels III, IV or VI (Grade A). Malignant lymphadenopathy should be suspected in case of cervical mass with cystic component on CT (Grade B), but benign or malignant status cannot be diagnosed only on radiological data (CT or MRI) (Grade A), and 18-FDG PET-CT should be performed, particularly in case of inconclusive ultrasound-guided fine needle aspiration biopsy (Grade C).

Transoral Endoscopic Thyroidectomy for Thyroid Cancer

The prevalence of low-risk differentiated thyroid cancer (DTC) is dramatically increasing because of superior diagnostic imaging technologies. Remote-access endoscopic thyroidectomy is becoming more popular for the lack of a noticeable neck scar. Transoral endoscopic thyroidectomy, vestibular approach (TOETVA) is the only technique that could be called a true scarless surgery; however, there is a scarcity of long-term studies about its safety and feasibility. Because thyroid cancer is a slow-growing lesion, with adequate follow-up and surveillance, TOETVA is a surgical procedure for the management of low-risk DTC without any difference of surgical and oncological outcome.

Ultrasonography of Cervical Lymph Nodes

Ultrasonography is an excellent method for imaging evaluation of cervical lymph nodes. This article provides an image-rich review of the sonographic manifestations of diseases involving the cervical lymph nodes, with an emphasis on the expected anatomic distribution of diseases.

Efficacy and Affecting Factors of 131I Thyroid Remnant Ablation After Surgical Treatment of Differentiated Thyroid Carcinoma

Purpose: Radioiodine (¹³¹I) thyroid remnant ablation is an important treatment of differentiated thyroid carcinoma (DTC) and various factors affecting its efficacy have been reported but not well defined. The aim of our study was to evaluate the efficacy and the affecting factors of ¹³¹I ablation after total or near-total thyroidectomy in a relative large DTC cohort. Methods: 261 DTC patients with negative thyroglobulin antibody received 100-200 mCi ¹³¹I for thyroid remnant ablation after total or near-total thyroidectomy between January 2012 and October 2015 in our hospital. The efficacy and affecting factors of ¹³¹I ablation therapy were retrospectively investigated. Results: The success rate of the first ¹³¹I thyroid remnant ablation was 65.90%. Univariate analysis demonstrated that larger tumor size, higher level of pre-ablation stimulated thyroglobulin (sTg), intermediate to high risk stratification for recurrence, and lymph node and distant metastases were associated with a lower success rate of the first ¹³¹I ablation (all p < 0.05). Multivariate logistic regression analysis showed that tumor size, pre-ablation sTg, and lymph node and distant metastases were independent factors affecting the efficacy of the first ¹³¹I ablation. Areas under receiver operating characteristic curves for sTg, sTg/TSH ratio, and tumor size to predict unsuccessful ablation were 0.831, 0.824, and 0.648, respectively. The threshold values were 4.595 ng/ml, 0.046 mg/IU, and 1.350 cm, respectively. The sensitivities were 95.51, 96.63, and 73.03% and the specificities were 64.54, 61.63, and 49.41%, respectively. The excellent response (ER) ratio of the successful group was significantly higher than that of the unsuccessful group. Conclusions: The efficacy of the first ¹³¹I thyroid remnant ablation after surgical treatment of DTC is well demonstrated, and tumor size, pre-ablation sTg, lymph node, and distant metastases are independent factors affecting its efficacy.

Clinical outcomes of low and intermediate risk differentiated thyroid cancer patients treated with 30mCi for ablation or without radioactive iodine therapy

OBJECTIVE

To retrospectively evaluate the outcomes of patients with low and intermediate risk thyroid carcinoma treated with total thyroidectomy (TT) and who did not undergo radioiodine remnant ablation (RRA) and to compare them to patients receiving low dose of iodine (30 mCi).

SUBJECTS AND METHODS

A total of 189 differentiated thyroid cancer (DTC) patients treated with TT followed by 30mCi for RRA or not, followed in two referral centers in Brazil were analyzed.

RESULTS

From the 189 patients, 68.8% was ATA low-risk, 30.6% intermediate and 0.6% high risk. Eighty-seven patients underwent RRA and 102 did not. The RRA groups tended to be younger and had a higher frequency of extra-thyroidal extension (ETE). RRA did not have and impact on response to initial therapy neither in low (p = 0.24) nor in intermediate risk patients (p = 0.66). It also had no impact on final outcome and most patients had no evidence of disease (NED) at final follow-up. Recurrence/persistence of disease was found in 1.2% of RRA group and 2% in patients treated only with TT (p = 0.59).

CONCLUSIONS

Our study shows that in low and intermediate-risk patients, RRA with 30 mCi seems to have no major advantage over patients who did not undergo RRA regarding response to initial therapy in each risk group and also in long term outcomes.

Metastatic lymph node characteristics as predictors of recurrence/persistence in the neck and distant metastases in differentiated thyroid cancer

OBJECTIVE

The aim of this study was to evaluate the association between this characteristic and outcomes in patients with lymph node metastasis in a Brazilian cohort.

SUBJECTS AND METHODS

This study examined a retrospective cohort of adult patients diagnosed with differentiated thyroid cancer and lymph node metastases from 1998 to 2015 in two referral centers. Number, location, size and extranodal extension (ENE) of metastatic lymph nodes were assessed and correlated with response to initial therapy.

RESULTS

A greater number of metastatic nodes, larger size, presence of lateral neck disease and ENE were all associated with a lower probability of achieving an excellent response to initial therapy (p ≤ 0.05 for all these parameters). Local recurrent disease had a significant association with lymph node number (6 in the recurrence/persistence group versus 4 in the non-recurrent group; p = 0.02) and ENE (19.2 versus 75%, p = 0.03). Lateral neck disease was the only characteristic associated with distant metastasis and was present in 52.1% of the group without metastasis and 70.4% of the group with metastasis (p = 0.001).

CONCLUSION

The lymph node characteristics were associated with response to initial therapy and neck recurrence/persistence, confirming the importance of the analysis of these factors in risk stratification in a Brazilian population and its possible use to tailor initial staging and long term follow-up.

Restratification of survival prognosis of N1b papillary thyroid cancer by lateral lymph node ratio and largest lymph node size

The current 7th TNM staging stratifies N1b papillary thyroid cancer (PTC) patients without distant metastasis into either stage I or stage IV merely by an age threshold (45 years). To date, no studies have adequately quantified the mortality risk of PTC patients with N1b disease. We hypothesized that incorporating lymph node (LN) factors into the staging system would better predict cancer-specific mortality (CSM). A total of 745 nonmetastatic PTC patients with N1b disease were enrolled. We identified factors related to LNs and cut-points using Cox regression and time-dependent ROC analysis. New prognostic groupings were derived based on minimal hazard differences for CSM among the groups stratified by LN risk and age, and prediction of CSM was assessed. Lateral lymph node ratio (LNR) and largest LN size were significant prognostic LN factors at cut-points of 0.3 and 3 cm. Without LN risk (lateral LNR >0.3 or largest LN size >3 cm), stage IV patients had prognosis [adjusted HR 1.10 (98% CI 0.19-6.20); P = 0.906] similar to stage I patients with LN risk. Patients were restratified into three prognostic groups: Group 1, <45 years without LN risk; Group 2, <45 years with LN risk or ≥45 years without LN risk; and Group 3, ≥45 with LN risk. This system had a lower log-rank P-value (<0.001 vs. 0.002) and higher C-statistics (0.80 vs. 0.71) than the 7th TNM. New prognostic grouping using lateral LNR and largest LN size predicts CSM accurately and distinguishes N1b patients with different prognosis.

Genome-Wide Expression Screening Discloses Long Noncoding RNAs Involved in Thyroid Carcinogenesis

CONTEXT

Long noncoding RNAs (lncRNAs) regulate pathological processes, yet their potential roles in papillary thyroid carcinoma (PTC) are poorly understood.

OBJECTIVE

To profile transcriptionally dysregulated lncRNAs in PTC and identify lncRNAs associated with clinicopathological characteristics.

DESIGN

We performed RNA sequencing of 12 paired PTC tumors and matched noncancerous tissues and correlated the expression of lncRNAs with clinical parameters. The 2 most significantly dysregulated lncRNAs were studied in an Ohio PTC cohort (n = 109) and in PTC data (n = 497) from The Cancer Genome Atlas.

SETTING

A combination of laboratory-based studies and computational analysis using clinical data and samples and a publically available database.

MAIN OUTCOME MEASURES

Correlation between expression values and clinical parameters.

RESULTS

We identified 218 lncRNAs showing differential expression in PTC (fold change ≥ 2.0, P < .01). Significant correlation was observed between the expression of 2 lncRNAs (XLOC_051122 and XLOC_006074) and 1) lymph node metastasis (N stage) and 2) BRAF(V600E) mutation. Among patients with wild-type BRAF, the expression of these 2 lncRNAs showed significantly higher levels in the patients with lymph node metastasis. In silico analysis of these lncRNAs pinpointed cell movement and cellular growth and proliferation as targeted functions.

CONCLUSIONS

Comprehensive expression screening identified 2 novel lncRNAs associated with risk factors of adverse prognosis in PTC patients. These lncRNAs may be novel players in PTC carcinogenesis.