Thyroid Carcinoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

Early efficacy of radiofrequency ablation for multifocal T1N0M0 papillary thyroid carcinoma: a multicenter study

OBJECTIVES

This study aimed to assess the efficacy and safety of radiofrequency ablation (RFA) for multifocal papillary thyroid carcinoma (M-PTC) and compare these outcomes with those for unifocal papillary thyroid carcinoma (U-PTC).

METHODS

This retrospective multicenter study included 465 patients (367 women and 98 men) who underwent RFA for either U-PTC (411 patients) or M-PTC (54 patients) between May 2015 and October 2022. Patients were followed up at 1, 3, 6, and 12 months post-RFA, then every 6 months in the second year, and annually thereafter. After 1:1 propensity score matching (PSM), local tumor progression rate (LTP), tumor volume, volume reduction rate (VRR), tumor complete response rate (CDR), and complications were evaluated and compared between the M-PTC and U-PTC groups during the follow-up period.

RESULTS

The median follow-up time was 23 months. The median follow-up time for the U-PTC and M-PTC groups was 23 months and 23.5 months, respectively. The overall local tumor progression rate was 0.9% (4/465), and the overall complication rate was 0.6% (3/465). After PSM, no significant differences were observed between the U-PTC and M-PTC groups regarding tumor volume (p = 0.377), VRR (p = 0.151), CDR (50% vs. 44.2%, p = 0.556), or LTP (1.9% vs. 0%, p = 0.556). Additionally, the complication rates were not significantly different between the groups (1.03% vs. 2.5%, p = 0.343).

CONCLUSION

After adequate preoperative evaluation, RFA is an effective and safe treatment for appropriately selected patients with M-PTC, with a prognosis similar to that of U-PTC.

Anaplastic thyroid cancer: Genetic roles, targeted therapy, and immunotherapy

Anaplastic thyroid cancer (ATC) stands as the most formidable form of thyroid malignancy, presenting a persistent challenge in clinical management. Recent years have witnessed a gradual unveiling of the intricate genetic underpinnings governing ATC through next-generation sequencing. The emergence of this genetic landscape has paved the way for the exploration of targeted therapies and immunotherapies in clinical trials. Despite these strides, the precise mechanisms governing ATC pathogenesis and the identification of efficacious treatments demand further investigation. Our comprehensive review stems from an extensive literature search focusing on the genetic implications, notably the pivotal MAPK and PI3K-AKT-mTOR signaling pathways, along with targeted therapies and immunotherapies in ATC. Moreover, we screen and summarize the advances and challenges in the current diagnostic approaches for ATC, including the invasive tissue sampling represented by fine needle aspiration and core needle biopsy, immunohistochemistry, and 18F-fluorodeoxyglucose positron emission tomography/computed tomography. We also investigate enormous studies on the prognosis of ATC and outline independent prognostic factors for future clinical assessment and therapy for ATC. By synthesizing this literature, we aim to encapsulate the evolving landscape of ATC oncology, potentially shedding light on novel pathogenic mechanisms and avenues for therapeutic exploration.

Prediction of lymph node metastasis in papillary thyroid carcinoma using non-contrast CT-based radiomics and deep learning with thyroid lobe segmentation: A dual-center study

Objectives

This study aimed to develop a predictive model for lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) patients by deep learning radiomic (DLRad) and clinical features.

Methods

This study included 271 thyroid lobes from 228 PTC patients who underwent preoperative neck non-contrast CT at Center 1 (May 2021-April 2024). LNM status was confirmed via postoperative pathology, with each thyroid lobe labeled accordingly. The cohort was divided into training (n = 189) and validation (n = 82) cohorts, with additional temporal (n = 59 lobes, Center 1, May-August 2024) and external (n = 66 lobes, Center 2) test cohorts. Thyroid lobes were manually segmented from the isthmus midline, ensuring interobserver consistency (ICC ≥ 0.8). Deep learning and radiomics features were selected using LASSO algorithms to compute DLRad scores. Logistic regression identified independent predictors, forming DLRad, clinical, and combined models. Model performance was evaluated using AUC, calibration, decision curves, and the DeLong test, compared against radiologists' assessments.

Results

Independent predictors of LNM included age, gender, multiple nodules, tumor size group, and DLRad. The combined model demonstrated superior diagnostic performance with AUCs of 0.830 (training), 0.799 (validation), 0.819 (temporal test), and 0.756 (external test), outperforming the DLRad model (AUCs: 0.786, 0.730, 0.753, 0.642), clinical model (AUCs: 0.723, 0.745, 0.671, 0.660), and radiologist evaluations (AUCs: 0.529, 0.606, 0.620, 0.503). It also achieved the lowest Brier scores (0.167, 0.184, 0.175, 0.201) and the highest net benefit in decision-curve analysis at threshold probabilities > 20 %.

Conclusions

The combined model integrating DLRad and clinical features exhibits good performance in predicting LNM in PTC patients.

First Report of SPECC1L::ALK Fusion in Medullary Thyroid Carcinoma with Remarkable Response to Alectinib

Background: Rearrangements of the ALK gene are rare in medullary thyroid carcinoma (MTC), with limited data on the efficacy of ALK inhibitors in this context. Novel fusions, such as SPECC1L::ALK, have not been extensively studied. Methods: We present a case of a 33-year-old woman with metastatic MTC, in whom molecular profiling using next-generation sequencing (Archer FusionPlex®) identified a SPECC1L::ALK gene fusion. Treatment with the ALK inhibitor alectinib was initiated at 600 mg twice daily. Results: The patient demonstrated a dramatic partial to near-complete response after 6 days of treatment, as shown by positron emission tomography-computed tomography. At 6 weeks, a complete response was confirmed. Treatment was generally well tolerated, aside from grade 3 myalgia with elevated creatine phosphokinase, managed with temporary cessation and dose adjustment. As of the latest follow-up (8 months), the patient remains on alectinib with sustained complete response. Conclusions: This is the first report of a SPECC1L::ALK fusion in MTC. The dramatic response to alectinib highlights the importance of molecular profiling and suggests that ALK inhibitors may benefit patients with rare ALK fusions in thyroid cancers.

Optimizing unsupervised feature engineering and classification pipelines for differentiated thyroid cancer recurrence prediction

BACKGROUND

Differentiated thyroid cancer (DTC) is a common endocrine malignancy with rising incidence and frequent recurrence, despite a generally favorable prognosis. Accurate recurrence prediction is critical for guiding post-treatment strategies. This study aimed to enhance predictive performance by refining feature engineering and evaluating a diverse ensemble of machine learning models using the UCI DTC dataset.

METHODS

Unsupervised data engineering-specifically dimensionality reduction and clustering-was used to improve feature quality. Principal Component Analysis (PCA) and Truncated Singular Value Decomposition (t-SVD) were selected based on superior clustering metrics: adjusted Rand Index (ARI > 0.55) and V-measure (> 0.45). These were integrated into classification pipelines using Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF), K-Nearest Neighbors (KNN), Feedforward Neural Network (FNN), and Gradient Boosting (GB). Model performance was evaluated through bootstrapping on an independent test set, stratified 10-fold cross-validation (CV), and subgroup analyses. Metrics included balanced accuracy, F1 score, AUC, sensitivity, specificity, and precision, each reported with 95% confidence intervals (CIs). SHAP analysis supported model interpretability.

RESULTS

The PCA-based LR pipeline achieved the best test set performance: balanced accuracy of 0.95 (95% CI: 0.90-0.99), AUC of 0.99 (95% CI: 0.97-1.00), and sensitivity of 0.94 (95% CI: 0.84-1.00). In stratified CV, it maintained strong results (balanced accuracy: 0.86; AUC: 0.97; sensitivity: 0.80), with consistent performance across clinically relevant subgroups. The t-SVD-based LR pipeline showed comparable performance on both test and CV sets. SVM and FNN pipelines also performed robustly (test AUCs > 0.99; CV AUCs > 0.96). RF and KNN had high specificity but slightly lower sensitivity (test: ~0.87; CV: 0.77-0.80). GB pipelines showed the lowest overall performance (test balanced accuracy: 0.86-0.88; CV: 0.85-0.88).

CONCLUSIONS

Dimensionality reduction via PCA and t-SVD significantly improved model performance, particularly for LR, SVM, FNN, RF and KNN classifiers. The PCA-based LR pipeline showed the best generalizability, supporting its potential integration into clinical decision-support tools for personalized DTC management.

CLINICAL TRIAL NUMBER

Not applicable.

Total thyroidectomy does not improve survival for all patients with unilateral papillary thyroid cancer exceeding 4 ​cm

BACKGROUND

Total thyroidectomy (TT) is recommended for papillary thyroid cancer (PTC) over 4 ​cm, but its universal benefit is uncertain. This study evaluates whether TT offers a significant advantage over lobectomy (LT) in improving overall survival (OS) and cancer-specific survival (CSS) for patients with unilateral PTC exceeding 4 ​cm.

METHODS

The study included 8862 patients from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2021) with unilateral PTC larger than 4 ​cm. The relationship between age and survival was assessed using the restricted cubic splines (RCS) model. The effects of LT and TT on OS and CSS across age groups were analyzed using Cox regression and Kaplan-Meier (KM) methods, with and without age stratification. Propensity score matching (PSM) and sensitivity analyses were conducted to assess the robustness of the results.

RESULTS

TT did not improve OS (P ​= ​0.888) or CSS (P ​= ​0.907) compared to LT in the overall cohort. However, TT significantly improved OS (HR ​= ​0.54, P ​= ​0.004) and CSS (HR ​= ​0.55, P ​= ​0.018) in high-risk patients (T4, N1, or M1 stage), but not in low-risk patients. Age-stratified analysis showed TT benefited only young (18-55 years) high-risk patients, enhancing OS (HR ​= ​0.29, P ​= ​0.001) and CSS (HR ​= ​0.35, P ​= ​0.035). Older patients did not gain significant survival advantages from TT, regardless of risk status. These results were consistent in the PSM and sensitivity analyses.

CONCLUSIONS

TT may not be the best approach for all unilateral PTC patients over 4 ​cm in terms of OS and CSS. It improves survival outcomes in young patients with advanced TNM stages but does not confer a significant OS or CSS advantage over LT for older or low-risk patients.

Recombinant TSH Performs as Well as Thyroid Hormone Withdrawal for Iodine-131 Therapy With Dosimetry for Thyroid Cancer

Introduction

Dosimetry helps calculate the optimal iodine-131 (I-131) dose for treating metastatic differentiated thyroid cancer (DTC). We aimed to evaluate if recombinant human TSH (rhTSH) and thyroid hormone withdrawal (THW) are equivalent methods of preparation for dosimetry-guided I-131 therapy in metastatic DTC.

Methods

We performed a retrospective cohort study of 51 adults with metastatic DTC who received I-131 with dosimetry from 2010 through 2022. Gamma camera and blood activity measurements were taken following the pretherapeutic I-131 dose. Statistical analysis compared rhTSH and THW groups; P < .05 was considered significant.

Results

Fifty-one adults undergoing 55 I-131 dosimetry-guided treatments were included: 22 by rhTSH and 33 by THW. The median age was lower (P = .0008), and the proportion of stage IV (P = .009) was higher in rhTSH compared to the THW group. The terminal effective half-life at 24 to 48 hours in the whole body was longer in rhTSH compared to THW group (21.9 vs 17.1 hours; P = .014), but this difference was less significant when limited to the n = 37 metastatic cases (P = .046) and not different for red marrow effective half-life. The calculated allowed I-131 dose was lower in rhTSH compared to THW group (187.5 mCi vs 259.9 mCi; P = .0000). Thyroglobulin was higher during treatment in the rhTSH group (P = .031), whereas its reduction at 3 months was not different after adjusting for age and stage.

Conclusion

rhTSH is noninferior to THW in preparation for I-131 dosimetry. Compared to THW, rhTSH results in lower calculated allowed I-131 dose after dosimetry, which could translate to fewer side effects or impact on quality of life.

Long noncoding RNA FAM111A-DT promotes aggressiveness of papillary thyroid cancer via activating NF-κB signaling

PURPOSE

Long noncoding RNAs (lncRNAs) play crucial regulatory roles in the tumorigenesis and progression of various cancers. However, the functional roles of lncRNAs in papillary thyroid cancer (PTC) remain unclear. In this study, we investigated the functional role of the lncRNA FAM111A-DT in PTC progression and the underlying mechanisms.

METHODS

Different expression levels of lncRNAs in PTC were compared via analysis of the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases. Bioinformatics analyses and qRT‒PCR were used to investigate the expression of FAM111A-DT in PTC. Cell proliferation was measured via CCK8, EdU, colony formation, and flow cytometry assays. Cell migration and invasion were examined by wound healing and Transwell assays. Apoptosis was detected via flow cytometry. RNA sequencing, qRT‒PCR, Western blot, immunofluorescence and dual-luciferase reporter assays were performed to assess the underlying mechanisms involved.

RESULTS

FAM111A-DT was highly expressed in PTC and associated with poor prognosis, thyroid dedifferentiation, various clinical features and the BRAFV600E mutation in PTC patients. Overexpression of FAM111A-DT enhanced the proliferation, migration and invasion of PTC cells while reducing their degree of apoptosis. The NF-κB signaling pathway was activated in FAM111A-DT-overexpressing PTC cells. The NF-κB inhibitor PDTC attenuated the promotive effects of FAM111A-DT on aggressive phenotypes and NF-κB pathway activity in PTC cells.

CONCLUSION

FAM111A-DT is upregulated in PTC, and its expression is associated with poor clinical outcomes. FAM111A-DT plays an oncogenic role by, at least partially, activating the NF-κB signaling pathway.

Beyond fluorodeoxyglucose: Molecular imaging of cancer in precision medicine

Cancer molecular imaging is the noninvasive visualization of a process unique to or altered in neoplasia, such as proliferation, glucose metabolism, and receptor expression, which is relevant to patient management. Several molecular imaging modalities are now available, including magnetic resonance, optical, and nuclear imaging. Nuclear imaging, particularly using fluorine-18-fluorodeoxyglucose positron emission tomography, is widely used in the staging and response assessment of multiple cancer types. However, at this writing, new nuclear medicine probes, especially positron emission tomography tracers, are increasingly used or are being investigated for cancer evaluation. This review focuses on these probes, their biologic targets, and the applications or potential applications for their use in the assessment of various neoplasms, including both probes available for commercial use-such as somatostatin receptor ligands in neuroendocrine tumors, prostate-specific membrane antigen ligands in prostate cancer, norepinephrine analogs in neural crest tumors like neuroblastoma, and estrogen analogs in breast cancer-and others in clinical development, such as fibroblast-activating protein inhibitors, C-X-C chemokine receptor type 4 ligands, and monoclonal antibodies targeting receptor tyrosine kinases, CD4-positive or CD8-positive tumor-infiltrating lymphocytes, tumor-associated macrophages, and cancer stem cell biomarkers. These developments represent a major step toward the integration of molecular imaging as a powerful tool in precision medicine, with an expectedly significant impact on patient management and outcome.

Redifferentiation therapy in unresectable or metastatic radioactive iodine refractory thyroid cancer: an International Thyroid Oncology Group statement

In patients with follicular cell-derived thyroid cancer that have distant metastases and no iodine uptake, redifferentiation-ie, the restoration of tumoural 131I uptake with systemic therapy-is now possible. The use of mitogen-activated protein kinase (MAPK) inhibitors for a short period of time before the administration of high activity 131I shows promising results with iodine uptake restoration and tumour response. Redifferentiation has been used in patients with BRAF-mutated and RAS-mutated tumours in prospective trials and in the case of patients with RET or NTRK fusions. The iodine uptake restoration ranges from 33% to 95%, and tumour response rates from 11% to 80%. There is substantial variability between trials with regards to inclusion criteria, duration of redifferentiation drug therapy, activity of radioactive iodine, and use of dosimetry. Randomised studies are missing to clearly establish the effectiveness and applicability of redifferentiation. Thus, long-term studies are needed to establish the most effective redifferentiation protocols. The objectives of this Review are to: (1) provide a comprehensive review of the available results from prospective trials and case reports, including results regarding the restoration of radioiodine uptake and treatment efficacy (morphological and biological); (2) describe the differences in redifferentiation trial design between studies and discuss their potential impact on treatment efficacy; (3) describe the implications and limitations of dosimetry; and (4) outline the key questions to be addressed in future redifferentiation trials.

ENDOCAN-TUTHYREF network consensus recommendations. Refractory medullary thyroid cancer

Medullary thyroid carcinoma (MTC) accounts for 2-4% of thyroid cancers. It has the particularity of being a neuroendocrine tumor associated with a proto-oncogene germline RET mutation: germline in 20-25% of cases, somatic in 70-80% of metastatic sporadic cases. Locally advanced and metastatic MTCs are called "refractory". Individual prognosis is difficult, since the clinical behavior of the disease varies greatly from one patient to another. However, histological factors, such as high-grade forms, associated with greater risk of tumor progression and death, have been recently identified, and biological factors, such as the doubling time of plasma calcitonin, may help assess prognosis. Treatment of refractory medullary thyroid carcinoma has progressed considerably over recent years, with the advent of targeted therapies such as multi-kinase inhibitors and selective RET inhibitors. Management requires multidisciplinary expertise, and is tailored to the individual clinical situation patient, the molecular characteristics of the tumor, and the progression of the disease. These advances have led the ENDOCAN-TUTHYREF rare-cancer network of the French National Institute for Cancer (INCa), dedicated to refractory thyroid cancer, to draw up a set of consensus recommendations. This article focuses on refractory medullary thyroid cancer.

Natural History of Cytologically Low-Risk Indeterminate Thyroid Nodules

CONTEXT

Thyroid nodules classified cytologically as low-risk indeterminate lesions (TIR3A) on fine-needle aspiration biopsy (FNAB) present a clinical challenge due to their uncertain malignancy risk.

OBJECTIVE

This single-center study aimed to evaluate the natural history of TIR3A nodules.

METHODS

FNABs performed between July 2017 and December 2019 were retrospectively retrieved and patients, with TIR3A nodules were evaluated at baseline and throughout a follow-up based on ultrasound (US) parameters and clinical data.

RESULTS

The final study group encompassed 371 patients with an initial TIR3A cytological result. Among them, 102 were directed to surgery after the first endocrinological evaluation, and 269 were directed to conservative follow-up. Repeat FNAB was performed in 120 out of 269 and 13 further patients underwent surgery following FNAB repetition. The malignancy rate among TIR3A nodules was 16.5%, with most interventions being performed for reasons unrelated to the TIR3A result. Repeat FNAB provided a more definitive diagnosis in 40% of cases, with a 5% increase in malignancy risk. The remaining patients were monitored with clinical and US follow-up. Among all patients with TIR3A cytology managed conservatively (149 without FNAB repetition and 66 with at least one FNAB repetition), no significant changes in nodule size and/or US pattern were observed during a median follow-up of 3.3 years.

CONCLUSION

These findings suggest that active surveillance is a safe option for managing TIR3A nodules, particularly when no additional risk factors are present. The study highlights the role of repeat FNAB in reducing unnecessary surgeries and underscores the generally indolent nature of TIR3A nodules.

Formulation-Based Cost Savings with Cabozantinib Capsules

This Viewpoint asserts that the formulation (tablet vs capsule) and the dosage of cabozantinib can be optimized to reduce toxicities and cost while maintaining efficacy.

[Update on papillary thyroid cancer-What is relevant for surgeons?]

Papillary thyroid cancer (PTC) is the most frequent malignant thyroid tumor in Germany. The diagnosis can only be confirmed by histological examination of the suspicious tissue. The clinical signs, sonographic findings, and the results of fine-needle aspiration, possibly supplemented by subsequent molecular genetic analysis, can confirm the suspected diagnosis before surgery. The prognosis is very good if the diagnosis is made early and, depending on the size of the tumor, complete surgical removal is achieved, with a 10-year survival rate of more than 90%; however, histologically PTC has several variants that are associated with either a high or low risk of metastases and recurrence in patients. Therefore, the extent of necessary treatment, in particular surgical interventions for PTC has been discussed for years. This article provides an overview of the current knowledge on the diagnosis, treatment and prognosis of PTC.

Development and validation of a multidimensional machine learning-based nomogram for predicting central lymph node metastasis in papillary thyroid microcarcinoma

Background

Papillary thyroid microcarcinoma (PTMC), a subset of papillary thyroid carcinoma (PTC), is characterized by tumors ≤10 mm in size. While generally indolent, central lymph node metastasis (CLNM) is associated with higher risks of recurrence and distant metastasis. Existing prediction models for CLNM predominantly depend on isolated clinical or imaging parameters, failing to integrate multidimensional predictors such as clinicopathological, ultrasonographic, and serological features. This limitation significantly undermines their clinical applicability. Therefore, we developed a machine learning-based nomogram that integrates comprehensive predictors to enhance preoperative risk stratification and facilitate personalized surgical decision-making.

Methods

A retrospective study was conducted on 503 PTMC patients who underwent thyroidectomy in Liaoyang Central Hospital between 2020 and 2023. Patients were randomly divided into training (n=352) and validation (n=151) cohorts. Inclusion criteria required preoperative imaging to confirm no cervical lymph node metastasis (LNM), complete clinicopathologic data, and initial surgery with central lymph node dissection, as well as postoperative pathology confirming PTC. Multidimensional predictors (clinical demographics, ultrasonographic features, serological markers, and histopathological characteristics) were analyzed. CLNM was definitively diagnosed via postoperative histopathology. Least absolute shrinkage and selection operator (LASSO) regression was used to identify key predictors, which were incorporated into a logistic regression model. The model's performance was evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

Results

Among 503 enrolled patients (mean age: 48.5 years; male: 24%, female: 76%), CLNM was pathology confirmed in 28.8% (145/503). Age, gender, tumor size, tumor location, and extrathyroidal extension (ETE) were identified as independent predictors of CLNM. The nomogram achieved an area under the curve (AUC) of 0.88 (sensitivity 0.84, specificity 0.76) in the training cohort and 0.78 (sensitivity 0.80, specificity 0.70) in the validation cohort. Calibration plots indicated excellent agreement between predicted and observed probabilities, with mean absolute errors below 0.05. DCA demonstrated clinical utility for threshold probabilities ranging from 15% to 88%. These results suggest that the nomogram has good predictive performance and clinical applicability in assessing the risk of CLNM in PTMC patients.

Conclusions

This Machine learning-based predictive nomogram provides a reliable tool for assessing CLNM risk in PTMC patients, supporting personalized surgical strategies. Further validation in external cohorts is required to confirm its generalizability.

Chinese management guidelines for radioactive iodine-refractory differentiated thyroid cancer (2025 edition)

PURPOSE

Radioactive iodine-refractory differentiated thyroid cancer (RAIR-DTC) has become a challenge in clinical practice, particularly in China with a high incidence and undesirable survival outcome. Since the publication of first China consensus on the diagnosis and treatment of RAIR-DTC in 2019, significant and rapid advances have occurred in the field both in China and internationally. This guideline aims to inform Chinese clinicians, researchers, patients, and health policy makers on the latest evidence and recommendations, to further standardize the clinical diagnosis and treatment of RAIR-DTC.

METHODS

The structured clinical questions addressed in this guideline were derived from clinical diagnostic and treatment processes, with references to study, prior guidelines, expert consensus, and systematic reviews, etc. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used for quantitative and qualitative evaluation of the evidence. The editorial process was completely independent of the guideline development group.

RESULTS

The guideline addressed 26 clinical questions and formed 35 recommendations. In this guideline, the definition criteria for RAIR-DTC was optimized, prediction and identification was based on evidence including molecular testing, dynamic biochemical changes, and multimodal imaging. Comprehensive pre-treatment clinical evaluation was emphasized and tailored for individualized decision-making. The combination of systematic therapy and surgery, and the redifferentiation followed by RAI therapy were also reviewed and updated. Molecular imaging plays a unique role in the pre-assessing and therapeutic response evaluation for RAIR-DTC.

CONCLUSIONS

We have updated and developed evidence-based recommendations with the aim of providing scientific, rigorous, and comprehensive guidance for the clinical diagnosis and treatment of RAIR-DTC patients in China. We hope to share our guideline with colleagues out of China, with the expectation of further comments and suggestions.

KRAS-SOS-1 Inhibition as New Pharmacological Target to Counteract Anaplastic Thyroid Carcinoma (ATC)

Anaplastic thyroid carcinoma (ATC) is the most aggressive type of thyroid cancer. Tumor cells have been shown to activate alternative signaling pathways, making treatments less effective. One of the major proteins involved in the progression of ATC is the proto-oncogene KRAS that belongs to a group of small guanosine triphosphate (GTP)-binding proteins. Despite its recognized importance in cancer malignancy, KRAS is considered non-druggable and has never been studied in the field of ATC. In this context, a new synthetic molecule, BAY-293, has recently been developed that selectively inhibits the KRAS-SOS-1 interaction. Based on these findings, the aim of this study was to evaluate for the first time the antitumor effect of BAY-293 using in vitro and in vivo models of ATC. The in vitro model included different thyroid cancer (TC) cell lines used to study the effect of BAY-293 on the modulation of mitogen-activated protein kinase (MAPK) pathways, apoptosis, and cell migration. To confirm the in vitro findings and better mimic the complex tumor microenvironment, an in vivo orthotopic model of ATC was used. The results of the study indicate that BAY-293, both in vitro and in vivo, effectively blocked the KRAS/MAPK/ERK pathway and β-catenin, which act as downstream effectors essential for cell migration, and increased the apoptotic process by slowing the progression of ATC. In conclusion, this study demonstrated that KRAS/SOS-1 inhibition could be a promising therapeutic target for the treatment of ATC and highlighted BAY-293 as an innovative molecule that needs further research to fully evaluate its efficacy in the field of thyroid cancer.

Bitter Taste Receptor Agonists Induce Apoptosis in Papillary Thyroid Cancer

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy, with a 20% recurrence rate. Bitter taste receptors (T2Rs) and their genes (TAS2Rs) may regulate survival in solid tumors. This study examined T2R expression and function in PTC cells.

METHODS

Three PTC cell lines (MDA-T32, MDA-T68, and MDA-T85) were analyzed for expression using RT-qPCR and immunofluorescence. Live cell imaging measured calcium responses to six bitter agonists. Viability and apoptosis effects were assessed using crystal violet and caspase 3/7 activation assays. Genome analysis of survival was conducted.

RESULTS

TAS2R14 was consistently highly expressed in all cell lines. Five bitter agonists produced significant cytoplasmic and mitochondrial calcium responses across all cell lines. All bitter agonists significantly decreased viability and induced apoptosis. Higher TAS2R14 expression correlated with better progression-free survival in patients (p < 0.05).

CONCLUSIONS

T2R activation by bitter agonists induces apoptosis, and higher TAS2R expression is associated with survival, suggesting potential therapeutic relevance in thyroid cancer management.

The impact of age at diagnosis on central lymph node metastasis in clinically low-risk papillary thyroid microcarcinoma patients

BACKGROUND

Age is an independent risk factor for central lymph node metastasis (CLNM) in clinically negative lymph node (cN0) papillary thyroid microcarcinoma (PTMC) patients. The objective of this study was to investigate the impact of age on CLNM in clinically low-risk PTMC patients.

METHODS

A retrospective analysis was performed on patients with clinically low-risk PTMC who underwent surgery between January 2016 and December 2018. Logistic regression analysis was used to examine the impact of age on the risk of CLNM. The associations between age and pN1a and the lymph node ratio (LNR) were examined by a restricted cubic spline (RCS) curve with logistic regression models.

RESULTS

A total of 1352 patients (mean [range] age, 43[18-76] years; 325 males [24.0%]) were enrolled in this study. Logistic regression analysis revealed that age was a significant factor influencing the risk of CLNM (OR 0.95, 95% CI 0.94-0.96; p < 0.001). The RCS curve revealed a significant nonlinear association between age and pN1a status and the LNR. For patients under the age of 55, the risk of CLNM (OR 0.59, 95% CI 0.55-0.65, p < 0.001) and the LNR (beta - 0.23, 95% CI -0.27, -0.19, p < 0.001) significantly decreased as age increased. For patients aged ≥ 55 years, the risk of LNM (OR 1.03, 95% CI 0.81-1.32; p = 0.79) and the LNR (Beta - 0.03, 95% CI -0.07,0.13, p = 0.54) did not change with age.

CONCLUSIONS

This study confirmed that age was a significant factor influencing the risk and severity of CLNM in patients with low-risk PTMC. The risk and severity of LNM were lowest in patients aged ≥ 55 years.

Inhibitory effect of luteolin on the metabolism of vandetanib in vivo and in vitro

This study aimed to examine the potential drug-drug interaction (DDI) between vandetanib and luteolin in vivo and in vitro, with the objective of establishing a scientific foundation for their appropriate utilization in clinical settings. Sprague-Dawley (SD) rats were randomly divided into two groups: a control group (vandetanib administered by gavage alone) and an experimental group (vandetanib and luteolin administered together). A series of blood samples were collected at different time intervals. The plasma concentrations of vandetanib and its metabolite N-demethyl vandetanib in rats were determined using an ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). Incubation systems were set up with rat liver microsomes (RLM) and human liver microsomes (HLM) to measure the Michaelis-Menten constant (Km) and half-maximum inhibitory concentration (IC50) values. Additionally, the inhibitory mechanism of luteolin on vandetanib was also investigated. Ultimately, the molecular mechanism of inhibition was examined through the utilization of molecular docking techniques. In vivo animal experiment results showed that compared with the control group, the AUC(0-t) and Cmax of vandetanib in the experimental group were significantly increased. The findings from the in vitro experiments revealed that luteolin exhibited a moderate inhibitory effect on the metabolism of vandetanib. The IC50 values for RLM and HLM were determined to be 8.56 μM and 15.84 μM, respectively. The identified inhibition mechanism was classified as mixed. This study utilized molecular docking analysis to provide additional evidence supporting the competitive inhibition of luteolin on vandetanib in CYP3A4. The data presented in our study indicated a potential interaction between vandetanib and luteolin, which may necessitate the need for dose adjustment during their co-administration in clinical settings.

Clinical outcomes of microwave ablation for solitary T1N0M0 papillary thyroid carcinoma: a more than 5-year follow-up study

OBJECTIVES

This study aimed to evaluate the long-term efficacy and safety of microwave ablation (MWA) for solitary T1N0M0 papillary thyroid carcinoma (PTC) and compare them between T1a and T1b disease.

MATERIALS AND METHODS

This retrospective study included 136 patients with solitary T1N0M0 PTC who were treated with MWA and followed up for more than 5 years. Outcomes were compared between patients with T1a and T1b disease. The primary outcomes were disease progression and disease-free survival (DFS). The secondary outcomes included the volume reduction rate (VRR), the rate of complete disappearance, and complications.

RESULTS

During a mean follow-up period of 70.6 ± 10.5 months, the overall disease progression rate was 5.88%. The incidences of lymph node metastases (LNMs) and new tumors were 2.21% and 5.15%, respectively. No patient was diagnosed with local recurrence, distant metastasis, or death due to PTC. There were no significant differences between the T1a and T1b groups in terms of disease progression (3.81% vs 12.90%, p = 0.15), LNMs (1.90% vs 3.23%, p = 0.54), or new tumors (2.86% vs 12.90%, p = 0.08). The 5-year DFS rate was 94.85%, the VRR was 99.7% ± 2.0%, and 97.79% of the tumors disappeared. Hoarseness occurred in five patients (3.68%).

CONCLUSION

MWA is a long-term effective and safe option for patients with solitary T1N0M0 PTC, providing a minimally invasive alternative for those who refuse surgery or active surveillance.

KEY POINTS

Question MWA, as a minimally invasive alternative for treating PTC, lacks comparison with surgical resection and active surveillance. Findings MWA resulted in overall disease progression in 5.88% of patients with solitary T1N0M0 PTC over more than 5 years of follow-up. Clinical relevance MWA is a safe, effective, and minimally invasive treatment for solitary T1N0M0 PTC, with high DFS rates and low complication rates, benefiting patients seeking alternatives to surgery or active surveillance.

Correlation of Cytologic Features With Molecular Testing of Indeterminate Oncocytic (Hürthle Cell) Thyroid Lesions

INTRODUCTION

Indeterminate oncocytic/Hürthle cell lesions on thyroid cytology are reflexed to molecular testing. This study aims to examine the cytologic characteristics of thyroid fine-needle aspiration (FNA) smears with oncocytes classified as atypia of undetermined significance (AUS) with particular molecular patterns that can aid in determining a more conclusive Bethesda category upfront thus decreasing unnecessary testing and associated costs.

MATERIALS AND METHODS

Our pathology database was searched for thyroid FNAs with AUS for oncocyte predominance from 2019 to 2022. Sixty six cases that underwent ThyroSeq testing (33 positive and 33 negative) were selected. Two cytopathologists reviewed the smears for cellularity, colloid: cell ratio, artifacts, lymphocytes, microfollicles, and oncocytic nuclear atypia. Molecular results and surgical follow-up were obtained through chart review. Statistical analysis was done using STATA16.1 (StataCorp LLC College Station, TX).

RESULTS

Among the 33 ThyroSeq-positive cases, 20 had surgical follow-up. Only 1 case was malignant. Hypercellularity, microfollicular architecture, and oncocytic atypia were associated with a higher incidence of molecular alterations. Five of 66 cases demonstrated microfollicles. Four of these had positive molecular findings, and one was negative. Twenty of 33 (61%) cases with positive molecular findings had no oncocytic nuclear atypia. Of the molecular positive cases with oncocytic atypia that underwent resection, seven of nine (78%) were neoplastic. RAS mutations were the most common finding detected in non-neoplastic and neoplastic lesions.

CONCLUSIONS

Microfollicles were infrequently seen in nodules with oncocytic predominance; however, those that had microfollicles had high incidence of positive molecular findings. Oncocytic nuclear atypia was present in all the resected neoplastic cases. NRAS and KRAS mutations were the most common molecular abnormalities detected.

Impact of nodal status evaluation on therapeutic strategy for clinically unifocal T1b/small T2 node negative papillary thyroid carcinoma

PURPOSE

In absence of nodal metastases or aggressive features, thyroid lobectomy (TL) should be preferred over total thyroidectomy (TT) for 1-4 cm unifocal, papillary thyroid carcinoma (PTC). However, occult, despite non-microscopic (≥2 mm), nodal metastases may be present in clinically node-negative (cN0) PTC.

METHODS

Among 4216 thyroidectomies for malignancy (2014-2023), 110 TL plus ipsilateral central neck dissection (I-CND) were scheduled for unifocal cT1b/small cT2 (≤3 cm) cN0 PTCs. Frozen section examination (FSE) of removed nodes was performed: when positive, completion thyroidectomy (CT) was accomplished during the same procedure. In presence of aggressive pathologic features, CT was suggested within 6 months from index operation.

RESULTS

FSE was positive for occult not-microscopic nodal metastases in 33 cases (30%), underwent synchronous CT. Among the remaining 77 patients, 24 (31.2%) were scheduled for CT, after multidisciplinary tumor board discussion, due to at least 2 high-risk factors. The median number of removed and metastatic nodes was 8 (5-11) and 2 (1-5), respectively, at definitive histopathology. Furthermore, multifocality was present in 53 (48.2%) cases, lymphovascular invasion in 66 (60%) cases, aggressive subtypes in 20 (18.2%) cases and extracapsular invasion in 5 (4.5%) cases. Overall, 57 (51.8%) patients underwent immediate or delayed CT.

CONCLUSION

More than 50% of patients with unifocal cT1b/small cT2 cN0 PTC scheduled for TL may be eligible for CT because of aggressive tumor features. An intraoperative decision-making approach based on I-CND and nodes FSE may ensure accurate staging and risk stratification, thus reducing the risk of recurrence and the need for reoperation.

Model Based on Ultrasound Radiomics and Machine Learning to Preoperative Differentiation of Follicular Thyroid Neoplasm

OBJECTIVES

To evaluate the value of radiomics based on ultrasonography in differentiating follicular thyroid carcinoma (FTC) and follicular thyroid adenoma (FTA) and construct a tool for preoperative noninvasive predicting FTC and FTA.

METHODS

The clinical data and ultrasound images of 389 patients diagnosed with FTC or FTA postoperatively were retrospectively analyzed at 3 institutions from January 2017 to December 2023. Patients in our hospital were randomly assigned in a 7:3 ratio to training cohort and validation cohort. External test cohort consisted of data collected from other 2 hospitals. Radiomics features were used to develop models based on different machine learning classifiers. A combined model was developed combining radiomics features with clinical characteristics and a nomogram was depicted. The performance of the models was assessed by area under the receiver operating characteristic curve (AUC), calibration curve and decision curve.

RESULTS

Radiomics model based on random forest showed best performance in discriminating FTC and FTA, with AUCs 0.880 (95% confidence interval [CI]: 0.8290-0.9308), 0.871 (95% CI: 0.7690-0.9734), and 0.821 (95% CI: 0.7036-0.9389) in training, validation, and test cohort, respectively. The combined model presented better efficacy comparing with clinical model and radiomics model, with AUCs 0.883 (95% CI: 0.8359-0.9295), 0.874 (95% CI: 0.7873-0.9615), and 0.876 (0.7809-0.9714) in training, validation, and test cohort, respectively. The calibration curves suggested good consistency and decision curves showed the highest overall clinical benefit for the combined model.

CONCLUSIONS

Ultrasound radiomics model based on random forest is feasible to differentiate FTC and FTA, and the combined model is an intuitively noninvasive tool for FTC and FTA preoperative identification.

Cancer and careers: Perspectives and experiences of patients with differentiated thyroid cancer

BackgroundAs new cases of differentiated thyroid cancer become younger and survival rates improve, young and middle-aged patients have become the main population with the disease. Therefore, most patients are in the developmental stage of work. Returning to work after cancer treatment has become common.ObjectiveTo explore the perceptions and experiences of patients with differentiated thyroid cancer about continuing to work after cancer.MethodsUsing the descriptive phenomenological research method, semi-structured in-depth interviews were conducted with 13 patients with differentiated thyroid cancer who entered the follow-up period, and the data were analyzed using the Colaizzi 7-step analysis method and managed with the help of Nvivo 11.ResultsThe themes of work experience are as follows: necessary reasons for continuing to work: survival needs, supporting family, work for recovery; negative effects of disease in work status: distressing cancer symptoms, fear of disease recurrence, difficult choice between health and future, labeling of cancer patients; support and coping: family support, social support, professional information support.ConclusionsEconomic factors play an important role in differentiated thyroid cancer survivors' choice to continue working. Patients who are currently in a work status have some distress, but to some extent, the work status facilitates survival and treatment. Multidisciplinary and individualized medical interventions, as well as employer and policy support, can help to mitigate the harm caused by cancer diagnosis and treatment and promote patients' continued work and improved quality of life.

Characteristics of RET gene mutations in Vietnamese medullary thyroid carcinoma patients: a single-center analysis

BACKGROUND

The RET gene point mutation is the main molecular alteration involved in medullary thyroid carcinoma (MTC) tumorigenesis. Previous studies in Vietnam mainly consisted of case reports, with limited data on larger sample sizes. In this study, we investigated RET gene mutations in exons 10, 11, and 16 and analyzed clinicopathological features of a series of Vietnamese MTC patients.

METHODS

We collected 33 tissue samples from patients with MTC and analyzed RET mutations using the Sanger sequencing method. The relationship between hotspot RET mutations (exons 10, 11, 16) and clinicopathological features were investigated.

RESULTS

Among the 33 analyzed cases, 17 tumors (52%) harbored RET mutations in exon 10, 11, or 16. A total of 10 distinct genetic alterations were identified, including eight missense mutations and two short indels. Of these, seven were classified as pathogenic mutations based on previous publications, with p.M918T being the most frequent (4 cases), followed by p.C634R (3 cases) and p.C618R (3 cases). Mutations were significantly associated with specific histological patterns, such as the nested/insular pattern (p=.026), giant cells (p=.007), nuclear pleomorphism (p=.018), stippled chromatin (p=.044), and amyloid deposits (p=.024). No mutations were found in germline analyses, suggesting these were somatic alterations.

CONCLUSIONS

Our results provided the first comprehensive analysis of RET mutations in Vietnamese MTC patients. The most frequent mutation was p.M918T, followed by p.C634R and p.C618R. Mutations in these three exons were linked to specific histopathological features. Information on mutational profiles of patients with MTC will further aid in the development of targeted therapeutics to ensure effective disease management.

Activity and safety of atezolizumab plus carboplatin and paclitaxel in patients with advanced or recurrent thymic carcinoma (MARBLE): a multicentre, single-arm, phase 2 trial

BACKGROUND

Despite the poor prognosis of advanced or recurrent thymic carcinoma, the rarity of thymic carcinoma has delayed the development and introduction of novel pharmacotherapy options. Carboplatin plus paclitaxel remains a standard treatment for chemotherapy-naive advanced or recurrent thymic carcinoma. We evaluated the activity and safety of atezolizumab combined with chemotherapy.

METHODS

In this multicentre, single-arm, phase 2 trial in 15 hospitals in Japan, patients with metastatic or recurrent thymic carcinoma were treated with atezolizumab plus carboplatin and paclitaxel. Eligible patients were aged 20 years or older with histologically confirmed Masaoka stage III, IVA, or IVB thymic carcinoma not amenable for definitive treatment or recurrent thymic carcinoma after definitive treatment; and no previous history of systemic drug therapy for thymic carcinoma. The data of sex and race were defined via self-report. Patients received atezolizumab 1200 mg, carboplatin area under the curve 6 mg/mL per min, and paclitaxel 200 mg/m2 intravenously every 3 weeks for up to six cycles, followed by atezolizumab 1200 mg intravenously every 3 weeks for up to 2 years until progression or unacceptable toxicity. The primary endpoint was objective response rate, based on an independent central review. The primary endpoint and safety were assessed in the per-protocol set. This trial was registered at Japan Registry of Clinical Trials, jRCT2031220144, and is closed to enrolment.

FINDINGS

Between June 14, 2022, and July 6, 2023, 48 patients were enrolled and included in the efficacy and safety analyses. Median follow-up was 15·3 months (IQR 13·8-16·6). 29 (60%) patients were male and 19 (40%) of 48 patients were female. Median age of patients was 67·5 years (IQR 56·5-72·5). All patients were Asian. The objective response rate was 56% (95% CI 41-71; Fisher's exact test p<0·0001); 27 (56%) of 48 participants had a partial response. The most common adverse reactions of grade 3 or worse were neutropenia (27 [56%] of 48 patients), leukopenia (16 [33%]), febrile neutropenia (11 [23%]), and maculopapular rash (six [13%]). There were no treatment-related deaths and eight deaths overall.

INTERPRETATION

In previously untreated advanced thymic carcinoma, the addition of atezolizumab to carboplatin and paclitaxel conferred clinically meaningful antitumour activity with a manageable safety profile. Thus, atezolizumab plus carboplatin and paclitaxel might become a viable treatment option for previously untreated advanced or recurrent thymic carcinoma.

FUNDING

Chugai Pharmaceutical.

TRANSLATIONS

For the Japanese translation of the abstract see Supplementary Materials section.

Multi-Omic Analysis Reveals a Lipid Metabolism Gene Signature and Predicts Prognosis and Chemotherapy Response in Thyroid Carcinoma

OBJECTIVE

Lipid metabolic reprogramming is closely intertwined with the development and progression of thyroid carcinoma (TC); however, its specific mechanism remains elusive. This study aimed to investigate the association between lipid metabolism and TC progression.

METHODS

We employed liquid chromatography-mass spectrometry (LC/MS) for an untargeted metabolomics analysis, comparing 12 TC patients and 12 healthy controls (HC). Additionally, we conducted the screening of differentially expressed genes (DEGs) and identified differentially expressed lipid metabolism genes (LMGs). Multi-omic findings related to lipid metabolism were integrated to establish a prognostic risk model. The resulting risk score stratified TC patients into high- and low-risk groups. Overall survival (O.S.) was assessed using Kaplan-Meier (K-M) analysis. The immune landscape was evaluated using the CIBERSORT algorithm, and chemotherapeutic response was predicted utilizing the "pRRophetic" R package.

RESULTS

Our metabolomic analysis revealed heightened lipid metabolic activity in TC, corroborated by similar findings in transcriptomic analysis. Multi-omic analysis identified key LMGs (FABP4, PPARGC1A, AGPAT4, ALDH1A1, TGFA, and GPAT3) associated with fatty acids and glycerophospholipids metabolism. A novel risk model, incorporating these LMGs, confirmed significantly worse O.S. (p = 0.0045) in the high-risk group based on TCGA_THCA. Furthermore, high-risk TC patients exhibited lower immune cell infiltration, and predictive outcomes indicated the efficacy of potential therapeutic drugs across risk groups.

CONCLUSION

This multi-omic analysis underscores the potential utility of the lipid metabolism risk model in guiding clinical treatment and improving outcomes for TC patients.

Rescue Tracheal Reconstruction via Platysma Myocutaneous Flap Following Necrosis of Sternocleidomastoid Muscle Myoperiosteal Flap

A case of a 60-year-old male patient with thyroid cancer invading the trachea was presented in the current study. After the initial surgery via a sternocleidomastoid muscle (SCM) clavicular periosteal flap for tracheal reconstruction, the patient experienced flap necrosis. Subsequent debridement and tracheocutaneostomy were performed, followed by a successful repair of the tracheal defect using a platysma myocutaneous flap. The case underscores the critical role of preserving the SCM's integrity to ensure adequate blood supply and reduce the risk of flap necrosis. A staged approach, involving initial debridement and tracheocutaneostomy, followed by secondary reconstruction with a platysma myocutaneous flap, proved effective in managing flap necrosis post-SCM myoperiosteal flap reconstruction. This strategy offers a safe and viable alternative for tracheal defect re-reconstruction.

The preliminary multicenter retrospective study on the efficacy and safety of thermal ablation for follicular thyroid neoplasms ≤ 3 cm

OBJECTIVES

To evaluate the efficacy and safety of thermal ablation (TA) for follicular thyroid neoplasms (FTN) ≤ 3 cm.

METHODS

This retrospective multicenter study enrolled 161 patients (131 females; mean age, 46 ± 15 years [range, 11-86]) who underwent TA for FTN ≤ 3 cm between January 2014 and October 2023 from eight centers in China. The median follow-up time was 12 months (IQR, 12-24 months). Based on the maximum diameter (MD) of the nodule, patients were divided into two groups: Group 1 (MD ≤ 2 cm) and Group 2 (2 < MD ≤ 3 cm). Post-ablation assessments encompassed evaluations of tumor size and volume changes, technical success rate, tumor disappearance, disease progression, complications, and risk factors associated with recurrent laryngeal nerve (RLN) injury.

RESULTS

All patients underwent complete ablation in a single session. The technical success rate was 100%. The mean volume reduction rate (VRR) of the ablation zone at 12 months was 78.11%. The VRR at 12 months was higher in Group 1 than that in Group 2 (Median VRR, 93.8% vs. 82.8%; P = 0.019). The complete tumor disappearance rate was 15.5% (25/161). Smaller tumors have a higher tumor disappearance rate (Group 1 vs Group 2 = 27.6% vs. 4.7%; P < 0.001). The disease progression rate was 2.5% (4/161), with no significant difference between Group 1 and Group 2 (P = 0.535). The complication rate was 3.1% (5/161), with no significant difference between Group 1 and Group 2 (P = 0.899). No risk factors were identified for RLN injury.

CONCLUSIONS

Thermal ablation is an effective and safe treatment option for patients with FTN ≤ 3 cm.

Diagnosis and treatment of a rare bilateral primary thyroid cancer: a case report

Preoperative ultrasound examination of thyroid nodules is the most economical and effective screening method for diagnosing thyroid nodules. Fine-needle aspiration biopsy (FNAB) cytology guided by ultrasound has high sensitivity and specificity in distinguishing benign and malignant thyroid nodules. However, approximately 25% of thyroid nodules cannot be determined by FNAB, and accurate differentiation of benign and malignant thyroid nodules is critical for patient prognosis. Here, we report the diagnosis and surgical treatment process of a rare patient with bilateral thyroid malignant tumor of independent origin. This patient had significantly elevated levels of calcitonin (Ctn: 130.00 pg/mL) and carcinoembryonic antigen (CEA: 16.13 ng/mL). Ultrasound shows a solid nodule on the left side of the thyroid gland, measuring 1.2*0.8*0.9cm, TI-RADS 4A; right solid nodule, 1.3*0.7*0.9 cm, TI-RADS 3. A fine needle biopsy of the left nodule showed little glandular epithelium and no evidence of malignancy. Multi-gene joint analysis of RET C634R in the left nodule and BRAF V600E in the right nodule indicated a potential diagnosis of left medullary thyroid carcinoma (MTC) and right papillary thyroid carcinoma (PTC). Postoperative pathology revealed the left thyroid nodule was MTC and the right nodule was PTC. The patient's bilateral thyroid nodules are independent primary malignant lesions. This case emphasizes the important significance of combined analysis of ultrasound, serum biomarkers, cellular pathology, molecular detection, and paraffin pathology in the differential diagnosis of benign and malignant multiple thyroid nodules. It provides a reference for future diagnosis and treatment decisions of multiple thyroid nodules.

A clinical study on microwave ablation of T1N0M0 papillary thyroid carcinoma locating in dangerous region

To evaluate the feasibility, safety and efficiency of the microwave ablation (MWA) of T1N0M0 papillary thyroid carcinoma (PTC) locating in dangerous region. This is a clinical retrospective study, and the data of patients who underwent thermal ablation for T1N0M0 PTC from June 2016 to March 2021 were reviewed. After ablation, the rates of technical success, as well as the changes in tumor size and volume, tumor disappearance, disease progression, and complications, were assessed. According to the tumor size, the patients were divided into T1a and T1b subgroups. There was a total of 94 cases enrolled in the present study. The mean age was 43.06 ± 11.51 years (22-65 years). The median follow-up time was 33 months (25-75% IQR 24-44; 12-85months). The technical success rate was 100%. Due to expanding ablation, the MD and volume of the ablation zone increased at the 1st and 3rd months and decreased from the 12th month after ablation (p < 0.05 for all). At the end of follow-up, the complete disappearance of ablation zone occurred in 78(78/94, 82.98%) cases, including 65 (65/75, 86.67%) cases in T1a subgroup and 13(13/19, 68.4%) cases in the T1b subgroup. There was no difference between the two subgroups (p = 0.121). 5 (5/94,5.3%) patients developed disease progression, and all of them were in T1a subgroup (5/75, 6.67%). There was not significantly different between two subgroups (p = 0.559). The complication rate was 15.96% (15/94). Recurrent laryngeal nerve (RLN) injury encountered in 11 (11/75, 14.7%) cases in the T1a subgroup and 4 (4/19, 21.1%) cases in the T1b subgroup. No significant difference between the two subgroups (p = 0.74). This preliminary study indicates that MWA is an effective treatment for T1N0M0 PTC locating in dangerous region.

CTR-FAPI PET Enables Precision Management of Medullary Thyroid Carcinoma

Medullary thyroid carcinoma (MTC) can only be cured through the excision of all metastatic lesions, but current clinical practice fails to localize the disease in 29% to 60% of patients. Previously, we developed a fibroblast activation protein inhibitor (FAPI)-based covalent targeted radioligand (CTR) for improved detection sensitivity and accuracy. In this first-in-class clinical trial, we head-to-head compared [68Ga]Ga-CTR-FAPI PET-CT and [18F]fluorodeoxyglucose ([18F]FDG) PET-CT in 50 patients with MTC. The primary endpoint was the patient-based detection rate, with [68Ga]Ga-CTR-FAPI exhibiting higher detection than [18F]FDG (98% vs. 66%, P = 0.0002). This improved detection was attributed to increased tumor uptake (maximum standardized uptake value = 11.71 ± 9.16 vs. 2.55 ± 1.73, P < 0.0001). Diagnostic accuracy, validated on lesions with gold-standard pathology, was greater for [68Ga]Ga-CTR-FAPI compared with [18F]FDG (96.7% vs. 43.3%, P < 0.0001). Notably, the management of 32% of patients was altered following [68Ga]Ga-CTR-FAPI PET-CT, and the surgical plan was changed for 66.7% of patients. Overall, [68Ga]Ga-CTR-FAPI PET-CT provided superior detection and diagnostic accuracy compared with [18F]FDG PET-CT, enabling precision management of patients with MTC. Significance: In this first-in-class clinical trial of CTR, [68Ga]Ga-CTR-FAPI demonstrated an improved patient-based detection rate (98%), tumor uptake (maximum standardized uptake value = 11.71 ± 9.16), and pathology-validated diagnostic accuracy (96.7%) compared with the currently approved method in MTC treatment. It directly altered management in 32% of patients, enabling precision diagnosis and management of MTC. See related commentary by Witney, p. 264.

Correlation analysis of Hashimoto's thyroiditis with papillary thyroid carcinoma occurrence and its central lymph node metastasis: a single center experience

Purpose

This study investigates the clinicopathological characteristics of papillary thyroid carcinoma (PTC) with coexisting Hashimoto's thyroiditis (HT) and further explores the risk factors for central lymph node metastasis (CLNM) in PTC.

Method

A retrospective analysis was conducted on 415 PTC patients who underwent surgical treatment for thyroid cancer at the First Affiliated Hospital of Anhui University of Chinese Medicine from 2016 to 2022. Clinicopathological features were compared between PTC patients with and without HT. Univariate and multivariate logistic regression were used to analyze the risk factors of CLNM.

Result

The PTC+HT group had a higher proportion of female patients (85.5%) than the PTC group (P<0.05). Univariate analysis revealed no statistically significant difference between the two groups in eight aspects (all P>0.05). Multivariate analysis showed that HT was positively associated with the total number of central lymph node (CLN) dissected, Thyroid-stimulating hormone (TSH), Thyroid peroxidase antibody (TPOAb), and Thyroglobulin antibodies (TgAb), while identified as a protective factor against invasion with an odds ratio of 0.422 (95%CI 0.209-0.853, P=0.016). Through univariate and multivariate logistic regression, we proved that tumor position, Capsule + Extrathyroidal extension (ETE), multifocal tumors, and the total number of CLN dissected were independent risk factors for CLNM. Multiple linear regression analysis told us that invasion (β= 0.093, p=0.048) had a positively predictive impact on CLN positive rate.

Conclusion

Female PTC patients are more prone to concurrent HT, which elevates the levels of TSH, TPOAb, and TgAb. HT not only promotes the longitudinal growth of nodules and PTC development, but also reduces the risk of invasion and CLNM. Therefore, we posit that the impact of HT on PTC patients is a "double-edged sword". Isthmus, Capsule + ETE, multifocality, age < 55 years old, and male are high-risk factors for CLNM in PTC, while HT is regarded as a protective factor. Capsule + ETE is the primary risk factor affecting the CLN positive rate.

Comparison of prognosis between oncocytic thyroid carcinoma and follicular thyroid carcinoma: a population-based propensity score matching analysis

BACKGROUND

Oncocytic thyroid carcinoma (OTC) is a rare subtype of thyroid cancer known for its distinctive morphology and high likelihood of recurrence, setting it apart from follicular thyroid carcinoma (FTC). Despite this, there is limited research comparing the clinicopathological characteristics and outcomes of OTC and FTC.

METHODS

We retrospectively searched through the Surveillance, Epidemiology, and End-Results (SEER) database (2004-2015) for histologically diagnosed OTC and FTC patients. Kaplan-Meier analysis, propensity score matching (PSM), univariate Cox proportional risk regression model, and subgroup analysis were employed to investigate the prognostic effect of clinicopathological features and treatment regimens on survival outcomes of OTC and FTC patients.

RESULTS

2329 OTC patients and 5679 FTC patients were included in the study. OTC patients were prone to older age, white race, lymph node metastasis, distal metastasis, extension and multiple primary tumors compared with FTC patients. After using a 1:1 PSM matching ratio, there were no significant differences in demographic and clinicopathological characteristics between the matched groups. Further Cox regression analysis showed that OTC patients had lower overall survival (OS) and cancer-specific survival (CSS) in contrast with FTC patients. Subgroup survival analysis suggested that the OTC patients were related to lower OS in subgroups including those over 55 years old, male sex, white ethnicity, extrathyroidal extension, single primary tumor, surgery and without chemotherapy compared with the FTC patients in these subgroups. In addition, the OTC patients were connected with lower CSS in subgroups including male sex, white ethnicity, married status, tumor size is less than 20 mm or more than 40 mm, N0 stage, localized stage, single primary tumor, surgery, radiotherapy, and without chemotherapy compared with the FTC patients in these subgroups. Meanwhile, the OTC patients had lower CSS compared to FTC patients regardless of age and extrathyroidal extension.

CONCLUSIONS

The results suggested that OTC patients have unique clinical features and poorer prognoses compared to FTC patients. Surgical resection and radioactive iodine therapy are recommended for OTC patients and FTC patients. It is worth noting that the prognosis of OTC relies largely on the selection of treatment strategies. Therefore, our results highlighted the clinical significance of the early distinguishment and the correct choice of treatment in OTC patients.

PET/CT imaging of differentiated and medullary thyroid carcinoma using the novel SSTR-targeting peptide [18F]SiTATE - first clinical experiences

PURPOSE

The novel 18F-labeled somatostatin receptor (SSTR)-directed radiotracer [18F]SiTATE demonstrated promising results for the imaging of various SSTR-expressing tumor types. Although thyroid carcinomas (TC) express SSTR, data on [18F]SiTATE PET/CT imaging in TC are lacking. This study explores the use of [18F]SiTATE PET/CT in a patient cohort with histologically proven TC.

METHODS

As part of a prospective observational study at a single tertiary cancer center, 21 patients with TC (10 medullary (MTC) and 11 differentiated (DTC)) who underwent at least one [18F]SiTATE PET/CT were included (37 scans in total). Mean SUVmax and SUVmean of tumoral lesions, mean total-tumor-volume (TTV), and whole-body (WB)-SUVmax and WB-SUVmean on PET with their standard deviations (SDs) were determined. PET parameters were correlated to clinical parameters including tumor marker levels (thyroglobulin for DTC, calcitonin for MTC).

RESULTS

89 lesions were included in the analysis. Metastases were localized in the bone, lymph nodes, lung, soft tissue, and thyroid bed. Osseous (31 lesions; SUVmax 8.6 ± 8.0; SUVmean 5.8 ± 5.4) and nodal (37 lesions; SUVmax 8.7 ± 7.8; SUVmean 5.7 ± 5.4) metastases showed the highest uptake. The MTC disease burden on PET significantly correlated with the calcitonin tumor marker level (e.g., TTV: r = 0.771, r2 = 0.594, p = 0.002). For DTC, no such correlation was present.

CONCLUSION

Our data demonstrate high feasibility of [18F]SiTATE PET/CT in a small cohort of patients with MTC and DTC. The use of [18F]SiTATE may overcome logistical disadvantages of 68Ga-based tracers and facilitate SSTR-targeted PET/CT imaging of thyroid carcinoma.

Lobectomy vs Total Thyroidectomy With Ipsilateral Lateral Neck Dissection for N1b Intermediate-Risk Papillary Thyroid Carcinoma

Importance

The management of papillary thyroid carcinoma (PTC), particularly in cases with clinically apparent lateral neck lymph node metastasis (cN1b), remains an area of debate. The surgical options for PTC, including total thyroidectomy and lobectomy, have distinct impacts on patients' outcomes and quality of life.

Objective

To compare survival and recurrence outcomes between patients who underwent a lobectomy plus ipsilateral lateral neck dissection (LND) and those who underwent a total thyroidectomy plus ipsilateral LND for intermediate-risk cN1b PTC with both primary tumors and lymph node metastases in the ipsilateral neck region.

Design, Setting, and Participants

This retrospective cohort study was conducted at Ito Hospital, Tokyo, Japan. Patients who underwent surgery for PTC between January 2005 and December 2012 were included, and those with high-risk PTCs and concurrent other thyroid cancers were excluded. Data were analyzed from April to August 2024.

Exposures

Lobectomy plus LND vs total thyroidectomy plus LND.

Main Outcomes and Measures

An inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier analysis and a Cox proportional hazards regression analysis were performed to compare the patients' overall survival, recurrence-free survival (RFS), and modified RFS (which considered the potential need for a future contralateral lobectomy).

Results

Of 401 included patients, 317 (79.1%) were female, and the median (IQR) age was 47 (36-59) years. A total of 157 patients underwent lobectomy plus ipsilateral LND and 244 underwent total thyroidectomy plus ipsilateral LND. The median (IQR) follow-up time was 13.0 (11.2-15.0) years. The IPTW-adjusted overall survival rates at 5, 10, and 15 years were 98.0% (95% CI, 93.9-99.3), 97.5% (95% CI, 93.2-99.1), and 96.8% (95% CI, 92.2-98.7), respectively, for the lobectomy group vs 99.4% (95% CI, 97.0-99.9), 97.4% (95% CI, 94.4-98.8), and 96.9% (95% CI, 93.3-98.5), respectively, for the total thyroidectomy group (hazard ratio [HR], 1.10; 95% CI, 0.35-3.47). The IPTW-adjusted RFS rates at 5, 10, and 15 years were 93.8% (95% CI, 88.5-96.7), 88.4% (95% CI, 82.0-92.6), and 84.1% (95% CI, 76.8-89.3), respectively, for the lobectomy group vs 95.4% (95% CI, 91.8-97.4), 92.9% (95% CI, 88.8-95.5), and 87.8% (95% CI, 80.8-92.4), respectively, for the total thyroidectomy group (HR, 1.41; 95% CI, 0.79-2.54). The IPTW-adjusted modified RFS rates at 5, 10, and 15 years were 96.7% (95% CI, 92.2-98.6), 93.8% (95% CI, 88.5-96.7), and 88.9% (95% CI, 82.4-93.1), respectively, for the lobectomy group vs 95.4% (95% CI, 91.8-97.4), 92.9% (95% CI, 88.8-95.5), and 87.8% (95% CI, 80.8-92.4), respectively, for the total thyroidectomy group (HR, 0.93; 95% CI, 0.49-1.76).

Conclusions and Relevance

In this study, for these selected intermediate-risk cN1b PTC cases, total thyroidectomy and lobectomy provided comparable outcomes in terms of prognosis and recurrence. These data may help inform future guideline revisions and support joint decision-making between patients and their clinicians.

Pretreatment level of circulating tumor cells is associated with lymph node metastasis in papillary thyroid carcinoma patients with ≤ 55 years old

OBJECTIVE

To investigate the relationship of pretreatment of circulating tumor cells (CTCs) and cervical lymph node metastasis (LNM) (central LNM (CLNM) and lateral LNM (LLNM)) in papillary thyroid carcinoma (PTC) patients with ≤ 55 years old.

METHODS

Clinicopathological data (CTCs level, Hashimoto's thyroiditis, thyroid function, multifocal, tumor size, invaded capsule, clinical stage, and LNM) of 588 PTC patients with ≤ 55 years old were retrospectively collected. The relationship of CLNM, LLNM and the clinical features of patients was analyzed. Univariate and multivariate logistic regression analyses were used to evaluate the relationship between the CTCs and CLNM, LLNM.

RESULTS

There were 273(46.4%) and 89(15.1%) patients with CLNM and LLNM, respectively. Patients with CLNM had higher proportions of multifocality, tumor size > 1 cm, invaded capsule, and positive CTCs level than those without (all p < 0.05). Patients with LLNM had higher proportions of multifocality, tumor size > 1 cm, and invaded capsule than those without (all p < 0.05). Logistic regression analysis showed that multifocality (odds ratio (OR): 1.821, 95% confidence interval (CI): 1.230-2.698, p = 0.003), tumor size > 1 cm (OR: 3.444, 95% CI: 2.296-5.167, p < 0.001), invaded capsule (OR: 1.699, 95% CI: 1.167-2.473, p = 0.006), and positive CTCs level (OR: 1.469, 95% CI: 1.019-2.118, p = 0.040) were independently associated with CLNM; and multifocality (OR: 2.373, 95% CI: 1.389-4.052, p = 0.002), tumor size > 1 cm (OR: 5.344, 95% CI: 3.037-9.402, p < 0.001), and invaded capsule (OR: 2.591, 95% CI: 1.436-4.674, p = 0.002) were independently associated with LLNM.

CONCLUSIONS

Preoperative CTCs positive was associated with CLNM in PTC patients with ≤ 55 years old, but not LLNM.

Radiofrequency Ablation for Locoregional Structural Incomplete Response in Differentiated Thyroid Cancer: Initial Experience in Greece

Background/Objectives: Structural incomplete response (SIR) (persistence/recurrence) may occur in 2-6% of low-risk differentiated thyroid cancer (DTC)-cases and in 67-75% of high risk. Regarding locoregional disease, surgery is the optimal therapeutic modality if the smallest dimension of the targeted node is ≥8 mm or ≥10 mm (central or lateral compartment). In the presence of smaller nodes, contraindications or the patient's unwillingness for reoperation, active surveillance (AS) or minimally invasive treatments (MITs) may be considered. Methods: We retrospectively studied eight DTC patients with SIR confirmed by ultrasound (U/S)-guided fine-needle aspiration cytology (FNAC) and the measurement of Thyroglobulin (Tg) in the washout fluid. Fourteen malignant lesions were ablated by radiofrequency (RF). We assessed prior to RF ablation (RFA) and consecutively at one month, three months and, then, every three months the volume of each lesion, serum Tg and Anti-Tg antibodies and calculated the volume reduction ratio (VRR). Results: Patients were followed for a mean period of 13.25 months (range: 4-24) after RFA was performed. The targeted lesions reduced significantly from a median volume of 0.24 mL (range: 0.09-0.9) to 0.02 mL (range: 0-0.03) (p < 0.05), with a median VRR of 94.5% (range: 78-100%) and concomitant significant biochemical remission (decrease in serum Tg from a median of 1.05 ng/mL to 0.2 ng/mL, p < 0.05). In one patient with an aggressive radioiodine (RAI)-refractory histological variant, re-recurrence was documented, which was successfully re-ablated by RF. In two patients, Horner syndrome was diagnosed as an RFA complication, which was totally resolved within six months. Conclusions: RFA may be considered as an effective and safe MIT in selective DTC patients with SIR, especially in cases of smaller lesions. Additional prospective studies are needed, including aggressive DTC histological variants towards a tailored therapeutic approach.

Second Primary Differentiated Thyroid Carcinoma in Adult Cancer Survivors: A SEER Database Analysis

CONTEXT

Adult cancer survivors are at a heightened risk for secondary primary differentiated thyroid carcinoma (2-DTC). The characteristics and outcomes of 2-DTC remain poorly understood.

OBJECTIVE

We aimed to explore the characteristics and outcomes of 2-DTC.

METHODS

We retrospectively analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database (2000-2017). 2-DTC was divided into 25 subgroups based on prior primary malignancies (PPMs). Baseline characteristics were compared using the chi-square test. Multivariable logistic analysis was used to identified if PPMs were associated with aggressive DTC characteristics. DTC-specific and cancer-specific mortality were analyzed using a univariable and multivariable competing risk regression model.

RESULTS

There were 138 555 1-DTC and 9253 2-DTC patients identified. 2-DTC patients were predominantly older, male, and White compared to first primary DTC (1-DTC) (all P < .05). In multivariable logistic regression analysis, only 4 types of PPMs were associated with higher rates of DTC aggressive characteristics, while 19 types exhibited lower rates (all P < .05). In multivariable competing risk analysis, 2-DTC showed no mortality risk in stages I (SHR: 1.16; 95% CI, 0.65-2.07) and II (SHR: 0.67; 95% CI, 0.45-1.01), but a protective role in stages III (SHR: 0.47; 95% CI, 0.27-0.83) and IV (SHR: 0.72; 95% CI, 0.52-0.99). Most PPMs that developed into 2-DTC had a lower risk of DTC-specific death than 1-DTC, but many PPMs had a higher risk of cancer-specific death.

CONCLUSION

Given the characteristics and outcomes of 2-DTC, aggressive treatment for 2-DTC, particularly for PPM with a high mortality risk, may not be advisable.

Medullary thyroid cancer in MEN2 pediatric/adolescent carriers of RET mutation: genotype/phenotype correlation and outcome in a retrospective series of 23 patients

Background

Multiple endocrine neoplasia type 2 syndrome (MEN2) is a hereditary disease resulting from mutations of the rearranged during transfection (RET) protooncogene subclassified into MEN2A [medullary thyroid carcinoma (MTC), pheochromocytoma, and primary hyperparathyroidism] and MEN2B (MTC, pheochromocytoma, Marfanoid habitus, mucous neuromas, and intestinal ganglioneuromatosis). Prophylactic thyroidectomy is recommended in RET-mutated patients. The age at which it should be performed depends on the type and aggressiveness of the mutation.

Aim of the study

This study aimed to evaluate the genotype/phenotype correlation and outcome in pediatric/adolescent carriers of MEN2 RET mutation.

Patients and methods

In a retrospective series of 23 carriers of RET MEN2 mutation who were ≤19 years old at diagnosis and had undergone total thyroidectomy ± lymphadenectomy, the following were analyzed: 1) specific RET mutation, 2) clinical and histopathological characteristics, 3) genotype/phenotype correlation, and 4) outcome at last follow-up.

Results

In our series, the female gender was more prevalent (F/M ratio 2.8/1), and the median age was 14.9 years [interquartile range (IQR) 12.6-17.2]. RET mutations were at very high risk in 4.3% of patients (M918T), high risk in 43.5% (C634), and moderate risk in 52.2% (47.8% C618 and 4.3% C620). All patients underwent surgery: at histology, MTC was found in 19/23 (82.6%) patients, C-cell hyperplasia in 2/23 (8.7%), and benign histology in 2/23 (8.7%). Ten patients (52.6%) had a disease event during the follow-up: 2/19 (10.5%) showed biochemical disease, 6/19 (31.6%) lymph node recurrences, and 2/19 (10.5%) distant metastases (50% liver, 50% bone). At the last follow-up, nine MTCs were not cured. One patient died after 9 years of follow-up at 21 years old (M918T RET+).

Conclusions

From these data, it is clear to see the importance of genetic counseling and RET screening in all first-degree relatives of patients with proven MEN2. The goal should be to subject patients to surgery for prophylactic and not curative purposes, i.e., before the onset of MTC, given the high risk of persistent or recurrent disease also in pediatric/adolescent patients.

An update on redifferentiation strategies for radioactive iodine-refractory differentiated thyroid carcinoma

PURPOSE

Although most patients with differentiated thyroid carcinoma (DTC) have an excellent prognosis, a subset will experience radioactive iodine refractory (RAI-R) disease, associated with recurrence, distant metastases and worse prognosis. In recent years, redifferentiation has emerged as an attractive approach for patients with RAI-R DTC, a strategy to induce iodine uptake in RAI-R DTC tumor cells and ultimately prolong time to initiation of systemic therapy.

METHODS

An overview and critical appraisal of the existing literature on redifferentiation will be presented in this review under the lens of the genotype-specific targeted therapy administered with redifferentiation intent.

RESULTS/CONCLUSIONS

Due to the significant heterogeneity across studies, it will be key to harmonize research methodology and support future larger, multicenter prospective trials in order to identify the most suitable candidates for this therapeutic strategy.

Observational cohort study on safety and efficacy of robotic thyroidectomy with super-meticulous capsular dissection versus open surgery for thyroid cancer: postoperative dynamic risk assessment of radioactive iodine therapy

OBJECTIVE

To assess the efficacy and safety of robotic thyroidectomy (RT) with super-meticulous capsular dissection (SMCD) versus open thyroidectomy (OT), the authors used a dynamic risk assessment system incorporating 131 I-WBS along with radioactive iodine (RAI) efficacy evaluation.

BACKGROUND

Currently, the therapeutic efficacy of robotic surgery remains controversial. The 131 I whole-body scan ( 131 I-WBS) dynamic risk assessment system can detect small residual thyroid tissues and lesions, which may be used as indicators for the surgical efficacy of RT or OT thyroidectomy in differentiated thyroid cancer (DTC).

METHODS

This retrospective cohort study included 2349 patients who underwent total thyroidectomy followed by RAI therapy in our department between August 2017 and June 2023. Propensity score matching was performed at a ratio of 1:3 based on surgical type and mean follow-up duration to minimize selection bias after excluding those lost to follow-up. The primary outcome was surgical completeness, assessed using a dynamic risk system incorporating 131 I-WBS along with RAI efficacy evaluation.

RESULTS

There was no significant difference in the number of metastatic lymph nodes removed between the two groups ( P =0.45). The incidence rate of parathyroid gland transplantation was 395 (68.7%) in the OT group and 8 (3.8%) in the RT group ( P <0.001). There were no differences in the thyroidectomy completeness based on the 3 h iodine uptake rate and 99m TcO 4- thyroid imaging between the two groups. The dynamic risk assessment with and without 131 I-WBS showed significant differences ( P <0.001). The postoperative and post-RAI dynamic risk scores, evaluated at the time of RAI and 6 months after RAI, did not differ significantly between the two groups ( P >0.05). The rates of transient and permanent hypoparathyroidism were higher in the OT group than in the RT group ( P <0.05). The local recurrence rates showed no significant difference between the groups.

CONCLUSIONS

This study demonstrates that RT with SMCD can achieve outcomes equivalent to those of traditional open surgery when integrating the 131 I-WBS dynamic evaluation system and the therapeutic effects of RAI. Additionally, robot surgery demonstrated a notable advantage in protecting parathyroid function.

Clinical application potential of large language model: a study based on thyroid nodules

BACKGROUND

Limited data indicated the performance of large language model (LLM) taking on the role of doctors. We aimed to investigate the potential for ChatGPT-3.5 and New Bing Chat acting as doctors using thyroid nodules as an example.

METHODS

A total of 145 patients with thyroid nodules were included for generating questions. Each question was entered into chatbot of ChatGPT-3.5 and New Bing Chat five times and five responses were acquired respectively. These responses were compared with answers given by five junior doctors. Responses from five senior doctors were regarded as gold standard. Accuracy and reproducibility of responses from ChatGPT-3.5 and New Bing Chat were evaluated.

RESULTS

The accuracy of ChatGPT-3.5 and New Bing Chat in answering Q2, Q3, Q5 were lower than that of junior doctors (all P < 0.05), while both LLMs were comparable to junior doctors when answering Q4 and Q6. In terms of "high reproducibility and accuracy", ChatGPT-3.5 outperformed New Bing Chat in Q1 and Q5 (P < 0.001 and P = 0.008, respectively), but showed no significant difference in Q2, Q3, Q4, and Q6 (P > 0.05 for all). New Bing Chat generated higher accuracy than ChatGPT-3.5 (72.41% vs 58.62%) (P = 0.003) in decision making of thyroid nodules, and both were less accurate than junior doctors (89.66%, P < 0.001 for both).

CONCLUSIONS

The exploration of ChatGPT-3.5 and New Bing Chat in the diagnosis and management of thyroid nodules illustrates that LLMs currently demonstrate the potential for medical applications, but do not yet reach the clinical decision-making capacity of doctors.

Evaluation of epithelial-to-mesenchymal transition and Ki-67 index in aggressive papillary thyroid cancer

OBJECTIVES

The present study aims to characterize immunohistochemical features of markers associated with Epithelial-Mesenchymal Transition (EMT) and proliferative activity that could lead to death in Papillary Thyroid Cancer (PTC).

METHODS

Clinical data and tumor material were retrospectively collected. The patients were separated into death from PTC (Group 1), metastatic cases with indolent behavior (Group 2) and non-metastatic indolent PTC (Group 3). Immunohistochemical assessment of E-cadherin, β-catenin, Vimentin, ZEB-1 and Ki-67 was performed in each tumor and a semiquantitative estimation of the percentage of expression was fulfilled on the best marking area at high of the tumor invasion front.

RESULTS

31 patients were included, 15 that died from PTC (Group 1), 6 in Group 2 and 10 in Group 3. The proliferative marker Ki-67 showed a significant difference in its expression in the tumor invasion front between the groups, specifically between groups 1 and 3 (p = 0.006). On the other hand, EMT-related immunohistochemical markers did not show significant difference in their percentage of expression, since loss of E-cadherin, β-catenin and Vimentin was observed in most cases at the invasion front.

CONCLUSION

Patients that died from PTC had a significantly higher Ki-67 labelling index compared to patients with indolent disease (cutoff of 11%). Ki-67 may have a role as a prognostic marker and could be considered for routine use in PTC.

LEVEL OF EVIDENCE: 4

Factors Associated With Psychological Distress Among Thyroid Cancer Patients

OBJECTIVE

To assess the prevalence of psychological distress (PD) among thyroid cancer patients (TCPs) and identify clinical, demographic, and socioeconomic factors associated with PD.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING

2016 to 2018 National Health Interview Survey.

METHODS

Adults with cancer were included. The primary outcome measure was moderate-to-severe psychological distress (MSPD), defined as a respondent score ≥5 on the validated K6 Psychological Distress Scale. χ2 tests were used to assess differences in MSPD by cancer type. Weighted multivariable logistic regression was used to elucidate factors associated with MSPD among TCPs.

RESULTS

The majority of TCPs (n = 684,674) were white (75.4%), female (78.5%), and on average 55.65 years old (SD = 13.2). 28.4% reported MSPD. On weighted analysis, TCPs were more likely to have MSPD than prostate (14.9%, P < .001), bladder (16.4%, P = .011), and nonmelanoma skin cancer (16.3%, P < .001) patients but less likely than pancreatic cancer (30.0%, P = .030) patients. TCPs who were older when surveyed (odds ratio [OR], 0.93; 95% confidence interval [CI, 0.88-0.98), previously drank alcohol (OR, 0.23; 95% CI, 0.06-0.91), and saw a general physician (GP) in the past year (OR, 0.14; 95% CI, 0.03-0.56) were less likely to have MSPD. Female sex (OR, 8.12; 95% CI, 1.61-40.89), increased number of medical comorbidities (OR, 1.46; 95% CI, 1.00-2.14), and functional limitations (OR, 4.55; 95% CI, 1.33-15.74) were associated with increased likelihood of MSPD.

CONCLUSION

Nearly 30% of TCPs have MSPD, especially younger patients who do not regularly see GPs. Future work to identify the most at-risk patients is needed to improve prevention and develop meaningful psychosocial interventions.

Is conservative treatment always safe in unifocal clinically T1a/node-negative papillary thyroid carcinoma?

BACKGROUND

Management of clinically unifocal node-negative papillary thyroid carcinoma ≤1 cm (PTMC) is controversial with nonsurgical treatment as a potential alternative to thyroid lobectomy (TL). However, conservative strategies, such as active surveillance or thermal ablation, do not allow the evaluation of biological aggressive features or occult lymph node metastases (LNMs), which play a primary role as prognostic factors.

METHODS

Among 4216 thyroidectomies for malignancy (between September 2014 and September 2023), TL plus ipsilateral central neck dissection was performed in 203 (4.8%) unifocal N0 PTMCs. Completion thyroidectomy was accomplished in case of positive frozen section examination of removed nodes or within 6 months from index operation in presence of biological aggressive features.

RESULTS

Seventy-six out of 203 (37.4%) patients were staged pN1a and extranodal extension was detected in 5 (6.6%) patients. At final histology, biological aggressive features, including multifocality, lymphovascular invasion (LVI), extracapsular invasion, tumor aggressive subtypes, and BRAF-V600E mutation, were detected in 69 (34%), 93 (45.8%), 3 (1.5%), 30 (14.8%), and 7 (3.5%) patients, respectively. A comparative analysis between pN0 and pN1a patients showed younger age (p < 0.001), LVI (p = 0.037), and multifocality (p < 0.001) as risk factors for occult central LNMs. After logistic regression analysis, age (p < 0.001) and multifocality (p < 0.001) were confirmed as independent risk factors for nodal involvement.

CONCLUSIONS

Although most PTMC has been widely defined as indolent disease, a non-negligible rate of patients may present one or more biologically aggressive features including nodal involvement. Nonsurgical management should be considered with caution to avoid undertreatment especially in the younger population.

Plasma exchange as a rescue therapy for treatment-resistant thyroid storm with concurrent heart failure: a literature review based on a case report

INTRODUCTION

Thyroid storm or severe hyperthyroidism can present with various signs and symptoms. They are mostly controlled by general treatment, such as anti-thyroid drugs and other medications to control clinical features. However, in rare cases, they are more severe, and they only respond to more aggressive treatments, such as plasmapheresis and total thyroidectomy. The final histopathological features, such as the loci of differentiated thyroid carcinoma, are sometimes surprising.

CASE PRESENTATION

Here, we present a 40-year-old female who presented with severe palpitation, diaphoresis, and chest pain. After taking the initial steps of treatment and stabilizing the patient, the history, physical exam, and laboratory results confirmed the diagnosis of a thyroid storm in the background of Graves' disease that is accompanied by heart failure with reduced ejection fraction (HFrEF). She was admitted to an ICU setting and received principal treatment of thyroid storm. However, the systematic treatment was not effective, and finally, plasmapheresis and total thyroidectomy were performed. Histopathologic evaluation following surgery confirmed the presence of foci of papillary thyroid carcinoma (PTC) in the background of the grave's disease. This case underscores the complexity of managing Grave's induced thyroid storm in severe cases, which might lead to plasmapheresis and total thyroidectomy. Urgent and invasive treatment may be necessary in rare cases when normally applied treatment modalities are not able to control the situation and result in life-threatening critical health conditions. In such a severe case, it can result in serious cardiovascular complications such as decompensated heart failure with a high rate of mortality.

KEY CLINICAL MESSAGE

Thyroid storm, though rare, can be accompanied by severe medical conditions such as heart failure and death. In cases in which primary medical and symptomatic therapies do not work, more aggressive treatment (such as plasmapheresis and total thyroidectomy) should be considered. On the other hand, precise histopathologic evaluation of the thyroid tissue is necessary.

Clinico-pathological factors and [18F]FDG PET/CT metabolic parameters for prediction of progression-free survival in radioiodine refractory differentiated thyroid carcinoma

OBJECTIVE

Identifying prognostic markers for clinical outcomes is crucial in selecting appropriate treatment options for patients with radioiodine-refractory (RAI-R) differentiated thyroid carcinoma (DTC). The aim of this study was to investigate the prognostic value of clinico-pathological features and semiquantitative [18F]FDG PET/CT metabolic parameters in predicting progression-free survival (PFS) in DTC patients with RAI-R.

PATIENTS AND METHODS

This prospective cohort study included 110 consecutive RAI-R DTC patients who were referred for [18F]FDG PET/CT imaging. The lesion standard uptake values (SUV)s, including SUVmax, SUVmean, SULpeak as well astotal metabolic tumor volume (tMTV)and total lesion glycolysis (tTLG) were measured. Disease progression was assessed using the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and/or Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) 1.0. PFS curves were plotted using Kaplan-Meier analysis. Univariate and multivariate Cox regression analyses were performed to identify the prognostic factors for PFS.

RESULTS

[18F]FDG PET/CT metabolic parameters demonstrate predictive value for PFS in RAI-R DTC patients, with sensitivity ranging from 70.7% to 81% and specificity from 75% to 92.3% (p < 0.001). PFS was significantly worse in patients with SUVmax > 6.39 g/ml, SUVmean > 3.68 g/ml, SULpeak > 3.14 g/ml, tTLG > 4.23 g/ml × cm3, and tMTV > 1.24 cm3. Clinico-pathological factors including age > 55, aggressive variant and follicular histological subtype, extra-thyroidal extension of the primary tumor, stage III - IV disease at initial DTC diagnosis, distant metastases detected on [18F]FDG PET/CT, and metabolic parameters of [18F]FDG PET/CT associated with PFS in univariate analysis (p < 0.01). In multivariate analysis, extra-thyroidal extension (HR: 2.25; 95% CI: 1.22 - 4.16; p = 0.01), distant metastases on [18F]FDG PET/CT (HR: 2.98; 95%CI: 1.62 - 5.5; p < 0.001), and tMTV > 1.24 cm3 (HR: 4.17; 95% CI: 2.02 - 8.6; p < 0.001), were independent prognostic factors for PFS.

CONCLUSIONS

In addition to classic clinico-pathological factors, the semiquantitative [18F]FDG PET/CT metabolic parameters can be utilized for dynamic risk stratification for progression in RAI-R DTC patients. Furthermore, extra-thyroidal extension of the primary tumor, distant metastases, and tMTV > 1.24 cm3 are independent prognostic factors for PFS.